HESI MED SURG REVIEW

HESI MED SURG REVIEW QUESTIONS AND RATIONALE 1. A client on telemetry has a pattern of uncontrolled atrial fibrillation with a rapid ventricular response. Based on this finding, the nurse anticipates assisting the physician with which treatment? A. Administer lidocaine, 75 mg intravenous push. B. Perform synchronized cardioversion. C. Defibrillate the client as soon as possible. D. Administer atropine, 0.4 mg intravenous push. Rationale: With uncontrolled atrial fibrillation, the treatment of choice is synchronized cardioversion to convert the cardiac rhythm back to normal sinus rhythm. Option A is a medication used for ventricular dysrhythmias. Option C is not for a client with atrial fibrillation; it is reserved for clients with life-threatening dysrhythmias, such as ventricular fibrillation and unstable ventricular tachycardia. Option D is the drug of choice in symptomatic sinus bradycardia, not atrial fibrillation. 2. A practical nurse (PN) tells the charge nurse in a long-term facility that she does not want to be assigned to one particular resident. She reports that the male client keeps insisting that she is his daughter and begs her to stay in his room. What is the best managerial decision? A. Notify the family that the resident will have to be discharged if his behavior does not improve. B. Notify administration of the PN’s insubordination and need for counseling about her statements. C. Ask the PN what she has done to encourage the resident to believe that she is his daughter. D. Reassign the PN until the resident can be assessed more completely for reality orientation. Rationale: Temporary reassignment is the best option until the resident can be examined and his medications reviewed. He may have worsening cerebral dysfunction from an infection or electrolyte imbalance. Option A is not the best option because the family cannot control the resident’s actions. The administration may need to know about the situation, but not as a case of insubordination. Implying that the PN is somehow creating the situation is inappropriate until a further evaluation has been conducted. 3. Client census is often used to determine staffing needs. Which method of obtaining census determination for a particular unit provides the best formula for determining long-range staffing patterns? A. Midnight census B. Oncoming shift census C. Average daily census D. Hourly census Rationale: An average daily census is determined by trend data and takes into account seasonal and daily fluctuations, so it is the best method for determining staffing needs. Options A and B provide data at a certain point in time, and that data could change quickly. It is unrealistic to expect to obtain an hourly census, and such data would only provide information about a certain point in time. 4. The nurse is counseling a healthy 30-year-old female client regarding osteoporosis prevention. Which activity would be most beneficial in achieving the client’s goal of osteoporosis prevention? A. Cross-country skiing B. Scuba diving C. Horseback riding D. Kayaking Rationale: Weight-bearing exercise is an important measure to reduce the risk of osteoporosis. Of the activities listed, cross- country skiing includes the most weight-bearing, whereas options B, C, and D involve less. 5. Which condition should the nurse anticipate as a potential problem in a female client with a neurogenic bladder? A. Stress incontinence B. Infection C. Painless gross hematuria D. Peritonitis Rationale: Infection is the major complication resulting from stasis of urine and subsequent catheterization. Option A is the involuntary loss of urine through an intact urethra as a result of a sudden increase in intra-abdominal pressure. Option C is the most common symptom of bladder cancer. Option D is the most common and serious complication of peritoneal dialysis. 6. A client is being discharged following radioactive seed implantation for prostate cancer. What is the most important information that the nurse should provide to this client’s family? A. Follow exposure precautions. B. Encourage regular meals. C. Collect all urine. D. Avoid touching the client. Rationale: Clients being treated for prostate cancer with radioactive seed implants should be instructed regarding the amount of time and distance needed to prevent excessive exposure that would pose a hazard to others. Option B is a good suggestion to promote adequate nutrition but is not as important as option A. Option C is unnecessary. Contact with the client is permitted but should be brief to limit radiation exposure. 7. In assessing a client with an arteriovenous (AV) shunt who is scheduled for dialysis today, the nurse notes the absence of a thrill or bruit at the shunt site. What action should the nurse take? A. Advise the client that the shunt is intact and ready for dialysis as scheduled. B. Encourage the client to keep the shunt site elevated above the level of the heart. C. Notify the health care provider of the findings immediately. D. Flush the site at least once with a heparinized saline solution. Rationale: Absence of a thrill or bruit indicates that the shunt may be obstructed. The nurse should notify the health care provider so that intervention can be initiated to restore function of the shunt. Option A is incorrect. Option B will not resolve the obstruction. An AV shunt is internal and cannot be flushed without access using special needles. 