HESI MS HESI Medical and Surgical Exam - Set 5 - Part 1

Correct Answer: Initiate bleeding precautions immediately

A platelet count below 20,000 per microliter places the client at risk for spontaneous hemorrhage. Bleeding precautions — including avoiding venipuncture when possible, using soft toothbrushes, and monitoring for petechiae — are the priority intervention to prevent life-threatening bleeding. Option a is incorrect because packed red blood cells are transfused to treat symptomatic anemia by improving oxygen-carrying capacity; they have no effect on platelet count or the risk of hemorrhage from thrombocytopenia. Option c is incorrect because increasing oral fluid intake addresses hydration status and has no therapeutic effect on thrombocytopenia; the hemorrhage risk from a platelet count of 18,000 requires bleeding precautions, not fluid management. Option d is incorrect because reverse isolation protects neutropenic clients from infection; the critical value here is the platelet count, signaling a hemorrhage risk rather than an infection risk.

Correct Answer: Seven to ten days after the start of her menstrual period

Breast tissue is least engorged and most easily palpated seven to ten days after the onset of menstruation, when estrogen levels are lowest. This timing allows detection of abnormal masses that might be obscured by cyclic swelling at other points in the cycle. Option b is incorrect because selecting a fixed calendar date does not account for the cyclical hormonal changes that affect breast tissue density; examination falls at different cycle phases each month, reducing consistency and accuracy. Option c is incorrect because the week before menstruation is when progesterone and estrogen levels peak, causing the greatest degree of breast engorgement and nodularity that can mask or mimic abnormal findings. Option d is incorrect because on the first day of menstruation the body has not yet returned to its least-congested state; hormonal effects on breast tissue persist into the early days of the cycle, affecting palpation accuracy.

Correct Answer: The markings ensure the radiation beam targets the same site each treatment

Radiation therapy requires precise beam targeting to deliver the prescribed dose to tumor tissue while sparing surrounding healthy structures. Skin markings delineate the treatment field so each fraction hits the identical site, maintaining cumulative dosing accuracy and reducing damage to adjacent tissue. Option a is incorrect because the markings are alignment guides only; preventing skin breakdown involves skin care measures such as gentle washing and avoiding direct sunlight, not the presence of markings. Option b is incorrect because the markings placed on the skin before radiation therapy are not medications and have no pharmacological function; they are geometric alignment markers that guide beam positioning, not therapeutic agents. Option c is incorrect because skin reaction is assessed through clinical observation and documentation, not through the markings themselves, which serve a targeting rather than a monitoring purpose.

Correct Answer: Notify the provider and prepare to obtain blood cultures

In a neutropenic client, even a low-grade fever represents a medical emergency because bacterial sepsis can progress rapidly without the immune system's normal response. The provider must be notified immediately and blood cultures drawn before antibiotic therapy begins to identify the causative organism. Option b is incorrect because administering acetaminophen to a neutropenic client with a fever masks the temperature elevation and delays provider notification and blood culture collection, which must precede antibiotic therapy. Option c is incorrect because contact precautions protect against transmission of specific pathogens to others; the neutropenic client needs protective (reverse) precautions to shield them from environmental organisms, not contact precautions. Option d is incorrect because restricting visitors alone does not address the immediate risk of infection already manifesting as fever, and it bypasses the essential steps of culture collection and antibiotic initiat

Correct Answer: I will drink the liquid iron through a straw and rinse my mouth afterward

Liquid iron preparations stain tooth enamel permanently. Drinking through a straw bypasses direct contact with teeth, and rinsing the mouth immediately after administration removes residual iron solution from oral surfaces, preventing irreversible discoloration. Option a is incorrect because dairy products bind iron in the gastrointestinal tract and significantly reduce absorption; iron should be taken with water or vitamin C-containing juice to enhance uptake. Option c is incorrect because iron supplements typically turn stools dark or tarry black, not pale or clay-colored; clay-colored stools indicate biliary obstruction and would warrant provider notification. Option d is incorrect because taking iron at bedtime increases the time teeth are exposed to residual solution and reduces the benefit of activity that aids absorption; the straw technique addresses staining more effectively regardless of timing.

