HESI RN
HESI RN Med Surg 3 Questions
Extract:
Question 1 of 5
A client is admitted to the critical care unit (CCU) with a third degree complete heart block. A temporary transvenous pacemaker is inserted by the healthcare provider (HCP). An hour after pacemaker insertion, the device stops sensing the client's intrinsic heart rate. Which action should the nurse implement first?
Correct Answer: B
Rationale: Loss of sensing means the pacemaker is not detecting intrinsic heart activity. Adjusting the sensitivity setting ensures proper recognition and pacing.
Question 2 of 5
A client is admitted to the intensive care unit (ICU) after a colon resection with the formation of a loop colostomy. The nurse determines the client's abdominal dressing is clean and dry. Vital signs are temperature 100° F (37.8° C) orally, heart rate 132 beats/minute, blood pressure 88/65 mm Hg, and urine output 10 mL/hour. Which intervention should the nurse implement?
Correct Answer: C
Rationale: The client has tachycardia, hypotension, and oliguria, suggesting hypovolemic shock. A fluid bolus is the first-line treatment to restore intravascular volume, improve blood pressure, and increase urine output.
Question 3 of 5
A client is admitted to the critical care unit (CCU) with a third degree complete heart block. A temporary transvenous pacemaker is inserted by the healthcare provider (HCP). An hour after pacemaker insertion, the device stops sensing the client's intrinsic heart rate. Which action should the nurse implement first?
Correct Answer: B
Rationale: Loss of sensing means the pacemaker is not detecting intrinsic heart activity. Adjusting the sensitivity setting ensures proper recognition and pacing.
Question 4 of 5
A pH level of ________ and bicarbonate (HCO3-) level of ________ indicate a resolution of ketoacidosis.
Correct Answer: C
Rationale: A pH of 7.38 and bicarbonate of 24 mEq/L are within normal ranges, indicating resolution of ketoacidosis.
Question 5 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.