HESI RN
HESI RN Med Surg 3 Questions
Question 1 of 5
A client is being prepared for discharge. The client's discharge plan includes resuming the lower dose of lithium and continuing to take desmopressin in oral form. The nurse teaches the client about safety measures. Click to indicate which client statements indicate teaching was effective related to management of diabetes insipidus and care.
| Options | Correct | Incorrect |
|---|---|---|
| I will monitor my urine output and pay attention to the volume and color. | ||
| I will always wear my medical alert bracelet. | ||
| I will use the same scale and wear a similar amount of clothing when I take my weekly weight. | ||
| If I gain more than 2.2 lb (1 kg), I will go to the emergency department (ED). | ||
| If I become thirstier, I may need another dose of the medication. |
Correct Answer: A,B,C
Rationale: Clients with diabetes insipidus (DI) must monitor urine output closely because polyuria and diluted urine indicate under-treatment, while sudden reduced output and darker urine may suggest fluid retention or excessive desmopressin dosing. A medical alert bracelet is essential for emergency situations since DI can lead to severe dehydration and electrolyte imbalances if left untreated. Monitoring body weight trends is crucial in DI management, as sudden weight gain may indicate fluid retention (over-treatment), while weight loss may suggest dehydration. Using a consistent method ensures accurate tracking.
Question 2 of 5
A client diagnosed with pancreatitis reports severe epigastric pain. After administering a narcotic analgesic, the client insists on sitting up and leaning forward. Which action should the nurse implement?
Correct Answer: A
Rationale: Clients with acute pancreatitis often experience severe epigastric pain that radiates to the back. Leaning forward helps reduce pressure on the inflamed pancreas and relieves pain by minimizing peritoneal irritation. Providing a bedside table allows the client to rest in a comfortable, supported position, improving pain management without additional interventions.
Question 3 of 5
After an endotracheal tube (ETT) is initially placed for a client requiring mechanical ventilation, which intervention should the nurse implement first?
Correct Answer: D
Rationale: The first action after ETT placement is to auscultate bilateral breath sounds to confirm proper tube positioning. If the tube is misplaced in the esophagus, breath sounds will be absent or diminished bilaterally. If placed too deep, breath sounds may be absent on one side, indicating mainstem bronchus intubation. This immediate assessment helps identify misplacement before obtaining a chest x-ray.
Question 4 of 5
The nurse assesses the telemetry monitor of a client who is 24 hours postoperative from having a permanent pacemaker insertion. The nurse observes that a pacemaker spike is present before each QRS complex in lead II of the electrocardiogram (ECG). Which intervention should the nurse implement?
Correct Answer: A
Rationale: A pacemaker spike before each QRS complex indicates that the pacemaker is functioning properly and triggering ventricular depolarization as intended. Since the client is 24 hours postoperative from a pacemaker insertion, this is an expected finding and should be documented accordingly.
Question 5 of 5
After intubating a client, correct placement of the endotracheal tube (ETT) is confirmed with a chest x-ray. Which intervention should the nurse implement to ensure that the ETT placement is maintained?
Correct Answer: C
Rationale: After proper ETT placement is confirmed with a chest x-ray, securing the tube with adhesive tape or a commercial ETT holder prevents displacement. Unintentional extubation or tube migration can lead to hypoxia, respiratory distress, or esophageal intubation, making proper tube fixation a priority intervention.