HESI Medical Surgical Practice Exam Quizlet

Questions 50

HESI RN

HESI RN Test Bank

HESI Medical Surgical Practice Exam Quizlet Questions

Question 1 of 5

What is the correct procedure for performing an ophthalmoscopic examination on a client's right retina?

Correct Answer: C

Rationale: During an ophthalmoscopic examination, the client should focus on a distant object behind the examiner to dilate the pupil, and the examiner should stand at a distance of 12-15 inches away and slightly to the side. This angle allows for better visualization of the retina. Holding the ophthalmoscope firmly against the examiner's face and shining the light into the client's pupil helps examine the retina effectively. Choice A is incorrect because the client should look at a distant object, not the examiner's nose. Choice B is incorrect as the ophthalmoscope should be directed towards the client's eye, not the examiner's eye. Choice D is incorrect because keeping the ophthalmoscope at least 3 inches away may not provide an optimal view of the retina.

Question 2 of 5

A client with gastroesophageal reflux disease (GERD) has been experiencing severe reflux during sleep. Which recommendation by the nurse is most effective to assist the client?

Correct Answer: D

Rationale: The correct answer is to raise the head of the bed on blocks (reverse Trendelenburg position). This elevation helps reduce reflux by using gravity to keep stomach contents from flowing back into the esophagus during sleep. Losing weight (Choice A) could be beneficial in managing GERD, but it may not be as effective for immediate relief during sleep. Decreasing caffeine intake (Choice B) and avoiding large meals (Choice C) are also valuable recommendations to manage GERD; however, they may not specifically address the issue of reflux during sleep as directly and effectively as elevating the head of the bed.

Question 3 of 5

The nurse assesses a client with advanced cirrhosis of the liver for signs of hepatic encephalopathy. Which finding would the nurse consider an indication of progressive hepatic encephalopathy?

Correct Answer: D

Rationale: Difficulty in handwriting is a common early sign of hepatic encephalopathy. Changes in handwriting can indicate progression or reversal of hepatic encephalopathy leading to coma. Choice (A) is a sign of ascites, not hepatic encephalopathy. Hypertension and a bounding pulse (Choice B) are not typically associated with hepatic encephalopathy. Decreased bowel sounds (Choice C) do not directly indicate an increase in serum ammonia level, which is the primary cause of hepatic encephalopathy.

Question 4 of 5

A client who has just undergone surgery suddenly experiences chest pain, dyspnea, and tachypnea. The nurse suspects that the client has a pulmonary embolism and immediately sets about:

Correct Answer: C

Rationale: When a client who has just undergone surgery experiences sudden chest pain, dyspnea, and tachypnea, indicating possible pulmonary embolism, the immediate priority for the nurse is to administer oxygen via nasal cannula. This intervention aims to improve oxygenation and alleviate respiratory distress, which is crucial in the setting of a potential pulmonary embolism. Preparing the client for a perfusion scan is not the immediate priority as stabilizing the client's respiratory status comes first. While attaching the client to a cardiac monitor is important for monitoring, administering oxygen takes precedence in this situation. Ensuring IV line patency is relevant for overall client care but is not the priority when a client is experiencing respiratory distress requiring immediate intervention.

Question 5 of 5

A 20-year-old female client calls the nurse to report a lump she found in her breast. Which response is the best for the nurse to provide?

Correct Answer: B

Rationale: The nurse advising the client to come in provides the best response because it addresses the client's anxiety most effectively and encourages prompt and immediate action for a potential problem.

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