Medical-Surgical Practice HESI Exam 2024 with the best solutions HESI EXAM

1. The nurse is caring for a client receiving tamoxifen for the treatment of breast cancer. Which action should the nurse include in the client's plan of care? a. Increase fluid intake. b. Monitor sodium chloride intake. c. Assist the client in coping with hot flashes. d. Encourage milk products to increase calcium intake. - CORRECT ANSWERS-c. Assist the client in coping with hot flashes. Tamoxifen, an estrogen receptor blocking agent, can cause hot flashes, so client education regarding menopausal-like symptoms should be included in the plan of care. 2. The nurse is caring for a client who is admitted with a hemorrhagic stroke. Which nursing action should be included in the plan of care? a. Perform active range of motion three times daily. b. Monitor for Battle's sign every four hours. c. Teach measures to avoid the Valsalva maneuver. d. Maintain the head of bed in a flat position. - CORRECT ANSWERS-c. Teach measures to avoid the Valsalva maneuver. The Valsalva maneuver, straining with bowel movements while holding one's breath, increases intracerebral pressure (ICP) which may induce bleeding or rupture of cerebral blood vessels. 3. The nurse is caring for a client with multiple trauma after a motor vehicle collision. The nurse learns that the client has secondary syphilis. Which precaution should the nurse implement? a. A mask should be worn by anyone entering the client's room. b. Handwashing is required before and after contact with the client. c. Gloves should be worn during direct contact with the client's skin. d. No precautions in addition to standard precautions are necessary. - CORRECT ANSWERS-c. Gloves should be worn during direct contact with the client's skin. The secondary stage of syphilis is a systemic blood-borne disease that presents with skin lesions and rashes that may drain the highly contagious spirochete, so gloves should be worn during direct contact with the client's skin. The client should be placed on contact precautions.