HESI RN
HESI RN Med Surg 3 Questions
Extract:
Question 1 of 5
A client has been treated for uncontrolled atrial fibrillation with cardioversion. Following the cardioversion, which assessment finding indicates to the nurse that the desired outcome was achieved?
Correct Answer: A
Rationale: The goal of cardioversion for atrial fibrillation (AFib) is to restore a normal sinus rhythm (NSR). NSR indicates that the atria and ventricles are depolarizing in a coordinated manner, reducing the risk of thromboembolism, stroke, and hemodynamic instability. A heart rate of 84 beats/minute is within the normal range, confirming the success of the procedure.
Question 2 of 5
A client is admitted to the intensive care unit (ICU) with sepsis and acute respiratory distress syndrome (ARDS). The client is orally intubated and mechanically ventilated. Which intervention is most important for the nurse to include in the client's plan of care (POC)?
Correct Answer: B
Rationale: Using antiseptic solution for oral care reduces bacterial colonization, decreasing the risk of ventilator-associated pneumonia (VAP), a critical intervention in ARDS.
Extract:
The client is a 29-year-old female with a history of type 1 diabetes mellitus from the age of 6. She controls her blood glucose with an insulin pump and uses a continuous glucose monitor. The client was out of town, and her insulin pump was damaged. She had forgotten her backup long-acting insulin at home, so she took the 6-hour drive home. By the time she arrived at home, she was having nausea and vomiting. Her blood glucose meter read over 500 mg/dL (27.8 mmol/L). She took a dose of insulin glargine and took herself to the emergency department (ED).
The nurse draws the arterial blood gas and waits for results
Question 3 of 5
Based on the client's diagnosis, which results does the nurse expect in the blood gas? Select all that apply.
Correct Answer: C,D
Rationale: Diabetic ketoacidosis (DK
A) causes metabolic acidosis due to ketone accumulation, leading to a pH below 7.35. Bicarbonate is depleted while neutralizing excess acids, resulting in levels below 18 mEq/L.
Extract:
Question 4 of 5
A client admitted to the intensive care unit (ICU) with acute respiratory distress syndrome (ARDS) is intubated and placed on assist-control mechanical ventilation. When suctioning pulmonary secretions from the endotracheal tube (ETT) using a closed suction system, which action should the nurse implement to ensure that the client receives adequate oxygenation?
Correct Answer: B
Rationale: Pre-oxygenating by delivering additional breaths via the ventilator prevents hypoxia during suctioning, ensuring adequate oxygenation.
Question 5 of 5
A client is admitted to the intensive care unit with multisystem organ dysfunction syndrome (MODS). The client is restless, febrile, and nauseated. Insulin is infusing at 5 units/hour per protocol to keep blood glucose less than 150 mg/dL (8.3 mmol/L). Dopamine is infusing at 5 mcg/kg/minute per protocol to keep mean arterial pressure (MAP) greater than 65 mm Hg. Serum blood glucose is 160 mg/dL and MAP is 66 mm Hg. The client is receiving oxygen at 50% via face mask and has an oxygen saturation of 92%. Which intervention should the nurse implement?
Correct Answer: B
Rationale: Blood glucose of 160 mg/dL requires increasing insulin by 1 unit/hour per protocol to maintain levels below 150 mg/dL.