Correct Answer: Graft-versus-host disease affecting the gut and liver

Acute graft-versus-host disease classically involves three target organs: skin, gastrointestinal tract, and liver. Diarrhea reflects GI tract involvement, and jaundice with right upper quadrant pain reflects hepatic involvement from donor T-lymphocytes attacking host tissues, a recognized complication in the first 100 days post-transplant. Option b is incorrect because CMV colitis can cause diarrhea but does not typically produce the concurrent hepatic findings; GVHD fits the triad of GI plus liver involvement seen here. Option c is incorrect because hepatic veno-occlusive disease typically presents earlier — within the first two to three weeks — and features weight gain, ascites, and hepatomegaly rather than the classic tri-organ GVHD pattern. Option d is incorrect because allogeneic bone marrow transplants are rarely rejected outright; the immune phenomenon running in the opposite direction — donor against host — is what produces GVHD.

Correct Answer: Spinal cord compression causing irreversible paralysis

A vertebral compression fracture in multiple myeloma can compress the spinal cord, and the combination of severe back pain with difficulty ambulating signals impending or evolving neurological compromise. Spinal cord compression is an oncological emergency that requires immediate intervention to prevent permanent paralysis. Option a is incorrect because hypercalcemia in multiple myeloma develops gradually from osteoclast activation over weeks and typically presents with systemic symptoms like fatigue, confusion, and polyuria rather than acute focal pain with ambulatory impairment. Option b is incorrect because Bence Jones proteinuria and renal involvement develop gradually over weeks to months and do not explain the acute presentation of severe back pain with ambulatory difficulty seen in this scenario. Option d is incorrect because while pathological fractures of long bones are a genuine risk in multiple myeloma, the immediate threat given the documented vertebral fracture and ambulat

Correct Answer: Stop the infusion immediately and disconnect the IV tubing

Burning, swelling, and blanching during vesicant infusion indicate extravasation — leakage of the agent into surrounding tissue. The absolute first action is to stop the infusion and disconnect the tubing while leaving the catheter in place to aspirate residual drug, preventing further tissue destruction that can cause severe necrosis. Option a is incorrect because slowing the rate of a vesicant that has already extravasated continues to deliver tissue-damaging drug; applying warmth before stopping the infusion worsens local spread of the vesicant. Option b is incorrect because flushing the IV line with saline when vesicant extravasation has already occurred forces more drug into the surrounding tissue, worsening the chemical burn that begins the moment the infusion is stopped. Option c is incorrect because notifying the physician and documenting are necessary steps, but they must follow the immediate action of stopping the infusion to limit ongoing tissue damage.

Correct Answer: CD4 count below 200 cells per microliter

The CDC defines AIDS in an HIV-positive individual when the CD4 T-lymphocyte count falls below 200 cells per microliter or when an AIDS-defining opportunistic illness develops. This threshold reflects severe immune suppression that makes the client highly vulnerable to infections like Pneumocystis jirovecii pneumonia. Option a is incorrect because a CD4 count below 500 indicates immune dysfunction and warrants closer monitoring, but it does not meet the diagnostic threshold for AIDS under CDC criteria. Option c is incorrect because 350 cells per microliter is a treatment initiation threshold used in some guidelines, not the AIDS-defining count; it represents moderate rather than severe immune suppression. Option d is incorrect because while a CD4 count below 100 indicates profoundly advanced disease, the AIDS-defining threshold established by the CDC is 200, not 100 cells per microliter.

Correct Answer: Reed-Sternberg cells unique to Hodgkin's lymphoma

Reed-Sternberg cells are large, multinucleated cells that are pathognomonic for Hodgkin's lymphoma. Their identification on lymph node biopsy is required to establish the diagnosis and distinguish Hodgkin's from non-Hodgkin's lymphoma, which has a different treatment approach and prognosis. Option a is incorrect because blast cells are immature hematopoietic precursors that characterize acute leukemia on bone marrow biopsy; they are not the biopsy finding used to confirm a lymphoma diagnosis such as Hodgkin's disease. Option b is incorrect because abnormal plasma cells producing excess monoclonal immunoglobulin are the pathological hallmark of multiple myeloma; this finding on biopsy identifies a plasma cell dyscrasia, not a lymphoma. Option d is incorrect because the Philadelphia chromosome, a translocation producing the BCR-ABL fusion gene, is the defining genetic abnormality of chronic myelogenous leukemia and has no association with Hodgkin's lymphoma diagn

Correct Answer: Warm or hot baths can worsen fatigue in SLE and should be avoided

