HESI - Medical Surgical Nursing Exam Latest Update
A client asks the nurse why it is important to be weighed every day if he has
right-sided heart failure. What is the nurse's best response?
A) "The hospital requires that all inpatients be weighed daily."
B) "Weight is the best indication that you are gaining or
losing fluid." C) "You need to lose weight to decrease the
incidence of heart failure."
D) "Daily weights will help us make sure that you're eating properly." -
Correct Answer: B
Daily weights are needed to document fluid retention or fluid loss. One liter
of fluid equals 2.2 pounds.
 A client has a deep wound covered with a wet-to-damp dressing. Which
intervention does the nurse include on this client's care plan?
A) Apply a new dressing when the seal breaks and the
dressing leaks. B) Change the dressing when the current
dressing is saturated.
C) Leave the dressing intact until next week.
D) Change the dressing every 6 hours around the clock. - Correct Answer: D
Wet-to-damp dressings are changed every 4 to 6 hours to provide maximum
débridement. Synthetic dressings can be left in place for extended periods
of time but need to be changed if the seal breaks and the exudate is
leaking. Dry gauze dressings should be changed when the outer layer
becomes saturated.
 A client has a small-bore nasoenteric feeding tube. The nurse assesses the
following vital signs: temperature, 100.2° F (37.8° C); pulse, 112 beats/min;
respiratory rate, 22 breaths/min; and blood pressure, 106/62 mm Hg. Which
action by the nurse takes priority?
A) Auscultate bowel sounds and slow the feeding down.
B) Remove the tube immediately and notify the heath care
provider. C) Auscultate lung sounds and obtain oxygen
saturation.
D) Add blue dye to the feeding tube formula. - Correct Answer: C
The client may have aspirated. The nurse should further assess the client's
respiratory and oxygenation status. The client may have another reason for
the abnormal vital signs, so the nurse should not pull out the tube before
performing other assessments. Adding blue dye to the tube feeding formula
is not recommended to check for aspiration. Slowing the feeding down will
not be helpful.