HESI Medical Surgical Assignment Exam

Correct Answer: D

Rationale: The correct action for the nurse to take to insert a nasogastric tube safely and easily is asking the client to swallow as the tube is being advanced. This action helps facilitate the passage of the tube through the esophagus into the stomach. Placing the tube in warm water (Choice A) is not a recommended practice for nasogastric tube insertion. Hyperextending the head (Choice B) can cause discomfort and is not necessary for safe insertion. Removing the tube if resistance is met (Choice C) is incorrect as it may cause harm or discomfort to the client. Asking the client to swallow helps the tube pass more smoothly and comfortably.

Correct Answer: D

Rationale: The correct answer is D. The nurse should instruct the client to avoid using deodorants, powders, or creams on the day of the mammogram. These products used in the axillary or breast area can interfere with the mammogram results and must be washed off before the test. Choices A, B, and C are incorrect because mammography typically takes less than 30 minutes, there is no need for fasting before the test, and some discomfort may be experienced during the procedure.

Correct Answer: C

Rationale: Severe hyperkalemia, with a potassium level of 6.9 mEq/L, requires aggressive treatment with Kayexalate and sorbitol to increase the body's excretion of potassium. The normal range for serum potassium is 3.5 to 5.5 mEq/L, so patients with the other potassium levels would not be treated aggressively or would need potassium supplementation. Therefore, option C (Sodium 135 mEq/L and potassium 6.9 mEq/L) is the correct choice as it indicates severe hyperkalemia warranting the administration of Kayexalate and sorbitol. Options A, B, and D have either potassium levels within normal limits, which would not necessitate this aggressive treatment, or potassium levels that are lower than what would typically prompt the need for Kayexalate and sorbitol.

Correct Answer: D

Rationale: The correct answer is D, as all the choices are correctly paired with their clinical manifestations. Stress incontinence is characterized by urine loss with physical exertion, coughing, sneezing, or exercising. Urge incontinence presents with a sudden and strong urge to void, often accompanied by a large amount of urine released during each occurrence. Overflow incontinence occurs when the bladder is distended, leading to a constant dribbling of urine. Functional incontinence, not mentioned in the options, is the leakage of urine due to factors unrelated to a lower urinary tract disorder. Reflex incontinence, also not mentioned, is a condition resulting from abnormal detrusor contractions.

Correct Answer: D

Rationale: The most crucial action for the nurse when preparing a client for intravenous pyelography (IVP) is to question the client about allergies to iodine or shellfish. Some IVP dyes contain iodine, and if the client is allergic to iodine or shellfish, they may experience severe allergic reactions such as itching, hives, rash, throat tightness, difficulty breathing, or bronchospasm. Administering a sedative (Choice A) may be needed for relaxation during the procedure, encouraging fluid intake (Choice B) is generally beneficial but not the most crucial for IVP preparation, and administering radiopaque dye (Choice C) should only be done after confirming the client's safety regarding allergies to iodine or shellfish.