HESI RN
RN Medical Surgical HESI Questions
Question 1 of 5
On the third postoperative day, a client who has had a hip replacement surgery becomes anxious and diaphoretic, and begins to experience auditory hallucinations. The client denies having any pain. The client's vital signs are pulse rate 125 beats/minute, respiratory rate 36 breaths/minute, and blood pressure 166/88 mm Hg. Which nursing intervention(s) should the nurse implement? (Select all that apply.)
Correct Answer: A,B,C
Rationale: A calm demeanor, reorientation, and lorazepam address anxiety and hallucinations effectively. Television may worsen symptoms, and restraints are a last resort.
Question 2 of 5
Following a motor vehicle accident, a client with chest trauma receives a chest tube to relieve a hemothorax. Two hours following the chest tube insertion, the nurse observes the water level in the water-seal chamber is rising during inspiration and falling during expiration. Which action should the nurse implement?
Correct Answer: C
Rationale: Water level fluctuations in the water-seal chamber are normal, indicating a functioning chest tube. The nurse should continue monitoring unless signs of complications arise.
Extract:
Flow sheets
1915
Arrival at emergency department
1920
Vital Signs:
- Temperature: 98.2° F (36.8° C)
- Heart rate: 92 beats/minute
- Respirations: 24 breaths/minute
- Blood pressure: 210/98 mmHg
- Oxygen saturation: 95% on room air
Imaging studies
1935
Head CT scan results:
- No evidence of intracranial hemorrhage
- No evidence of acute disease
Orders
- Obtain CT scan of the head.
- Insert a large bore peripheral IV.
- Start normal saline infusion at 50 mL/hour.
The nurse administered tPA and conducted neurologic assessments every 15 minutes during the infusion.
The tPA infusion finished and the nurse performed neurologic assessments every 30 minutes for the 6 hours following the administration.
The client was noted to be stable with unchanged neurologic assessments.
The nurse begins to plan care for the client's recovery and identifies interdisciplinary team members who can assist with the client's recovery.
Question 3 of 5
The nurse begins to plan care for the client's recovery and identifies interdisciplinary team members who can assist with the client's recovery. Select the interdisciplinary team members who should assist the client in recovery.
| Occupational Therapist |
| Speech Therapist |
| Case manager |
| Physical therapist |
| Chief Nursing Officer |
Correct Answer: A,B,C,D
Rationale: Occupational, speech, and physical therapists address functional and communication deficits post-stroke, while a case manager coordinates care.
Extract:
Question 4 of 5
The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding requires immediate action by the nurse?
Correct Answer: C
Rationale: A high-pitched sound (stridor) indicates airway obstruction, a life-threatening emergency requiring immediate action. Other findings are expected or less urgent post-appendectomy.
Extract:
The patient is a 68-year-old with a history of diabetes, hypertension (HTN), coronary artery disease (CAD), and recently diagnosed with end-stage renal disease (ESRD). She has been placed on hemodialysis three times a week for one month. She presents to the emergency department (ED) with fatigue, generalized weakness, muscle cramps, tingling sensation in arms and legs, and lightheadedness following 3 days of illness during which her husband reports she has complained of nausea and had a poor appetite and was not able to go for her scheduled dialysis 2 days ago.
Question 5 of 5
For each assessment finding, explain whether the actions taken were effective or ineffective.
| Options | Effective | Ineffective |
|---|---|---|
| Denies cramps, weakness, or nausea | ||
| BP 116/68 mm Hg, HR 75 bpm | ||
| Potassium level 3.6 mEq/L (3.6 mmol/L) | ||
| Verbalizes commitment to dialysis appointments | ||
| Client states that she will need to resume her Lisinopril to control blood pressure | ||
| Client is eager to add dark green vegetables and potatoes to her diet |
Correct Answer: A,B,C,D
Rationale: Denying symptoms, normalized vitals, potassium, and dialysis commitment indicate effective actions. Misunderstandings about Lisinopril and diet suggest ineffective education.