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HESI Comprehensive Review for the NCLEX-PN® Examination - E-Book
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Stuvia.com - The Marketplace to Buy and Sell your Study MaterialHESI MED SURG REVIEW
1. A client on telemetry has a pattern of uncontrolled atrial fibrillation with a rapid ventricular response. Based on
this finding, the nurse anticipates assisting the physician with which treatment?
A. Administer lidocaine, 75 mg intravenous push.
B. Perform synchronized cardioversion.
C. Defibrillate the client as soon as possible.
D. Administer atropine, 0.4 mg intravenous push.
Rationale:
With uncontrolled atrial fibrillation, the treatment of choice is synchronized cardioversion to convert the cardiac
rhythm back to normal sinus rhythm. Option A is a medication used for ventricular dysrhythmias. Option C is not for
a client with atrial fibrillation; it is reserved for clients with life-threatening dysrhythmias, such as ventricular
fibrillation and unstable ventricular tachycardia. Option D is the drug of choice in symptomatic sinus bradycardia,
not atrial fibrillation.
2. A practical nurse (PN) tells the charge nurse in a long-term facility that she does not want to be assigned to one
particular resident. She reports that the male client keeps insisting that she is his daughter and begs her to stay in his
room. What is the best managerial decision?
A. Notify the family that the resident will have to be discharged if his
behavior does not improve.
B. Notify administration of the PN’s insubordination and need for
counseling about her statements.
C. Ask the PN what she has done to encourage the resident to believe
that she is his daughter.
D. Reassign the PN until the resident can be assessed more completely
for reality orientation.
Rationale:
Temporary reassignment is the best option until the resident can be examined and his medications reviewed. He may
have worsening cerebral dysfunction from an infection or electrolyte imbalance. Option A is not the best option
because the family cannot control the resident’s actions. The administration may need to know about the situation,
but not as a case of insubordination. Implying that the PN is somehow creating the situation is inappropriate until a
further evaluation has been conducted.
3. Client census is often used to determine staffing needs. Which method of obtaining census determination for a
particular unit provides the best formula for determining long-range staffing patterns?
A. Midnight census
B. Oncoming shift census
C. Average daily census
D. Hourly census
Rationale:
An average daily census is determined by trend data and takes into account seasonal and daily fluctuations, so it is
the best method for determining staffing needs. Options A and B provide data at a certain point in time, and that data
could change quickly. It is unrealistic to expect to obtain an hourly census, and such data would only provide
information about a certain point in time.
4. The nurse is counseling a healthy 30-year-old female client regarding osteoporosis prevention. Which activity
would be most beneficial in achieving the client’s goal of osteoporosis prevention?
A. Cross-country skiing
B. Scuba diving
C. Horseback riding
D. Kayaking
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Rationale:
Weight-bearing exercise is an important measure to reduce the risk of osteoporosis. Of the activities listed, cross-
country skiing includes the most weight-bearing, whereas options B, C, and D involve less.
5. Which condition should the nurse anticipate as a potential problem in a female client with a neurogenic bladder?
A. Stress incontinence
B. Infection
C. Painless gross hematuria
D. Peritonitis
Rationale:
Infection is the major complication resulting from stasis of urine and subsequent catheterization. Option A is the
involuntary loss of urine through an intact urethra as a result of a sudden increase in intra-abdominal pressure.
Option C is the most common symptom of bladder cancer. Option D is the most common and serious complication
of peritoneal dialysis.
6. A client is being discharged following radioactive seed implantation for prostate cancer. What is the most
important information that the nurse should provide to this client’s family?
A. Follow exposure precautions.
B. Encourage regular meals.
C. Collect all urine.
D. Avoid touching the client.
Rationale:
Clients being treated for prostate cancer with radioactive seed implants should be instructed regarding the amount of
time and distance needed to prevent excessive exposure that would pose a hazard to others. Option B is a good
suggestion to promote adequate nutrition but is not as important as option A. Option C is unnecessary. Contact with
the client is permitted but should be brief to limit radiation exposure.
7. In assessing a client with an arteriovenous (AV) shunt who is scheduled for dialysis today, the nurse notes the
absence of a thrill or bruit at the shunt site. What action should the nurse take?
A. Advise the client that the shunt is intact and ready for dialysis as
scheduled.
B. Encourage the client to keep the shunt site elevated above the level of
the heart.
C. Notify the health care provider of the findings immediately.
D. Flush the site at least once with a heparinized saline solution.
Rationale:
Absence of a thrill or bruit indicates that the shunt may be obstructed. The nurse should notify the health care
provider so that intervention can be initiated to restore function of the shunt. Option A is incorrect. Option B will not
resolve the obstruction. An AV shunt is internal and cannot be flushed without access using special needles.
8. The nurse is concerned about infection for a client after an esophagogastrostomy for esophageal cancer. Which
actions should the nurse include in the client’s plan of care? (Select all that apply.)
A. Frequent oral care every 2 hours while awake.
B. Use incentive spirometer every 2 hours.
C. Empty contents from NG tube every 8 hours.
D. Ambulate within 1 hour of return from the PACU.
E. Limit visitors until postoperative day 2.
Rationale:
One hour post op is too soon to ambulate for this client. Visitors help support the patient and are encouraged to visit.
