HESI RN
HESI RN Medical Surgical Nursing Questions
Extract:
Question 1 of 5
A client is admitted to the emergency department 5 days after an acute coronary syndrome (ACS) troubled by severe fatigue, muscle weakness, and shortness of breath. The client's electrocardiogram (ECG) Indicates sinus tachycardia and the laboratory findings indicate an elevated serum brain natriuretic peptide (BNP) level. Which action is most important for the nurse to implement?
Correct Answer: D
Rationale: Auscultating for rales assesses for pulmonary congestion, indicated by elevated BNP and symptoms, prioritizing over catheter insertion or emotional support.
Question 2 of 5
A client admitted with thyrotoxicosis is reporting a 'pounding heart in the chest.' Which assessment finding warrants immediate intervention by the nurse?
Correct Answer: D
Rationale: Dyspnea may indicate severe complications like heart failure or thyroid storm, requiring immediate intervention due to potential life-threatening respiratory distress.
Question 3 of 5
When learning to use an insulin pen, a client with diabetes dials 28 units of regular insulin instead of 24 units, the prescribed dose. Which action should the nurse take?
Correct Answer: A
Rationale: Discarding the incorrect dose ensures accurate insulin administration, preventing hypoglycemia from an overdose.
Question 4 of 5
A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which observation warrants immediate intervention by the nurse?
Correct Answer: C
Rationale: Asymmetrical chest wall expansion may indicate pneumothorax, a serious complication requiring immediate intervention.
Extract:
History and Physical
Nurses' Notes
Orders
Imaging Studies
The client is a young male who appears to be 25 to 30 years old. He was found unconscious on a sidewalk by a jogger who was passing by. The jogger called an ambulance, and the emergency medical technicians (EMTS) transported the client to the hospital. The client is arousable but unable to say what his name is or what happened to him. A STAT head computed tomography (CT) scan in the emergency department showed no abnormalities, so the client will be admitted to the medical floor for observation and further tests.
Question 5 of 5
The healthcare provider comes to the bedside following the seizure and prescribes phenytoin. The nurse administers the phenytoin as prescribed. Which possible side effect(s) of phenytoin should the nurse assess for after administration? Select all that apply.
Correct Answer: B,C,D,F
Rationale: Phenytoin may cause altered coagulation, visual disturbances, drowsiness, and ataxia, affecting safety and monitoring needs.