HESI RN
HESI RN Med Surg 3 Questions
Question 1 of 5
The nurse is caring for a client who has hemorrhaged postoperatively and is in an early stage of shock. Which cardiopulmonary symptoms are most indicative of progressive hypovolemic shock?
Correct Answer: C
Rationale: Tachycardia, lowered systolic BP, and peripheral mottling are characteristic of progressive hypovolemic shock due to reduced circulating volume.
Question 2 of 5
After 15 minutes of cardiopulmonary resuscitation (CPR) and multiple defibrillations, a client has return of spontaneous circulation (ROSC) with a heart rate of 130 beats/minute and ST elevation in leads I,II, III, aVF, aVL, V5, V6. Which serum laboratory values are most important for the nurse to monitor?
Correct Answer: D
Rationale: Troponin is the most specific and sensitive biomarker for myocardial infarction, indicated by ST elevation in multiple leads.
Question 3 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 4 of 5
The nurse is monitoring for signs of increased intracranial pressure (ICP) in a client who attempted suicide by jumping from a tenth floor balcony. The client is intubated and mechanically ventilated. Which intervention should the nurse implement to minimize rises in ICP?
Correct Answer: C
Rationale: Clustering too many nursing interventions together can overstimulate the client and cause spikes in ICP. Providing adequate rest periods between activities such as repositioning, suctioning, and assessments allows intracranial pressure to return to baseline levels, helping to prevent sustained increases.
Extract:
Client is a 61-year-old male with COVID pneumonia. He was on high-flow oxygen for 3 days and was transferred to the intensive care unit (ICU) after being intubated and placed on a mechanical ventilator. Has sedation and a neuromuscular blockade infusing due to the high inspiratory pressures required to ventilate the client.
Question 5 of 5
Click to mark whether the actions are indicated, contraindicated, or nonessential for this client.
| Options | Indicated | Contraindicated | Nonessential |
|---|---|---|---|
| Increase the fraction of inspired oxygen (FiOâ‚‚). | |||
| Collect equipment for a needle aspiration. | |||
| Replace the ventilator. | |||
| Measure the nasogastric tube output. | |||
| Place the client in Trendelenburg. |
Correct Answer: A,D
Rationale: Increasing FiOâ‚‚ is indicated if oxygenation is inadequate. Measuring NG output is essential to assess for gastrointestinal issues. Other actions lack clinical justification.