Heat sensitivity is a well-recognized feature of SLE. Exposure to hot water increases vasodilation and can precipitate or worsen fatigue, and in some clients can trigger a disease flare. Clients are advised to use lukewarm water and avoid prolonged heat exposure to manage energy levels effectively. Option b is incorrect because warm or hot baths are specifically contraindicated in SLE due to heat-induced vasodilation that exacerbates fatigue; this advice would directly harm the client's symptom management. Option c is incorrect because temperature exposure has a documented clinical effect in SLE; heat is a recognized trigger for fatigue exacerbation and clients must be taught to avoid it. Option d is incorrect because the distinction drawn between baths and showers is not clinically meaningful; the harmful effect is the temperature itself, and both hot baths and hot showers should be avoided.

Correct Answer: Confusion, bradycardia, and blood pressure of 162 over 94

Confusion, bradycardia, and hypertension form the classic triad of TUR syndrome, caused by absorption of large volumes of hypotonic bladder irrigant into the systemic circulation during or after TURP. This dilutional hyponatremia is a medical emergency requiring immediate provider notification and intervention before the client is discharged. Option a is incorrect because light pink urine after three days of continuous irrigation is an expected finding indicating the bleeding has largely resolved; dark red or clot-filled drainage would be concerning. Option b is incorrect because mild perineal discomfort is expected after transurethral instrumentation and is manageable with analgesics; it does not require urgent provider contact prior to discharge. Option c is incorrect because a slightly positive fluid balance of 200 mL in a client with bladder irrigation is within an acceptable range and does not indicate dangerous fluid accumulation.

Correct Answer: Vitamin B12 deficiency causes demyelination of peripheral and spinal cord nerves

Vitamin B12 is essential for myelin synthesis in the nervous system. In pernicious anemia, the absence of intrinsic factor prevents B12 absorption, leading to progressive demyelination of peripheral nerves and posterior columns of the spinal cord, producing numbness, paresthesia, and loss of coordination that can become permanent if untreated. Option b is incorrect because folate deficiency causes megaloblastic anemia similar to B12 deficiency in terms of red cell morphology, but it does not cause the neurological demyelination that characterizes B12 deficiency. Option c is incorrect because iron deficiency produces microcytic hypochromic anemia characterized by small, pale red cells and fatigue; iron does not play a role in myelin synthesis, so neurological symptoms are not a feature of iron deficiency anemia. Option d is incorrect because pernicious anemia results from impaired production of healthy red cells rather than hemolysis; the neurological symptoms arise from B12 deficiency

Correct Answer: Liquid to semi-liquid stool because water absorption is incomplete

The ascending colon is the primary site of water reabsorption from digested material. A colostomy in the right colon bypasses most of the absorptive surface, resulting in stool that remains liquid to semi-liquid. Clients with right-sided colostomies require pouching systems that manage high-volume liquid output continuously. Option a is incorrect because firm, formed stool reflects adequate passage through the full colon to the sigmoid or descending segment; a right-sided ostomy produces output before water reabsorption is complete. Option b is incorrect because bloody mucoid discharge from a colostomy indicates active hemorrhage or mucosal inflammation requiring urgent assessment; it is a complication requiring provider notification rather than an expected post-surgical stool character. Option d is incorrect because paste-like output and irrigation schedules are associated with sigmoid colostomies, where the stool has traversed most of the colon and formed to a manageable consistency.

Correct Answer: Infection due to severe neutropenia

Aplastic anemia causes pancytopenia — loss of all three cell lines. Because neutrophils provide the primary defense against bacterial and fungal pathogens, severe neutropenia leaves clients unable to mount an adequate immune response. Overwhelming infection, particularly bacterial sepsis and fungal infections, is the most common cause of death in aplastic anemia. Option a is incorrect because while thrombocytopenia does increase bleeding risk in aplastic anemia, hemorrhagic stroke is less common than infection as a cause of death; neutropenia-driven sepsis carries higher mortality. Option c is incorrect because chronic anemia can cause cardiac strain, but the cardiovascular system typically compensates through increased cardiac output; fatal cardiac failure from anemia alone is less common than infection. Option d is incorrect because hemoglobin precipitation in renal tubules occurs in conditions involving massive hemolysis such as hemolytic anemia, not aplastic anemia, which impairs p

