Question

While caring for a client with full-thickness burns covering 40% of the body, the nurse observes purulent drainage from the wounds. Before reporting this finding to the health care provider, the nurse should evaluate which laboratory value?

Answer 1

Correct Answers:

Neutrophil count.

Rationale :

🧪The presence of purulent drainage is a strong indicator of infection, and the most relevant lab to evaluate infection is the neutrophil count, which reflects the client’s ability to fight bacterial infections.

🧬A low neutrophil count (neutropenia) would suggest the client may not be able to mount an effective immune response, increasing risk for sepsis.

🦠In contrast, an elevated neutrophil count would support the suspicion of an active infection, warranting antibiotic therapy.

📈Monitoring neutrophil count allows for early recognition of systemic infection and guides prompt interventions in burn clients, who are at high risk of complications from infection.

📌Core Message

The neutrophil count is the most direct marker for evaluating infection, especially when purulent drainage is present in a burn client, as it reflects the immune system’s response and risk for systemic involvement.

Answer 2

Correct Answers:

Teach the client breathing exercises.
Perform chest physiotherapy.
Encourage use of incentive spirometer.

Rationale :

💨Breathing exercises help enhance respiratory muscle function, which is critical in ALS where muscle weakness impairs breathing.

🫁Chest physiotherapy assists in clearing secretions and preventing pulmonary infections, a common cause of morbidity in ALS clients.

📟Using an incentive spirometer helps maintain lung expansion, improving ventilation and preventing atelectasis.

🚫Interventions like bladder routines and passive ROM are helpful for other symptoms but do not directly prevent pulmonary complications in ALS.

📌Core Message

Pulmonary hygiene measures like breathing exercises, chest physiotherapy, and incentive spirometry are crucial in ALS to reduce the risk of respiratory complications, which are the leading cause of death in these clients.

Answer 3

Correct Answers:

Hematuria.

Rationale :

🩸Hematuria may signal renal involvement, such as lupus nephritis, which can progress to renal failure if not managed urgently.

🔴While joint pain and low-grade fever are common and expected findings during lupus flares, hematuria requires immediate intervention.

🚨Kidney involvement represents a serious systemic complication of SLE that can be subtle in early stages but highly damaging.

🧪Reporting this finding early ensures prompt diagnostics and intervention to preserve renal function.

📌Core Message

Hematuria indicates possible renal involvement in SLE, requiring prompt medical evaluation to prevent irreversible kidney damage.

Answer 4

Correct Answers:

Has everyone at home already had varicella?

Rationale :

👨‍👩‍👧‍👦Herpes zoster (shingles) results from reactivation of the varicella-zoster virus and is contagious to those who haven't had chickenpox.

🦠Asking about household varicella exposure helps assess the risk of transmission to unvaccinated or vulnerable individuals.

🛡️This question aids in implementing appropriate infection control precautions, especially for immunocompromised or unvaccinated contacts.

🚫The other options refer to fungal infections, unrelated symptoms, or irrelevant hygiene practices.

📌Core Message

Determining if household members have had varicella is essential to assess the risk of transmission of herpes zoster to susceptible contacts.

Answer 5

Correct Answers:

Begin a weight loss program.

Rationale :

⚖️Obesity is a major contributing factor to obstructive sleep apnea (OSA) due to excess tissue compressing the airway.

💤Weight loss improves airway patency, potentially reducing OSA severity and dependence on CPAP.

🍷Sedatives and alcohol worsen OSA by relaxing airway muscles, and sleeping flat increases airway obstruction.

✅This non-invasive lifestyle change is often effective and recommended alongside or in place of CPAP in mild to moderate cases.

📌Core Message

Weight loss is a key non-invasive intervention that reduces airway obstruction and improves sleep apnea symptoms in OSA clients.

Answer 6

Correct Answers:

Demonstrate the use of visual scanning during meals to the client and family.

Rationale :

👁️Visual scanning techniques help clients with visual neglect or perception deficits post-stroke to recognize the entire plate.

🍽️This promotes independent eating, improves nutritional intake, and prevents unintentional undernourishment.

👨‍👩‍👧‍👦Involving the family in the technique allows them to support the client effectively without taking over feeding tasks unnecessarily.

🖋️Other responses may offer comfort or support but do not address the core deficit causing reduced intake.

📌Core Message

Teaching visual scanning compensates for perception deficits, enabling stroke clients to consume more food and maintain proper nutrition.

Answer 7

Correct Answers:

Washes the radiation site with antibacterial soap and water.

Rationale :

🧴Antibacterial soaps are too harsh and can irritate the sensitive skin in a radiation treatment area.

🧼The skin becomes fragile and prone to breakdown, so mild soaps and lukewarm water are recommended instead.

🛡️Protecting the irradiated skin from further damage is essential to prevent complications like burns or infection.

☀️Clothing, gentle patting dry, and prescribed lotions are correct practices that help maintain skin integrity.

📌Core Message

Using antibacterial soap is contraindicated for radiation sites due to its irritating effect on already compromised skin.

Answer 8

Correct Answers:

Insert a nasogastric tube (NGT) and attach to low intermittent suction.

Rationale :

🚑In acute exacerbation of peptic ulcer disease, vomiting and epigastric pain suggest possible gastric distention or bleeding.

🧪Inserting an NG tube helps decompress the stomach, remove blood, and reduce the risk of aspiration or further gastric injury.

🩸This intervention stabilizes the client and improves symptoms before additional diagnostics like x-ray or administering analgesics.

⛔Pain meds or x-ray are secondary priorities after addressing potential GI bleeding or obstruction.

📌Core Message

Gastric decompression via NG tube is the first-line intervention for clients with acute peptic ulcer exacerbation and vomiting.

