HESI Medical Surgical Practice Exam Quizlet

Correct Answer: B

Rationale: The correct answer is B: 'Inability to get pregnant.' The symptoms described in the client's complaints, which include severe abdominal pain before menstruation, painful intercourse, and painful defecation, are indicative of endometriosis. Endometriosis is a condition characterized by the abnormal presence of endometrial tissue outside the uterus, commonly leading to infertility. While choices A, C, and D may be associated with other conditions, they are not directly related to the symptoms described by the client, making them incorrect choices. Frequent urinary tract infections may suggest a different issue, premenstrual syndrome does not typically present with severe abdominal pain, and chronic use of laxatives is not a typical symptom of endometriosis.

Correct Answer: C

Rationale: The correct nursing intervention indicated based on the nursing diagnosis 'Potential for impairment of skin integrity related to immobility from traction' is to provide back and skin care while maintaining the traction. This intervention is crucial for maintaining the client's skin integrity and preventing potential complications. Releasing the traction every 4 hours (Choice A) may disrupt the treatment plan and compromise the effectiveness of traction. Turning the client for back care while suspending traction (Choice B) does not address the need for skin care while the client is in traction. Giving back care after the client is released from traction (Choice D) neglects the immediate need to prevent skin impairment while in traction. Therefore, providing back and skin care while maintaining the traction (Choice C) is the most appropriate intervention in this scenario.

Correct Answer: D

Rationale: The onset of pneumonia in the elderly may be signaled by general deterioration, confusion, increased heart rate or increased respiratory rate due to the decreased oxygen- carbon dioxide exchange at the alveoli, known as the V-Q mismatch.

Correct Answer: D

Rationale: After a gastroscopy, it is crucial for the nurse to prioritize checking the client's gag and swallow reflexes before allowing them to drink anything. This is because the effects of local anesthesia need to dissipate, and the airway's protective reflexes, including the gag and swallow reflexes, must have returned to prevent aspiration. Listening to lung and bowel sounds (Choice A) may be important but does not take precedence over ensuring the client's safety post-gastroscopy. Obtaining the client's pulse and blood pressure (Choice B) is also important but not the priority in this scenario. Assisting the client to the bathroom to void (Choice C) is a routine nursing action and is not directly related to the immediate safety concern of checking the client's gag and swallow reflexes post-gastroscopy.

Correct Answer: A

Rationale: The priority nursing diagnosis for a client on a mechanical ventilator receiving vecuronium bromide is 'Impaired communication related to paralysis of skeletal muscles.' Vecuronium is a skeletal muscle relaxant that causes diaphragmatic paralysis, leading to the inability of the client to communicate effectively. This is a crucial nursing concern as it impacts the client's ability to express needs and participate in care. Option B 'High risk for infection related to increased intracranial pressure' is not the priority in this scenario as the client's condition is related to the effects of the medication and mechanical ventilation, not directly to increased intracranial pressure. Option C 'Potential for injury related to impaired lung expansion' is important but not the priority over impaired communication. Option D 'Social isolation related to inability to communicate' is not the priority nursing diagnosis in this situation as it focuses more on psychosocial aspects rather than the immediate physiological concern of communication impairment.