Correct Answer: Ototoxicity causing cochlear damage and tinnitus

Cisplatin is known to cause direct damage to the outer hair cells of the cochlea, producing sensorineural hearing loss and tinnitus. This ototoxicity is dose-dependent and can be permanent. Audiometric testing is recommended before and during cisplatin therapy, and persistent tinnitus warrants dose reduction or discontinuation. Option a is incorrect because cisplatin-induced peripheral neuropathy causes numbness and paresthesia in the hands and feet, not tinnitus; dorsal root ganglion damage produces sensory loss rather than auditory symptoms. Option b is incorrect because while cisplatin causes nephrotoxicity and electrolyte wasting including hypomagnesemia and hypokalemia, the tinnitus here reflects direct cochlear damage rather than being a secondary effect of electrolyte imbalance. Option c is incorrect because hypersensitivity reactions to cisplatin typically present with urticaria, bronchospasm, hypotension, or facial flushing rather than the gradual onset of bilateral tinnitus d

Correct Answer: Use long-handled forceps to place the implant in a lead-lined container

A dislodged radioactive implant must never be touched with bare or gloved hands, as direct contact exposes the nurse to dangerous radiation doses. Standard protocol requires using long-handled forceps to maximize distance from the source and placing the implant in a lead-lined container kept in the room for this purpose, then contacting radiation safety personnel. Option a is incorrect because even gloved hands provide no radiation shielding; placing the hands near a radioactive cesium source without distance protection results in significant radiation exposure to the nurse. Option b is incorrect because evacuating the room is not the standard protocol for a dislodged intracavitary implant; the priority is safe containment of the source using forceps and a lead container. Option d is incorrect because covering the implant with a pillow provides no radiation shielding and leaves the source uncontained; a lead-lined container is required for proper isolation of the radioactive material.

Correct Answer: Sun exposure can trigger and worsen the butterfly rash in SLE through photosensitivity

Photosensitivity is a hallmark feature of SLE. Ultraviolet radiation triggers immune activation in susceptible clients, precipitating or intensifying the malar butterfly rash and potentially inducing systemic flares. Clients must be instructed to use high-SPF sunscreen consistently and limit sun exposure, particularly during peak UV hours. Option b is incorrect because ultraviolet light is a well-documented trigger for SLE flares including the malar rash; dismissing the role of sun exposure would leave the client without critical self-management information. Option c is incorrect because sunscreen significantly reduces UV-triggered immune activation in SLE and is a standard part of the management plan; telling the client it is optional undermines disease control. Option d is incorrect because the butterfly rash in SLE is a dynamic inflammatory process that worsens with UV exposure and improves with photoprotection and disease management; it is not a fixed cosmetic feature.

Correct Answer: Contact precautions to prevent direct transmission from skin lesions

Kaposi's sarcoma lesions can be open or draining, requiring contact precautions — gown and gloves — to prevent direct contact transmission of potentially infectious material. This protects both the healthcare worker and other clients. Standard precautions alone are insufficient when draining lesions are present. Option a is incorrect because Kaposi's sarcoma is a skin malignancy associated with HHV-8, not a respiratory pathogen; droplet precautions address organisms transmitted through respiratory secretions, which is not the route of concern here. Option b is incorrect because handwashing alone does not provide the physical barrier — gown and gloves — necessary to prevent contact with potentially infectious exudate from open Kaposi's sarcoma lesions. Option d is incorrect because Kaposi's sarcoma itself is not communicable by the airborne route; it is a malignancy, not an airborne infectious disease, and airborne precautions are not indicated.

Correct Answer: Follow provider guidelines limiting prolonged close contact with pregnant women and young children

Permanent prostate brachytherapy seeds continue emitting low-level radiation for weeks to months. Although the exposure to others is minimal, providers typically recommend limiting prolonged close contact — sitting in close proximity for extended periods — with pregnant women and young children who are more sensitive to radiation effects, until the seeds' activity declines. Option a is incorrect because permanent seeds remain radioactive for a period after implantation; they decay gradually, meaning some external emission occurs during the initial weeks and specific precautions are appropriate. Option b is incorrect because strict 30-day home isolation is not required for permanent seed implants; the low-level emission allows normal home activity with targeted precautions rather than complete isolation. Option c is incorrect because while most radiation is absorbed locally, a small amount of low-level emission does occur externally; stating that no external risk exists is inaccura