8. The nurse is concerned about infection for a client after an esophagogastrostomy for esophageal cancer. Which actions should the nurse include in the client’s plan of care? (Select all that apply.) A. Frequent oral care every 2 hours while awake. B. Use incentive spirometer every 2 hours. C. Empty contents from NG tube every 8 hours. D. Ambulate within 1 hour of return from the PACU. E. Limit visitors until postoperative day 2. Rationale: One hour post op is too soon to ambulate for this client. Visitors help support the patient and are encouraged to visit. Oral care is necessary as the client will be NPO. To decrease the risk of infection post operatively, implement routine pulmonary exercises. The client will have an NG tube in place, likely to intermittent suction, to decompress the stomach post surgery. 9. The nurse notes that the client’s drainage has decreased from 50 to 5 mL/hr 12 hours after chest tube insertion for hemothorax. What is the best initial action for the nurse to take? A. Document this expected decrease in drainage. B. Clamp the chest tube while assessing for air leaks. C. Milk the tube to remove any excessive blood clot buildup. D. Assess for kinks or dependent loops in the tubing. Rationale: The least invasive nursing action should be performed first to determine why the drainage has diminished. Option A is completed after assessing for any problems causing the decrease in drainage. Option B is no longer considered standard protocol because the increase in pressure may be harmful to the client. Option C is an appropriate nursing action after the tube has been assessed for kinks or dependent loops. 10. The nurse is assessing a 75-year-old client for symptoms of hyperglycemia. Which symptom of hyperglycemia is an older adult most likely to exhibit? A. Polyuria B. Polydipsia C. Weight loss D. Infection Rationale: Signs and symptoms of hyperglycemia in older adults may include fatigue, infection, and evidence of neuropathy (e.g., sensory changes). The nurse needs to remember that classic signs and symptoms of hyperglycemia, such as options A, B, and C and polyphagia, may be absent in older adults. 11. Which abnormal laboratory finding indicates that a client with diabetes needs further evaluation for diabetic nephropathy? A. Hypokalemia B. Microalbuminuria C. Elevated serum lipid levels D. Ketonuria Rationale: Microalbuminuria is the earliest sign of diabetic nephropathy and indicates the need for follow-up evaluation. Hyperkalemia, not option A, is associated with end-stage renal disease caused by diabetic nephropathy. Option C may be elevated in end-stage renal disease. Option D may signal the onset of diabetic ketoacidosis (DKA). 12. Which change in laboratory values indicates to the nurse that a client with rheumatoid arthritis may be experiencing an adverse effect of methotrexate therapy? A. Increase in rheumatoid factor B. Decrease in hemoglobin level C. Increase in blood glucose level D. Decrease in erythrocyte sedimentation rate (ESR; sed rate) Rationale: Methotrexate is an immunosuppressant. A common side effect is bone marrow depression, which would be reflected by a decrease in the hemoglobin level. Option A indicates disease progression but is not a side effect of the medication. Option C is not related to methotrexate. Option D indicates that inflammation associated with the disease has diminished. 13. Which consideration is most important when the nurse is assigning a room for a client being admitted with progressive systemic sclerosis (scleroderma)? A. Provide a room that can be kept warm. B. Make sure that the room can be kept dark. C. Keep the client close to the nursing unit. D. Select a room that is visible from the nurses’ desk. Rationale: Abnormal blood flow in response to cold (Raynaud phenomenon) is precipitated in clients with scleroderma. Option B is not a significant factor. Stress can also precipitate the severe pain of Raynaud phenomenon, so a quiet environment is preferred to option C, which is often very noisy. Option D is not necessary. 14. The nurse is reviewing routine medications taken by a client with chronic angle-closure glaucoma. Which medication prescription should the nurse question? A. Antianginal with a therapeutic effect of vasodilation B. Anticholinergic with a side effect of pupillary dilation C. Antihistamine with a side effect of sedation D. Corticosteroid with a side effect of hyperglycemia Rationale: Clients with angle-closure glaucoma should not take medications that dilate the pupil because this can precipitate acute and severely increased intraocular pressure. Options A, C, and D do not cause increased intracranial pressure, which is the primary concern with angle-closure glaucoma. 