Answer 9

Correct Answers:

Restrict physical activities.

Rationale :

🛑After TUNA (transurethral needle ablation), rest is vital to avoid bleeding or trauma to the healing prostate.

⚠️Strenuous activity can exacerbate hematuria or delay healing, making activity restriction a key part of discharge education.

💧While monitoring urinary output is important, temporary hematuria is expected, and only bright red or heavy bleeding is alarming.

📋Activity restrictions usually include avoiding heavy lifting, straining, or vigorous movement for a prescribed period.

📌Core Message

Clients recovering from TUNA should restrict physical activity to reduce the risk of bleeding and promote healing.

Answer 10

Correct Answers:

Cleanse the tongue and mouth with swabs.

Rationale :

🧼Mucositis causes painful inflammation and ulceration in the mouth, requiring gentle cleansing to reduce microbial load and discomfort.

👅Using soft swabs minimizes trauma while removing debris from the oral mucosa and tongue surface.

🧪This promotes healing and reduces the risk of secondary infections, which can complicate chemotherapy-induced mucositis.

🛡️Initial management prioritizes non-pharmacologic comfort measures before introducing other interventions like analgesics or dietary changes.

📌Core Message

Initial care for chemotherapy-induced mucositis should focus on gentle cleansing with swabs to prevent trauma, reduce microbial load, and relieve discomfort.

HESI RN Med- Surg 2025 Exam-2

No.

1 :
While caring for a client with full-thickness burns covering 40% of the body, the nurse observes purulent drainage from the wounds. Before reporting this finding to the health care provider, the nurse should evaluate which laboratory value?

2 :
To reduce the risk for pulmonary complications for a client with Amyotrophic Lateral Sclerosis (ALS), which interventions should the nurse implement? (Select all that apply)

3 :
A client is admitted to the medical unit during an exacerbation of systemic lupus erythematosus (SLE). It is most important to report which assessment finding to the health care provider?

4 :
The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition?

5 :
A client with obstructive sleep apnea (OSA) calls the clinic to report difficulty wearing the continuous positive air pressure (CPAP) mask because it is uncomfortable. The client asks the nurse for an alternative way to manage sleep apnea. Which recommendation should the nurse provide?

6 :
An older client who experienced a cerebrovascular accident (CVA) has difficulty with visual perception and eats only half of the food on the meal tray. The client's family expresses concern about the client's nutritional status. How should the nurse respond to the family's concern?

7 :
The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action about skin care indicates a need for further teaching?

8 :
A client admitted to the emergency department with an acute exacerbation of peptic ulcer disease is vomiting and describing epigastric pain and nausea. After obtaining vital sign measurements, which prescription should the nurse implement first?

9 :
A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?

10 :
The nurse is caring for a client with chemotherapy-induced mucositis who is describing soreness of the tongue and oral issues. Which is the best initial nursing action?

HESI RN Med- Surg 2025 Exam-2

No.

1 : While caring for a client with full-thickness burns covering 40% of the body, the nurse observes purulent drainage from the wounds. Before reporting this finding to the health care provider, the nurse should evaluate which laboratory value?

2 : To reduce the risk for pulmonary complications for a client with Amyotrophic Lateral Sclerosis (ALS), which interventions should the nurse implement? (Select all that apply)

3 : A client is admitted to the medical unit during an exacerbation of systemic lupus erythematosus (SLE). It is most important to report which assessment finding to the health care provider?

4 : The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition?

5 : A client with obstructive sleep apnea (OSA) calls the clinic to report difficulty wearing the continuous positive air pressure (CPAP) mask because it is uncomfortable. The client asks the nurse for an alternative way to manage sleep apnea. Which recommendation should the nurse provide?

6 : An older client who experienced a cerebrovascular accident (CVA) has difficulty with visual perception and eats only half of the food on the meal tray. The client's family expresses concern about the client's nutritional status. How should the nurse respond to the family's concern?

7 : The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action about skin care indicates a need for further teaching?

8 : A client admitted to the emergency department with an acute exacerbation of peptic ulcer disease is vomiting and describing epigastric pain and nausea. After obtaining vital sign measurements, which prescription should the nurse implement first?

9 : A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?

10 : The nurse is caring for a client with chemotherapy-induced mucositis who is describing soreness of the tongue and oral issues. Which is the best initial nursing action?

1 :
While caring for a client with full-thickness burns covering 40% of the body, the nurse observes purulent drainage from the wounds. Before reporting this finding to the health care provider, the nurse should evaluate which laboratory value?

2 :
To reduce the risk for pulmonary complications for a client with Amyotrophic Lateral Sclerosis (ALS), which interventions should the nurse implement? (Select all that apply)

3 :
A client is admitted to the medical unit during an exacerbation of systemic lupus erythematosus (SLE). It is most important to report which assessment finding to the health care provider?

4 :
The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition?

5 :
A client with obstructive sleep apnea (OSA) calls the clinic to report difficulty wearing the continuous positive air pressure (CPAP) mask because it is uncomfortable. The client asks the nurse for an alternative way to manage sleep apnea. Which recommendation should the nurse provide?

6 :
An older client who experienced a cerebrovascular accident (CVA) has difficulty with visual perception and eats only half of the food on the meal tray. The client's family expresses concern about the client's nutritional status. How should the nurse respond to the family's concern?

7 :
The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action about skin care indicates a need for further teaching?

8 :
A client admitted to the emergency department with an acute exacerbation of peptic ulcer disease is vomiting and describing epigastric pain and nausea. After obtaining vital sign measurements, which prescription should the nurse implement first?

9 :
A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?

10 :
The nurse is caring for a client with chemotherapy-induced mucositis who is describing soreness of the tongue and oral issues. Which is the best initial nursing action?