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HESI 101MED-SURGE HESI RN.100%CORRECT ANSWERS WITH RATIONALES GRADED A-PLUS
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HESI 101MED-SURGE HESI RN.100%CORRECT ANSWERS WITH RATIONALES GRADED A-PLUS
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HESI 101 MED-SURGE HESI RN.MED-SURGE HESI RN
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.
,HESI 101 MED-SURGE HESI RN.
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
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
,HESI 101 MED-SURGE HESI RN.
as a result of a sudden increase in intraabdominal 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.
, HESI 101 MED-SURGE HESI RN.
8. The nurse includes frequent oral care in the plan of care for a client scheduled
for an esophagogastrostomy for esophageal cancer. This intervention is included
in the client's plan of care to address which nursing diagnosis?
A. Fluid volume deficit
B. Self-care deficit
C. Risk for infection
D. Impaired nutrition
Rationale:
The primary reason for performing frequent mouth care preoperatively is to reduce
the risk of postoperative infection because these clients may be regurgitating
retained food particles, blood, or pus from the tumor. Meticulous oral care should
be provided several times a day before surgery. Although oral care will be of
benefit to the client who may also be experiencing option A, B, or D, these
problems are not the primary reason for the provision of frequent oral care.
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.
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