HESI Medical Surgical Exam

Correct Answer: B

Rationale: The correct answer is 'B: Hypotension.' Hypotension is a common complication of hemodialysis because fluid removal during the process can lead to a drop in blood pressure. The nurse should closely monitor the client for signs of hypotension such as dizziness, lightheadedness, or a decrease in blood pressure readings. Choice 'A: Hyperkalemia' is incorrect because hemodialysis actually helps lower potassium levels by removing excess potassium from the blood. Choice 'C: Infection' is incorrect as it is not a direct complication of hemodialysis but rather a risk associated with invasive procedures. Choice 'D: Fever' is incorrect as fever is not a typical immediate post-hemodialysis complication unless an underlying infection is present.

Correct Answer: A

Rationale: The most important nursing action when administering a blood transfusion is monitoring the patient's blood pressure. This is crucial because monitoring blood pressure allows for the prompt identification of any signs of adverse transfusion reactions, such as transfusion reactions or fluid overload. Immediate intervention can be initiated if any complications arise. While monitoring temperature, heart rate, and oxygen saturation are also essential aspects of patient care, they are not as critical as blood pressure monitoring during a blood transfusion. Therefore, the correct answer is to monitor the patient's blood pressure.

Correct Answer: B

Rationale: Peritonitis is the most likely complication to occur in clients receiving peritoneal dialysis due to the risk of infection. Peritonitis is a serious inflammation of the peritoneum lining the abdominal cavity, commonly caused by infection. While electrolyte imbalance and hyperglycemia are possible complications in some cases, peritonitis poses a more immediate and severe threat to the client's health. Infection is a general term that can encompass peritonitis but is not as specific as directly identifying peritonitis as the primary concern in this scenario.

Correct Answer: C

Rationale: Autonomic dysreflexia is a life-threatening condition commonly seen in clients with spinal cord injuries above the T6 level. It is characterized by a sudden onset of excessively high blood pressure due to a noxious stimulus below the level of injury, often a distended bladder. The exaggerated sympathetic response leads to vasoconstriction, resulting in symptoms such as profuse diaphoresis (sweating) and a severe, pounding headache. These symptoms are the body's attempt to lower blood pressure. Complaints of chest pain and shortness of breath (Choice A) are not typical findings in autonomic dysreflexia. Hypotension and venous pooling (Choice B) are opposite manifestations of autonomic dysreflexia, which is characterized by hypertension. Pain and burning sensation upon urination and hematuria (Choice D) are indicative of a urinary tract infection and not specific to autonomic dysreflexia.

Correct Answer: A

Rationale: Elevating the head of the bed to 30 degrees is crucial for a patient with increased intracranial pressure (ICP) because it helps promote venous drainage from the brain, thereby reducing ICP. Keeping the head of the bed elevated helps facilitate cerebral perfusion and can prevent a further increase in ICP. Administering diuretics (Choice B) may be considered in some cases to reduce fluid volume, but it is not the most critical intervention for immediate ICP management. Administering corticosteroids (Choice C) is not typically indicated for managing increased ICP unless there is a specific underlying condition requiring their use. Keeping the patient in a supine position (Choice D) can actually worsen ICP by impeding venous outflow from the brain, making it an incorrect choice for this scenario.