HESI RN
HESI RN Med Surg Exam 2 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: B
Rationale: The correct answer is B because headache, fever, nuchal rigidity, and petechial rash are classic for meningococcal meningitis.
Choice A lacks rash and rigidity.
Choice C may have rash but not rigidity.
Choice D does not include rash or rigidity.
Question 2 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.
Question 3 of 5
A nurse is caring for a client with diabetes insipidus (DI). Which data warrants the most immediate intervention by the nurse?
Correct Answer: A
Rationale: The correct answer is A because severe hypernatremia (185 mEq/L) can cause neurological damage and requires urgent correction.
Choice B is a symptom of DI but less urgent.
Choice C indicates dehydration but is secondary.
Choice D is elevated but not as critical.
Question 4 of 5
A client receives a prescription for 2 liters of lactated Ringer's IV to be infused over 12 hours. The IV administration set delivers 20 gtt/mL. How many gtt/min should the nurse regulate the infusion?
Correct Answer: A
Rationale: The correct answer is A (56 gtt/min). Calculation: 2000 mL ÷ 12 hr = 166.67 mL/hr; 166.67 mL/hr × 20 gtt/mL = 3333.4 gtt/hr; 3333.4 gtt/hr ÷ 60 min/hr = 55.56 gtt/min, rounded to 56 gtt/min. This ensures accurate IV infusion.
Question 5 of 5
Four days following an abdominal aortic aneurysm repair, the client is exhibiting edema of both lower extremities, and pedal pulses are not palpable. Which action should the nurse implement first?
Correct Answer: A
Rationale: The correct answer is A because a Doppler assesses blood flow, critical for detecting complications like thrombosis.
Choice B is secondary.
Choice C is unrelated to pulses.
Choice D addresses edema but not pulses.