15. The nurse is observing an unlicensed assistive personnel (UAP) performing care for a bedridden client with advanced Huntington disease. Which care measures are most important for the nurse to supervise? (Select all that apply.) A. Oral care B. Bathing C. Foot care D. Catheter care E. Enteral feeding Rationale: The client with Huntington disease experiences problems with motor skills such as swallowing and is at high risk for aspiration, so the highest priority for the nurse to observe is the UAP’s ability to perform oral care and feeding safely. Options B, C, and D do not necessarily require registered nurse (RN) supervision because they do not ordinarily pose life-threatening consequences. 16. During the change of shift report, the charge nurse reviews the infusions being received by clients on the oncology unit. The client receiving which infusion should be assessed first? A. Continuous IV infusion of magnesium B. One-time infusion of albumin C. Continuous epidural infusion of morphine D. Intermittent infusion of IV vancomycin Rationale: All four of these clients have the potential to have significant complications. The client with the morphine epidural infusion is at highest risk for respiratory depression and should be assessed first. Option A can cause hypotension. The client receiving option B is at lowest risk for serious complications. Although option D can cause nephrotoxicity and phlebitis, these problems are not as immediately life threatening as option C. 17. The nurse assesses a postoperative client whose skin is cool, pale, and moist. The client is very restless and has scant urine output. Oxygen is being administered at 2 L/min, and a saline lock is in place. Which action should the nurse take first? A. Measure the urine specific gravity. B. Obtain IV fluids for infusion per protocol. C. Prepare for insertion of a central venous catheter. D. Auscultate the client’s breath sounds. Rationale: The client is at risk for hypovolemic shock because of the postoperative status and is exhibiting early signs of shock. A priority intervention is the initiation of IV fluids to restore tissue perfusion. Options A, C, and D are all important interventions but are of lower priority than option B. 18. A client with type 2 diabetes takes metformin daily. The client is scheduled for major surgery requiring general anesthesia the next day. The nurse anticipates which approach to manage the client’s diabetes best while the client is NPO during the perioperative period? A. NPO except for metformin and regular snacks B. NPO except for oral antidiabetic agent C. Novolin N insulin subcutaneously twice daily D. Regular insulin subcutaneously per sliding scale Rationale: Regular insulin dosing based on the client’s blood glucose levels (sliding scale) is the best method to achieve control of the client’s blood glucose while the client is NPO and coping with the major stress of surgery. Option A increases the risk of vomiting and aspiration. Options B and C provide less precise control of the blood glucose level. 19. A client is diagnosed with an acute small bowel obstruction and suddenly spikes a temperature of 102°F/38.9°C. What other assessments should the nurse include in the client’s focused assessment? (Select all that apply.) A. Nausea and vomiting B. Loss of appetite C. Abdominal cramping D. Guarding with abdominal palpation E. Low urine output F. Cool, clammy skin Rationale: The client is showing signs of peritonitis with the sudden spike in temperature. Low urine output and cool clammy skin are not seen with peritonitis. Peritonitis is a medical emergency and the health care provider must be notified immediately. 20. The nurse witnesses a baseball player receive a blunt trauma to the back of the head with a softball. What assessment data should the nurse collect immediately? (Select all that apply.) A. Reactivity of deep tendon reflexes B. Heart rate and respiratory rate C. Memory of recent events D. Ability to open the eyes spontaneously E. Dizziness F. Ringing in the ears Rationale: The level of consciousness (LOC) should be established immediately when a head injury has occurred. Deep tendon reflexes are not an indicator of LOC or concussion. Spontaneous eye opening is a simple measure of alertness that indicates that arousal mechanisms are intact. The remaining assessments are included in the concussion protocol. 21. The nurse is preparing a teaching plan for a group of healthy adults. Which individual is most likely to maintain optimum health? A. A teacher whose blood glucose levels average 126 mg/dL daily with oral antidiabetic drugs B. An accountant whose blood pressure averages 140/96 mm Hg and who says he does not have time to exercise C. A stock broker whose total serum cholesterol level dropped to 290 mg/dL with diet modifications D. A recovering IV heroin user who contracted hepatitis more than 10 years ago Rationale: The diabetic teacher has assumed responsibility for self-care, so among those listed, he or she is the most likely to maintain optimum health. Option B has expressed a lack of interest in health promotion. Option C continues to demonstrate a high-risk cholesterol level despite a reported attempt at dietary modifications. Previous IV drug use and a history of hepatitis make this individual a health risk despite the fact that the individual is in recovery. 