HESI RN
HESI RN Med Surg Exam 2 Questions
Extract:
Question 1 of 5
A client is recovering from the surgical removal of glass in the right eye. Which intervention should the nurse implement immediately following the procedure?
Correct Answer: C
Rationale: The correct answer is C because an eye shield protects the surgical site from trauma and infection, which is critical immediately post-procedure.
Choice A is unrelated to eye surgery.
Choice B is routine but not immediate.
Choice D is important for ongoing care but not the priority.
Question 2 of 5
The nurse observes an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which is the best initial nursing action?
Correct Answer: B
Rationale: The correct answer is B because increasing irrigation flow helps clear blood clots and maintain catheter patency.
Choice A is routine but not immediate.
Choice C supports hydration but is secondary.
Choice D addresses spasms, not clots.
Question 3 of 5
A client with diabetes mellitus is admitted with an upper respiratory infection. Which changes in blood glucose management should the nurse tell the client to expect?
Correct Answer: C
Rationale: The correct answer is C, as infections can elevate blood glucose, necessitating higher insulin doses.
Choice A is incorrect because frequent monitoring is needed.
Choice B supports hydration but not glucose management directly.
Choice D is incorrect as nutrition is essential during recovery.
Question 4 of 5
The nurse determines that an adult client who is admitted to the postanesthesia care unit (PACU) following abdominal surgery has a tympanic temperature of 94.6°F (34.8°C), a heart rate of 88 beats/minute, a respiratory rate of 14 breaths/minute, and a blood pressure of 94/68 mm Hg. Which action should the nurse implement?
Correct Answer: B
Rationale: The correct answer is B because a low tympanic temperature may result from improper measurement, requiring verification with another method.
Choice A is unrelated to temperature.
Choice C is not the priority.
Choice D is routine but not immediate.
Question 5 of 5
A client reports to the nurse of recently visiting someone who has a shingles infection. The client believes that having had chickenpox as a child will be protective against shingles. How should the nurse respond? Select all that apply.
Correct Answer: B,E
Rationale: The correct answers are B and E because shingles (herpes zoster) is caused by the reactivation of the varicella-zoster virus, which also causes chickenpox (herpes varicella). Affirming the connection between chickenpox and shingles (
B) clarifies the client's understanding of the virus's role. Distinguishing between herpes varicella and herpes zoster (E) educates the client that having had chickenpox does not prevent shingles, as the virus remains dormant and can reactivate.
Choice A is irrelevant to the client's concern about their own risk.
Choice C addresses symptom monitoring but not the client's question.
Choice D is incorrect because the risk of shingles increases with age.