HESI Medical Surgical Assignment Exam

Questions 45

HESI RN

Home > HESI RN > HESI Medical Surgical > HESI Medical Surgical Assignment Exam
HESI RN Test Bank

HESI Medical Surgical Assignment Exam Questions

Question 1 of 5

A nurse is conducting an assessment of a client who underwent thoracentesis of the right side of the chest 3 hours ago. Which findings does the nurse report to the physician? Select all that apply.

Correct Answer: A

Rationale: After thoracentesis, the nurse should assess the client for signs of pneumothorax, which include increased respiratory rate, dyspnea, retractions, unequal chest expansion, diminished breath sounds, and cyanosis. Unequal chest expansion is a key sign of pneumothorax due to the accumulation of air in the pleural space, causing the affected lung to collapse partially. Pulse rate and respiratory rate within normal ranges, like in choices B and C, are not the priority findings to report in this situation. Diminished breath sounds in the right lung could be expected after thoracentesis and may not necessarily indicate a complication like pneumothorax, making choice D less urgent to report.

Question 2 of 5

A nurse cares for a client with urinary incontinence. The client states, "I am so embarrassed. My bladder leaks like a young child's bladder." How should the nurse respond?

Correct Answer: C

Rationale: The nurse should accept and acknowledge the client's concerns, and assist the client to learn techniques that will allow control of urinary incontinence. The nurse should not diminish the client's concerns with the use of pads or stating statistics about the occurrence of incontinence.

Question 3 of 5

A nurse is teaching a nursing student how to measure a carotid pulse. The nurse should tell the student to measure the pulse on only one side of the client's neck primarily because:

Correct Answer: D

Rationale: The correct answer is D. Applying pressure to both carotid arteries at the same time is contraindicated. Excess pressure to the baroreceptors in the carotid vessels could cause the heart rate and blood pressure to reflexively drop. Palpating both carotid pulses simultaneously could also interfere with the flow of blood to the brain, possibly causing dizziness and syncope. Choices A, B, and C are incorrect. It is necessary to use both hands to measure the carotid pulse accurately. Feeling dual pulsations does not lead to an incorrect measurement, and palpating both carotid pulses simultaneously does not occlude the trachea.

Question 4 of 5

A nurse is conducting an assessment of a client who underwent thoracentesis of the right side of the chest 3 hours ago. Which findings does the nurse report to the physician? Select all that apply.

Correct Answer: A

Rationale: After thoracentesis, the nurse should assess the client for signs of pneumothorax, which include increased respiratory rate, dyspnea, retractions, unequal chest expansion, diminished breath sounds, and cyanosis. Unequal chest expansion is a key sign of pneumothorax due to the accumulation of air in the pleural space, causing the affected lung to collapse partially. Pulse rate and respiratory rate within normal ranges, like in choices B and C, are not the priority findings to report in this situation. Diminished breath sounds in the right lung could be expected after thoracentesis and may not necessarily indicate a complication like pneumothorax, making choice D less urgent to report.

Question 5 of 5

The provider has ordered Kayexalate and sorbitol to be administered to a patient. The nurse caring for this patient would expect which serum electrolyte values prior to administration of this therapy?

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.

Similar Questions

The provider has ordered Kayexalate and sorbitol to be administered to a patient. The nurse caring for this patient would expect which serum electrolyte values prior to administration of this therapy?
During a paracentesis procedure on a client with abdominal ascites, into which position would the nurse assist the client?
When preparing a client for intravenous pyelography (IVP), which action by the nurse is most important?
After delegating to an unlicensed assistive personnel (UAP) the task of completing a bladder scan examination for a client, the nurse evaluates the UAP's performance. Which action by the UAP indicates the nurse must provide additional instructions when delegating this task?
The nurse is providing teaching to a patient who will begin taking a cephalosporin to treat an infection. Which statement by the patient indicates a need for further teaching?

Join Our Community Today!

Join Over 10,000+ nursing students using Nurselytic. Access Comprehensive study Guides curriculum for HESI-RN and 3000+ practice questions to help you pass your HESI-RN exam.

Call to Action Image