HESI RN
HESI RN Med Surg 3 Questions
Extract:
Question 1 of 5
A client diagnosed with pancreatitis reports severe epigastric pain. After administering a narcotic analgesic, the client insists on sitting up and leaning forward. Which action should the nurse implement?
Correct Answer: A
Rationale: Clients with acute pancreatitis often experience severe epigastric pain that radiates to the back. Leaning forward helps reduce pressure on the inflamed pancreas and relieves pain by minimizing peritoneal irritation. Providing a bedside table allows the client to rest in a comfortable, supported position, improving pain management without additional interventions.
Question 2 of 5
After an endotracheal tube (ETT) is initially placed for a client requiring mechanical ventilation, which intervention should the nurse implement first?
Correct Answer: D
Rationale: The first action after ETT placement is to auscultate bilateral breath sounds to confirm proper tube positioning. If the tube is misplaced in the esophagus, breath sounds will be absent or diminished bilaterally. If placed too deep, breath sounds may be absent on one side, indicating mainstem bronchus intubation. This immediate assessment helps identify misplacement before obtaining a chest x-ray.
Question 3 of 5
The vital signs for a client with heart failure (HF), who is admitted to the intensive care unit (ICU), are a temperature of 98.6° F (37°C), heart rate 125 beats/minute, respirations 22 breaths/minute, and blood pressure 140/50 mm Hg. The nurse determines the client's central venous pressure (CVP) and pulmonary artery wedge pressure (PAWP) are elevated. Which intervention should the nurse implement?
Correct Answer: C
Rationale: Elevated CVP and PAWP indicate fluid overload. Furosemide reduces preload and promotes diuresis, improving symptoms.
Question 4 of 5
A young male adult walks into the emergency department (ED) holding a dead poisonous snake that bit him on his right calf within the last hour. After killing the snake, he tied a tablecloth about 4 inches (10 cm) above the bite. The client is now reporting numbness and tingling from the right knee to ankle. His heart rate is 123 beats/minute, respirations 28 breaths/minute, blood pressure 86/40 mm Hg, and oxygen saturation 94% on room air. Which intervention should the nurse implement?
Correct Answer: A
Rationale: Signs of shock due to envenomation require rapid IV access for fluid resuscitation and antivenom administration.
Extract:
Client is a 61-year-old male with COVID pneumonia. He was on high-flow oxygen for 3 days and was transferred to the intensive care unit (ICU) after being intubated and placed on a mechanical ventilator. Has sedation and a neuromuscular blockade infusing due to the high inspiratory pressures required to ventilate the client.
Question 5 of 5
Click to mark whether the actions are indicated, contraindicated, or nonessential for this client.
| Options | Indicated | Contraindicated | Nonessential |
|---|---|---|---|
| Increase the fraction of inspired oxygen (FiOâ‚‚). | |||
| Collect equipment for a needle aspiration. | |||
| Replace the ventilator. | |||
| Measure the nasogastric tube output. | |||
| Place the client in Trendelenburg. |
Correct Answer: A,D
Rationale: Increasing FiOâ‚‚ is indicated if oxygenation is inadequate. Measuring NG output is essential to assess for gastrointestinal issues. Other actions lack clinical justification.