Hesi RN Medical Surg

Question 1 of 5

The practical nurse (PN) is assisting in a community center clinic when four clients simultaneously arrive seeking help. In which order should the PN prioritize care to be provided based on the client needs? (Arrange the client with the highest priority first, on top, and lowest priority last, on bottom.)

A. A 12-year-old child with history of asthma who is wheezing and complaining of shortness of breath.B. A 7-year-old child who has type 1 diabetes mellitus and is experiencing extreme hunger and shakinessC. A 10-year-old child with bleeding lacerations on both knees after falling on the playgroundD. A 5-year-old child who is crying uncontrollably because of an incontinent bowel episode.

Correct Answer: A,B,C,D

Rationale: Prioritization is based on the urgency and potential life-threatening nature of the conditions. The asthma attack is the highest priority due to potential airway compromise. Hypoglycemia is next due to the risk of neurological complications. Bleeding lacerations pose a risk of infection and blood loss, and the incontinent episode is primarily psychosocial, making it the lowest priority.

Question 2 of 5

A nurse is preparing to administer digoxin orally to a client. Identify the sequence of steps the nurse should take (Move the steps into the box on the right, placing them in the order of performance. Use all the steps)

A. Remove the medication from the dispensing system.B. Compare the client's wristband to the medication administration record.C. Document administration of the medication.D. Open the medication package.E. Obtain the client's apical heart rate.

Correct Answer: E,A,B,D,C

Rationale: The sequence ensures safety and accuracy: checking the apical heart rate first prevents administration if contraindicated; removing the medication , verifying patient identity , opening the package , and documenting follow standard medication administration protocols.

Extract:

Patient Data
History and Physical
A 34-year-old male client presents to the emergency department (ED) for an acute asthma attack which began after jogging through a local park. The client is able to answer questions, pausing every few words to catch his breath. The client reports using a rescue inhaler three times, but he just couldn't catch his breath. The client reports that symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous. The client reports that it has been a couple of months since he had an asthma attack, and he came to the ED today because he noticed that his inhaler was expired and was worried the medication was not working.
The nurse reviews the client's history of the presenting illness in the electronic medical record.

Question 3 of 5

Click to highlight the two pieces of key subjective data which indicate the client is in need of health interventions.

A. The client reports using a rescue inhaler three times, but he just couldn't catch his breath.B. The client reports that symptoms seem worse when outdoors and when exercising.

Correct Answer: A,B

Rationale: The ineffective use of the rescue inhaler indicates a severe asthma attack requiring intervention, and worsening symptoms with exercise suggest environmental triggers needing management.

Extract:

History & Physical
Initial Assessment Findings
Chief Complaint: Acute asthma attack after jogging; worsened by outdoor activity and exercise.
Current Treatment: Used rescue inhaler three times, expired inhaler, worried about effectiveness.
Patient Data
Exhibits
The nurse has identified the priority problem for the client and now must determine proper care interventions.

Question 4 of 5

Based on the client's history and the assessment data, what action(s) should the nurse anticipate? Select all that apply.

A. Administer medications as ordered.B. Provide client teaching.C. Place the client in Trendelenburg positionD. Ask the client for a list of current medications.E. Notify the healthcare provider of the client's need for intubationF. Apply oxygen via nasal cannula

Correct Answer: A,B,D,F

Rationale: Administering medications and oxygen (F) address the acute asthma attack. Obtaining a medication list ensures safe treatment, and teaching prevents future exacerbations. Trendelenburg position is inappropriate, and intubation is premature without further assessment.

Extract:

History and Physical
Nurses' Notes
Orders
A 34-year-old male client presents to the emergency department (ED) for an acute asthma attack which began after jogging through a local park. The client is able to answer questions, pausing every few words to catch his breath. The client reports using a rescue inhaler three times, but he just couldn't catch his breath. The client reports that symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous. The client reports that it has been a couple of months since he had an asthma attack, and he came to the ED today because he noticed that his inhaler was expired and was worried the medication was not working.

Question 5 of 5

After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen. Which action(s) should the nurse take next? Select all that apply.

A. Administer additional nebulizer treatment as ordered.B. Take and monitor vital signs.C. Apply a nonrebreather oxygen mask.D. Increase oxygen flow.E. Raise the head of the bed.F. Provide client incentive spirometer and instruct on use.

Correct Answer: A,B,D,E

Rationale: Additional nebulizer treatment targets persistent wheezing, monitoring vital signs tracks response, increasing oxygen flow addresses low saturation, and raising the bed aids breathing. A nonrebreather is unnecessary at this stage, and incentive spirometry (F) is not indicated during an acute attack.

Hesi RN Medical Surg | Nurselytic

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HESI RN

HESI RN