HESI RN
HESI RN Med Surg 3 Questions
Extract:
Question 1 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 2 of 5
The nurse is monitoring for signs of increased intracranial pressure (ICP) in a client who attempted suicide by jumping from a tenth floor balcony. The client is intubated and mechanically ventilated. Which intervention should the nurse implement to minimize rises in ICP?
Correct Answer: C
Rationale: Clustering too many nursing interventions together can overstimulate the client and cause spikes in ICP. Providing adequate rest periods between activities such as repositioning, suctioning, and assessments allows intracranial pressure to return to baseline levels, helping to prevent sustained increases.
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 3 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⺠= 3.2 mEq/L), which can cause cardiac arrhythmias and muscle weakness, necessitating potassium replacement.
Extract:
Question 4 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.
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.