HESI RN
Samuel Merrit University Hesi Med Surg Questions
Extract:
Question 1 of 5
A client arrives at the emergency department (ED) with severe right upper quadrant pain.To assess the quality of the client's pain, which approach should the nurse use?
Correct Answer: A
Rationale:
To assess the quality of the client's pain, the nurse should ask the client to describe the pain. This will help the nurse to understand the characteristics of the pain and how it is affecting the client.
Question 2 of 5
The nurse observes an unlicensed assistive personnel (UAP) feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration.Which action by the UAP should the nurse recognize indicates the need for additional teaching?
Correct Answer: B
Rationale: Raising the head of the bed to 80 degrees is too high and can increase the risk of choking or aspiration by making it harder for the client to control the food bolus during swallowing. A more appropriate position is raising the head of the bed to 45–60 degrees, which facilitates safe swallowing while maintaining comfort.
Question 3 of 5
The nurse observes the skin over a client's greater trochanter, as seen in the picture with pressure sores.What actions should the nurse implement?
Correct Answer: B
Rationale: Pressure redistribution is an important part of preventing and treating pressure sores.
Question 4 of 5
The nurse observes that a client is using accessory muscles. Which vital sign should the nurse obtain first?
Correct Answer: B
Rationale: If a nurse observes that a client is using accessory muscles, it indicates an obstruction of the airways, which reduces oxygen saturation. Accessory muscles help in the act of forced expiration to wash out carbon dioxide and improve oxygen saturation.
Therefore, the nurse should obtain the respiratory rate first.
Question 5 of 5
After a long bed rest, a client with a Foley catheter and wrist restraints has repeatedly removed the antibiotic (G) tube and NG tube.At checking the restraints, which action is most important for the nurse to take?
Correct Answer: C
Rationale: When checking the restraints, the most important action for the nurse to take is to assess capillary refill distal to the restraints. This helps to ensure that the restraints are not too tight and that blood flow to the extremities is not compromised.