Oral care is necessary as the client will be NPO. To decrease the risk of infection post operatively, implement
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routine pulmonary exercises. The client will have an NG tube in place, likely to intermittent suction, to decompress
the stomach post surgery.
9. The nurse notes that the client’s drainage has decreased from 50 to 5 mL/hr 12 hours after chest tube insertion for
hemothorax. What is the best initial action for the nurse to take?
A. Document this expected decrease in drainage.
B. Clamp the chest tube while assessing for air leaks.
C. Milk the tube to remove any excessive blood clot buildup.
D. Assess for kinks or dependent loops in the tubing.
Rationale:
The least invasive nursing action should be performed first to determine why the drainage has diminished. Option A
is completed after assessing for any problems causing the decrease in drainage. Option B is no longer considered
standard protocol because the increase in pressure may be harmful to the client. Option C is an appropriate nursing
action after the tube has been assessed for kinks or dependent loops.
10. The nurse is assessing a 75-year-old client for symptoms of hyperglycemia. Which symptom of hyperglycemia is
an older adult most likely to exhibit?
A. Polyuria
B. Polydipsia
C. Weight loss
D. Infection
Rationale:
Signs and symptoms of hyperglycemia in older adults may include fatigue, infection, and evidence of neuropathy
(e.g., sensory changes). The nurse needs to remember that classic signs and symptoms of hyperglycemia, such as
options A, B, and C and polyphagia, may be absent in older adults.
11. Which abnormal laboratory finding indicates that a client with diabetes needs further evaluation for diabetic
nephropathy?
A. Hypokalemia
B. Microalbuminuria
C. Elevated serum lipid levels
D. Ketonuria
Rationale:
Microalbuminuria is the earliest sign of diabetic nephropathy and indicates the need for follow-up evaluation.
Hyperkalemia, not option A, is associated with end-stage renal disease caused by diabetic nephropathy. Option C
may be elevated in end-stage renal disease. Option D may signal the onset of diabetic ketoacidosis (DKA).
12. Which change in laboratory values indicates to the nurse that a client with rheumatoid arthritis may be
experiencing an adverse effect of methotrexate therapy?
A. Increase in rheumatoid factor
B. Decrease in hemoglobin level
C. Increase in blood glucose level
D. Decrease in erythrocyte sedimentation rate (ESR; sed rate)
Rationale:
Methotrexate is an immunosuppressant. A common side effect is bone marrow depression, which would be reflected
by a decrease in the hemoglobin level. Option A indicates disease progression but is not a side effect of the
medication. Option C is not related to methotrexate. Option D indicates that inflammation associated with the
disease has diminished.
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13. Which consideration is most important when the nurse is assigning a room for a client being admitted with
progressive systemic sclerosis (scleroderma)?
A. Provide a room that can be kept warm.
B. Make sure that the room can be kept dark.
C. Keep the client close to the nursing unit.
D. Select a room that is visible from the nurses’ desk.
Rationale:
Abnormal blood flow in response to cold (Raynaud phenomenon) is precipitated in clients with scleroderma. Option
B is not a significant factor. Stress can also precipitate the severe pain of Raynaud phenomenon, so a quiet
environment is preferred to option C, which is often very noisy. Option D is not necessary.
14. The nurse is reviewing routine medications taken by a client with chronic angle-closure glaucoma. Which
medication prescription should the nurse question?
A. Antianginal with a therapeutic effect of vasodilation
B. Anticholinergic with a side effect of pupillary dilation
C. Antihistamine with a side effect of sedation
D. Corticosteroid with a side effect of hyperglycemia
Rationale:
Clients with angle-closure glaucoma should not take medications that dilate the pupil because this can precipitate
acute and severely increased intraocular pressure. Options A, C, and D do not cause increased intracranial pressure,
which is the primary concern with angle-closure glaucoma.
15. The nurse is observing an unlicensed assistive personnel (UAP) performing care for a bedridden client with
advanced Huntington disease. Which care measures are most important for the nurse to supervise? (Select all that
apply.)
A. Oral care
B. Bathing
C. Foot care
D. Catheter care
E. Enteral feeding
Rationale:
The client with Huntington disease experiences problems with motor skills such as swallowing and is at high risk for
aspiration, so the highest priority for the nurse to observe is the UAP’s ability to perform oral care and feeding
safely. Options B, C, and D do not necessarily require registered nurse (RN) supervision because they do not
ordinarily pose life-threatening consequences.
16. During the change of shift report, the charge nurse reviews the infusions being received by clients on the
oncology unit. The client receiving which infusion should be assessed first?
A. Continuous IV infusion of magnesium
B. One-time infusion of albumin
C. Continuous epidural infusion of morphine
D. Intermittent infusion of IV vancomycin
Rationale:
All four of these clients have the potential to have significant complications. The client with the morphine epidural
infusion is at highest risk for respiratory depression and should be assessed first. Option A can cause hypotension.
The client receiving option B is at lowest risk for serious complications. Although option D can cause nephrotoxicity
and phlebitis, these problems are not as immediately life threatening as option C.
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