22. A client with hypertension has been receiving ramipril, 5 mg PO, daily for 2 weeks and is scheduled to receive a dose at 0900. At 0830, the client’s blood pressure is 120/70 mm Hg. Which action should the nurse take? A. Administer the prescribed dose at the scheduled time. B. Hold the dose and contact the health care provider. C. Hold the dose and recheck the blood pressure in 1 hour. D. Check the health care provider’s prescription to clarify the dose. Rationale: The client’s blood pressure is within normal limits, indicating that the ramipril, an antihypertensive, is having the desired effect and should be administered. Options B and C would be appropriate if the client’s blood pressure was excessively low (<100 mm Hg systolic) or if the client were exhibiting signs of hypotension such as dizziness. This prescribed dose is within the normal dosage range, as defined by the manufacturer; therefore, option D is not necessary. 23. When assigning clients on a medical-surgical floor to an RN and a PN, it is best for the charge nurse to assign which client to the PN? A. A young adult with bacterial meningitis with recent seizures B. An older adult client with pneumonia and viral meningitis C. A female client in isolation with meningococcal meningitis D. A male client 1 day postoperative after drainage of a brain abscess Rationale: The most stable client is option B. Options A, C, and D are all at high risk for increased intracranial pressure and require the expertise of the RN for assessment and management of care. 24. A resident in a long-term care facility is diagnosed with hepatitis B. Which action should the nurse take with the staff caring for this client? A. Determine if all employees have had the hepatitis B vaccine series. B. Explain that this type of hepatitis can be transmitted when feeding the client. C. Assure the employees that they cannot contract hepatitis B when providing direct care. D. Tell the employees that wearing gloves and a gown are required when providing all care. Rationale: Hepatitis B vaccine should be administered to all health care providers. Hepatitis A (not hepatitis B) can be transmitted by fecal–oral contamination. There is a chance that staff could contract hepatitis B if exposed to the client’s blood and/or body fluids; therefore, option C is incorrect. There is no need to wear gloves and gowns except with blood or body fluid contact. 25. During report, the nurse learns that a client with tumor lysis syndrome is receiving an IV infusion containing insulin. Which action should the nurse complete first? A. Review the client’s history for diabetes mellitus. B. Observe the extremity distal to the IV site. C. Monitor the client’s serum potassium and blood glucose levels. D. Evaluate the client’s oxygen saturation and breath sounds. Rationale: Clients with tumor lysis syndrome may experience hyperkalemia, requiring the addition of insulin to the IV solution to reduce the serum potassium level. It is most important for the nurse to monitor the client’s serum potassium and blood glucose levels to ensure that they are not at dangerous levels. Options A, B, and D provide valuable assessment data but are of less priority than option C. 26. A tornado warning alarm has been activated at the local hospital. Which action should the charge nurse working on a surgical unit take first? A. Instruct the nursing staff to close all window blinds and curtains in clients’ rooms. B. Move clients and visitors into the hallways and close all doors to clients’ rooms. C. Visually confirm the location of the tornado by checking the windows on the unit. D. Assist all visitors with evacuation down the stairs in a calm and orderly manner. Rationale: In the event of a tornado, all persons should be moved into the hallways, away from windows, to prevent flying debris from causing injury. Although option A may help decrease the amount of flying debris, it is not safe to leave clients in rooms with closed blinds; option B is a higher priority at this time. Hospital staff should stay away from windows to avoid injury and should focus on client evacuation into hallways rather than option C. Option D is not the first action that should be taken. 27. The nurse is assessing a client with acute pancreatitis. Which finding requires the most immediate intervention by the nurse? A. The client’s amylase level is three times higher than the normal level. B. The client has a carpal spasm when taking a blood pressure. C. On a 1 to 10 scale, the client tells the nurse that her epigastric pain is at 7. D. The client states that she will continue to drink alcohol after going home. Rationale: A positive Trousseau sign indicates hypocalcemia and always requires further assessment and intervention, regardless of the cause (40% to 75% of those with acute pancreatitis experience hypocalcemia, which can have serious, systemic effects). A key diagnostic finding of pancreatitis is serum amylase and lipase levels that are two to five times higher than the normal value. Severe boring pain is an expected symptom for this diagnosis, but dealing with the hypocalcemia is a priority over administering an analgesic. Long-term planning and teaching do not have the same immediate importance as a positive Trousseau sign.