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HESI RN Med Surg 3 Questions

Extract:


Question 1 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:

History and Physical
Flow Sheet
Laboratory Results
The client is a 59-year-old female with hyperosmolar hyperglycemic syndrome (HHS). She developed abdominal pain several days ago and nausea starting yesterday. This morning, she was extremely drowsy and confused at work. Her coworker brought her to the hospital.


Question 2 of 5

Based on the client's laboratory values at 1600, which are appropriate nursing actions? Select all that apply.

Correct Answer: D,E,F

Rationale: Once circulatory volume is restored, fluids should be switched to 0.45% sodium chloride to correct hypernatremia and intracellular dehydration. Glucose levels are improving but still high (250 mg/dL), requiring adjustments in fluid and insulin therapy, so the provider should be informed. Insulin therapy drives potassium into cells, leading to hypokalemia (K⁺ = 3.2 mEq/L), which can cause cardiac arrhythmias and muscle weakness, necessitating potassium replacement.

Extract:


Question 3 of 5

The nurse is caring for a client with massive gastrointestinal bleeding from a gastric ulcer who received 6 units packed red blood cells (PRBCs) and 2 units fresh frozen plasma (FFP). The most recent laboratory results are a hemoglobin of 8.0 g/dL (4.96 mmol/L), platelets of 82,000/gi bleeding, requiring urgent volume replacement to restore perfusion.

Correct Answer: A

Rationale: Administer a PRN bolus normal saline. The client is exhibiting signs of hypovolemic shock, including tachycardia (HR 110 bpm), tachypnea (RR 24), and hypotension (BP 80/50 mmHg) following massive gastrointestinal bleeding and multiple blood transfusions. Immediate fluid resuscitation with a normal saline bolus is the priority to restore intravascular volume, maintain perfusion, and prevent further deterioration.

Question 4 of 5

After intubating a client, correct placement of the endotracheal tube (ETT) is confirmed with a chest x-ray. Which intervention should the nurse implement to ensure that the ETT placement is maintained?

Correct Answer: C

Rationale: After proper ETT placement is confirmed with a chest x-ray, securing the tube with adhesive tape or a commercial ETT holder prevents displacement. Unintentional extubation or tube migration can lead to hypoxia, respiratory distress, or esophageal intubation, making proper tube fixation a priority intervention.

Question 5 of 5

The nurse is evaluating a client's central venous pressure (CVP) also called right atrial pressure (RAP) readings that are trending upwards. Which nursing problem is supported by the pathophysiologic mechanism most likely causing the increases?

Correct Answer: A

Rationale: Increasing CVP indicates fluid overload or impaired right ventricular function, leading to decreased cardiac output.

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The client is a 43-year-old male who had a surgical removal of a benign tumor from the left hemisphere of his brain. The client's estimated blood loss (EBL) is 100 mL during surgical procedure. There were no complications. Vital signs remained stable throughout the procedure. The client will be admitted to the neurological intensive care unit for monitoring. Complete the diagram by specifying which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

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