HESI RN
HESI RN Med Surg 3 Questions
Question 1 of 5
The nurse is evaluating a client's central venous pressure (CVP) also called right atrial pressure (RAP) readings that are trending upwards. Which nursing problem is supported by the pathophysiologic mechanism most likely causing the increases?
Correct Answer: A
Rationale: Increasing CVP indicates fluid overload or impaired right ventricular function, leading to decreased cardiac output.
Question 2 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.
Extract:
History and Physical
Flow Sheet
Laboratory Results
The client is a 59-year-old female with hyperosmolar hyperglycemic syndrome (HHS). She developed abdominal pain several days ago and nausea starting yesterday. This morning, she was extremely drowsy and confused at work. Her coworker brought her to the hospital.
Question 3 of 5
Based on the client's laboratory values at 1600, which are appropriate nursing actions? Select all that apply.
Correct Answer: D,E,F
Rationale: Once circulatory volume is restored, fluids should be switched to 0.45% sodium chloride to correct hypernatremia and intracellular dehydration. Glucose levels are improving but still high (250 mg/dL), requiring adjustments in fluid and insulin therapy, so the provider should be informed. Insulin therapy drives potassium into cells, leading to hypokalemia (K⺠= 3.2 mEq/L), which can cause cardiac arrhythmias and muscle weakness, necessitating potassium replacement.
Extract:
Question 4 of 5
A pH level of ________ and bicarbonate (HCO3-) level of ________ indicate a resolution of ketoacidosis.
Correct Answer: C
Rationale: A pH of 7.38 and bicarbonate of 24 mEq/L are within normal ranges, indicating resolution of ketoacidosis.
Question 5 of 5
The nurse is completing a neurological assessment on a client with a head injury. The Glasgow Coma Scale (GCS) score is 14. Which intervention should the nurse implement?
Correct Answer: D
Rationale: A GSC of 14 indicates mild head injury. Frequent monitoring every 2 hours detects worsening conditions.