HESI RN
Samuel Merrit University Hesi Med Surg Questions
Extract:
Question 1 of 5
A client is in contact isolation due to a stage IV coccyx wound infected with MRSA. The nurse plans interventions to prevent multiple infections.Which intervention is most appropriate to prevent the spread of MRSA to others?
Correct Answer: C
Rationale: Restate the vital importance of performing hand hygiene. The most effective way to prevent MRSA is frequent hand washing.
Question 2 of 5
The nurse is preparing to give an emergency sedative injection to an agitated client.Which action by the nurse is inappropriate?
Correct Answer: A
Rationale: Placing a client in restraints without having a healthcare provider's order is inappropriate for a nurse to do.
Question 3 of 5
The nurse observes that a client is using accessory muscles. Which vital sign should the nurse obtain first?
Correct Answer: B
Rationale: If a nurse observes that a client is using accessory muscles, it indicates an obstruction of the airways, which reduces oxygen saturation. Accessory muscles help in the act of forced expiration to wash out carbon dioxide and improve oxygen saturation.
Therefore, the nurse should obtain the respiratory rate first.
Question 4 of 5
Which of the following responses would be the most therapeutic when communicating with a client who has recently had a visit from their significant other and is displaying changes in behavior?
Correct Answer: D
Rationale: This response is most therapeutic because it offers the client an opportunity to talk and express their feelings while also focusing on the positive aspects of their visit.
Question 5 of 5
The nurse observes the skin over a client's greater trochanter, as seen in the picture with pressure sores.What actions should the nurse implement?
Correct Answer: B
Rationale: Pressure redistribution is an important part of preventing and treating pressure sores.