HESI RN
HESI RN Medical Surgical Exam I Questions
Question 1 of 5
The nurse assesses an adult client 24 hours after a bowel exploration and formation of a sigmoid colostomy. Which assessment finding should be reported to the surgeon immediately?
Correct Answer: D
Rationale: Purple stoma mucosa indicates possible ischemia, requiring immediate reporting to prevent tissue necrosis.
Question 2 of 5
A client with oral cancer is receiving radiotherapy (RT) prior to surgery. Which intervention should the nurse teach the client to implement in managing mucositis related to RT?
Correct Answer: B
Rationale: Normal saline mouth rinses as swish and spit after meals and bedtime is an effective intervention for managing mucositis. Rinsing with saline helps to keep the mouth clean, reduce bacterial load, and soothe inflamed tissues.
Extract:
History and Physical
A 34-year-old male client presents to the emergency department (ED) for an asthma attack that began after jogging through a local park. The client is able to answer questions every few words to catch his breath. He reports using his rescue inhaler three times, but he couldn't catch his breath. He reports that his symptoms are worse when outdoors and when exercising, and episodes like this make him extremely nervous. He says that it has been a couple of months since his last asthma attack, and he came to the ED today because he noticed his inhaler was expired and was worried the medication was not working.
Question 3 of 5
The nurse reviews the client's history of the presenting illness in the electronic medical record. Highlight the pieces of key subjective data which indicate the client is in need of health interventions.
Correct Answer: A,B,C
Rationale: Key data: difficulty speaking, ineffective inhaler use, and expired inhaler indicate severe asthma requiring intervention.
Extract:
Vital Signs
Nurses Notes
History and Physical
Imaging Studies
Laboratory Results
Orders
0930
• Temperature: 100.8°F (38.2°C) orally
• Heart rate: 121 bpm
• Respirations: 28 bpm
• Blood pressure: 115/76
• Oxygen saturation: 95% on room air
Question 4 of 5
The nurse is stabilizing the client and preparing her for surgery. Which goals should the nurse prioritize in the plan of care for the client while in the emergency department (ED)? Select all that apply.
Correct Answer: A,B,C,D,G
Rationale: Infection prevention (
A), pain relief (
B), education (
C), anxiety coping (
D), and fluid management (G) are critical for appendicitis surgery preparation.
Extract:
Question 5 of 5
A client who suffered an electrical injury with the entrance site on the left hand and the exit site on the left foot is admitted to the burn unit. Which intervention is most important for the nurse to include in this client's plan of care?
Correct Answer: A
Rationale: Continuous cardiac monitoring is crucial due to the risk of arrhythmias from electrical injuries.