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HESI RN Med Surg 3 Questions

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Question 1 of 5

A client is admitted to the neurological intensive care unit after having just sustained a C5 spinal cord injury (SCI). Which assessment finding for this client warrants immediate intervention by the nurse?

Correct Answer: A

Rationale: A C5 spinal cord injury can impair diaphragmatic function and respiratory effort, leading to respiratory failure. Shallow and labored breathing suggests that the client is experiencing respiratory compromise, which can quickly progress to hypoventilation, hypoxia, and respiratory arrest. Immediate intervention, such as assisted ventilation or intubation, may be necessary to maintain adequate oxygenation and prevent further complications.

Question 2 of 5

A client who was involved in a motor vehicle collision while riding a motorcycle without wearing a helmet, is brought the emergency department (ED) by emergency medical services (EMS). Which assessment should the nurse obtain first?

Correct Answer: B

Rationale: Assessing pulse and blood pressure determines hemodynamic stability, a priority in trauma resuscitation following the ABCs (Airway, Breathing, Circulation).

Question 3 of 5

A client is brought to the emergency department (ED) following a motor vehicle collision with blunt trauma to the chest. Which finding should the nurse report immediately to the healthcare provider (HCP)?

Correct Answer: A

Rationale: Muffled heart tones suggest cardiac tamponade, a life-threatening emergency requiring immediate intervention.

Question 4 of 5

After 15 minutes of cardiopulmonary resuscitation (CPR) and multiple defibrillations, a client has return of spontaneous circulation (ROSC) with a heart rate of 130 beats/minute and ST elevation in leads I,II, III, aVF, aVL, V5, V6. Which serum laboratory values are most important for the nurse to monitor?

Correct Answer: D

Rationale: Troponin is the most specific and sensitive biomarker for myocardial infarction, indicated by ST elevation in multiple leads.

Question 5 of 5

The nurse identifies the collaborative problem of potential electrolyte imbalance in a client with acute pancreatitis. Which assessment finding should the nurse associate with an electrolyte imbalance related to acute pancreatitis?

Correct Answer: D

Rationale: Hypocalcemia in acute pancreatitis causes neuromuscular excitability, leading to muscle twitching and numbness.

Similar Questions

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Based on the client's diagnosis, which results does the nurse expect in the blood gas? Select all that apply.
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)?
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.
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?

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