HESI RN
HESI RN Med Surg Questions
Extract:
Question 1 of 5
A client presents with the onset of a severe headache, fever, nuchal rigidity, and a petechial rash on arms and legs. The nurse recognizes the client is exhibiting symptoms of which condition?
Correct Answer: A
Rationale: Severe headache, fever, nuchal rigidity, and petechial rash are classic symptoms of meningococcal meningitis, caused by Neisseria meningitidis, requiring urgent recognition and treatment.
Question 2 of 5
A mother brings her preteen daughter to the clinic for her first female examination. During the health assessment, the nurse should implement which technique to determine if the client has reached the age of menarche?
Correct Answer: B
Rationale: Tanner staging assesses puberty stage, indicating likelihood of menarche. Other techniques are irrelevant or unreliable.
Question 3 of 5
A client who had a biliopancreatic diversion procedure (BDP) 3 months ago is admitted with severe dehydration. Which assessment finding warrants immediate intervention by the nurse?
Correct Answer: B
Rationale: Occult positive emesis indicates vomiting, which can exacerbate dehydration through significant fluid loss, requiring immediate intervention in a post-BDP client already dehydrated.
Question 4 of 5
A client with type 2 diabetes mellitus arrives to the clinic reporting episodes of weakness and palpitations. Which finding is most important for the nurse to monitor?
Correct Answer: C
Rationale: Weakness and palpitations suggest hypoglycemia, with excessive perspiration (diaphoresis) being a classic symptom, indicating the body's response to low blood sugar, requiring immediate monitoring.
Question 5 of 5
Following a motor vehicle accident, a client with chest trauma receives a chest tube to relieve a hemothorax. Two hours following the chest tube insertion, the nurse observes the water level in the water-seal chamber is rising during inspiration and falling during expiration. Which action should the nurse implement?
Correct Answer: B
Rationale: Rising water levels during inspiration and falling during expiration, known as tidaling, indicate proper chest tube function, as it reflects pressure changes in the pleural space. Continuing to monitor the drainage system ensures ongoing assessment of drainage characteristics without disrupting the system unnecessarily.