HESI RN
Medical Surgical Nursing I NSG123 TPA 12025 Summer C16 Questions
Question 1 of 5
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who develops an onset of dyspnea and tachypnea with coughing. After positioning the client upright, which action should the nurse take next?
Correct Answer: A
Rationale: The nursing process requires assessment before intervention. An acute onset of dyspnea and tachypnea signals a potential change in respiratory status that must be assessed first. Obtaining a pulse oximetry reading provides immediate, objective data on the client's oxygenation status, which is critical for determining the severity of the situation and guiding subsequent interventions. Initiating a treatment (B,
C) or coaching a technique (
D) without first assessing the client's current oxygenation status could be ineffective or harmful.
Question 2 of 5
A client with chronic obstructive pulmonary disease (COPD) is admitted to the telemetry unit with severe pneumonia. Which assessment is most important for the nurse to obtain?
Correct Answer: A
Rationale: A client with pre-existing COPD and a new, severe respiratory infection like pneumonia is at high risk for hypoxemia. Hypoxemia can directly lead to cardiac dysrhythmias, which is a primary reason for admission to a telemetry unit where the heart rhythm is continuously monitored. Identifying a dysrhythmia is urgent as it can be life-threatening. While assessing the posterior lung fields (
C) is relevant to pneumonia, the specific admission to telemetry indicates cardiac monitoring is the priority. Assessing short-term memory (
B) or peripheral pulses (
D) is less critical in this acute, potentially unstable situation.
Question 3 of 5
While a continuous infusion of benzodiazepine is being administered, the nurse initiates a prescribed enteral feeding When preparing to reposition the client, which action should the nurse take?
Correct Answer: D
Rationale: The primary safety risk during repositioning for a client receiving enteral feeding is aspiration. Lowering the head of the bed increases this risk significantly. Placing the feedings on hold during this time is a standard precaution to prevent regurgitation and aspiration of the feeding formula. Stopping a continuous medication infusion (
C) is not indicated for routine repositioning and could disrupt therapeutic levels. There is no need to leave feedings off for an extended period (
A) after repositioning if the head of the bed is returned to an elevated position. Administering pain medication (
B) is unrelated to the task of repositioning and the associated aspiration risk.
Question 4 of 5
The practical nurse (PN) reports to the charge nurse that a client who is receiving a parenteral nutrition infusion has a capillary glucose of 365 mg/dL (20.3 mmol/L). Which action should the charge nurse implement? Reference Range: Blood glucose [70 to 110 mg/dL (3.9 to 6.1 mmol/L)]
Correct Answer: D
Rationale: The client has severe hyperglycemia, which is a known and common complication of parenteral nutrition due to its high dextrose content. The most immediate and appropriate action is to determine if there is an existing prescription, such as a sliding scale for insulin, to treat this acute high blood sugar. This addresses the urgent problem directly. Stopping the essential nutrition infusion (
C) is not the first action and could be harmful. While reviewing the history (
A) and assessing for complications like osmotic diuresis (
B) are relevant, they do not address the immediate, dangerous elevation in blood glucose as directly as checking for a treatment order.
Question 5 of 5
A female client with rheumatoid arthritis (RA) comes to the clinic reporting joint pain and swelling. She has been taking prednisone and ibuprofen every day. To assist with self-management of her pain, which information should the nurse obtain?
Correct Answer: C
Rationale: The client is reporting a problem with pain and swelling.
To assist with self-management, the nurse needs to assess the client's current non-pharmacological strategies. Therapeutic exercise is a cornerstone of managing RA to maintain joint function and reduce pain. Assessing this provides a direct pathway to coaching the client on effective self-management techniques. While assessing for medication side effects like GI discomfort from ibuprofen (
A) or bruising/weakness from prednisone (
B) is important for safety, it does not directly address the client's stated problem of pain self-management. Dietary protein intake (
D) is less directly related to immediate pain control strategies.