HESI RN
HESI RN Medical Surgical Questions
Question 1 of 5
A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing care plan?
Correct Answer: A
Rationale: Assessing pin sites for signs of infection is essential to detect early signs of complications in skeletal traction.
Extract:
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.
Question 2 of 5
Click to highlight the two pieces of key subjective data which indicate the client is in need of health interventions.
Correct Answer: A,B
Rationale: The client's report of using a rescue inhaler multiple times without relief and the exacerbation of symptoms when outdoors and during exercise suggest that the client's asthma is not well-controlled, warranting immediate medical attention.
Extract:
Question 3 of 5
The nurse is caring for a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?
Correct Answer: A
Rationale: Eating patterns and dietary intake are crucial in managing chronic pancreatitis as certain foods can exacerbate symptoms. Identifying dietary triggers and making appropriate dietary modifications can help alleviate abdominal pain.
Question 4 of 5
The nurse is caring for a client in the post anesthesia care unit (PACU) who underwent a thoracotomy two hours ago. The nurse observes vital signs of a heart rate of 140 beats/minute, a respiratory rate of 26 breaths/minute, and a blood pressure of 140/90 mm Hg. Which intervention is most important for the nurse to implement?
Correct Answer: B
Rationale: Medicating for pain and monitoring vital signs is the most important intervention, as the elevated vital signs are likely due to inadequate pain control following a thoracotomy, which can lead to increased sympathetic activity.
Question 5 of 5
The nurse is caring for a client who reports a sudden, severe headache, and facial numbness. The nurse asks the client to smile and observes an uneven smile with facial droop to the right side and a hand grasp strength that is weaker on the right than the left. The client denies a recent history of headaches or trauma. Which intervention should the nurse perform in the immediate management of the client?
Correct Answer: A
Rationale: Starting two large bore IV catheters and reviewing criteria for IV fibrinolytic therapy is essential for managing a suspected stroke, enabling time-sensitive interventions.