HESI RN
HESI RN Medical Surgical Exam I Questions
Extract:
Question 1 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? (Enter numerical value only. If rounding is required, round to the nearest whole number.)
Correct Answer: A
Rationale: Calculation: 2 liters = 2000 mL, 2000 mL × 20 gtt/mL = 40,000 gtt, 12 hours = 720 minutes, 40,000 ÷ 720 = 55.56, rounded to 56 gtt/min.
Question 2 of 5
The healthcare provider prescribes 100 mL of 0.9% normal saline to be infused within 15 minutes. The nurse should program the infusion pump to deliver how many mL/hr? (Enter numerical value only.)
Correct Answer: A
Rationale: Calculation: 100 mL ÷ 0.25 hours (15 minutes) = 400 mL/hr.
Question 3 of 5
The healthcare provider (HCP) prescribes diazepam 8 mg IM every 4 hours PRN for muscle spasms for a client with a fractured femur. The available vial is labeled 'Diazepam Injection, USP 10 mg/2 mL.' How many mL should the nurse administer to the client? (Enter numerical value only. If rounding is required, round to the nearest tenth.)
Correct Answer: A
Rationale: Calculation: 10 mg/2 mL = 0.2 mL/mg, 8 mg × 0.2 mL/mg = 1.6 mL.
Extract:
Vital Signs
Nurses' Notes
History and Physical
Orders
1030
• Temperature: 99.8°F
• Heart rate: 98 beats/minute
• Respirations: 20 breaths/minute
• Blood pressure: 178/89 mmHg
• Oxygen saturation: 96% on room air
Question 4 of 5
Complete the diagram by choosing from the choices below to specify which condition the client is most likely experiencing, two actions the nurse should take to address the condition, and two parameters the nurse should monitor to assess the client's progress.
| Hypoglycemia |
| Hemorrhagic stroke |
| Urinary tract infection |
| Transient ischemic stroke |
| Actions to take Choices A. Start administering 0.9% sodium chloride IV at a rate of 100 ml/hr B. Administer oxygen at 2 l/min via nasal cannula C. Request a prescription to administer the client's home medication of aspirin D. Request a prescription for a computerized tomography (CT) scan of the client's head and neck E. Perform a National Institute of Health Stroke Scale (NIHSS) assessment |
| Parameters to Monitor Choices A. Neurological status B. Respiratory rate C. Blood pressure D. Urine output E. Oxygen saturation |
Correct Answer: D
Rationale: Condition: Transient ischemic stroke (
D). Actions: Request CT scan (
D), perform NIHSS assessment (E). Parameters: Neurological status (
A), blood pressure (
C).
Rationale: Symptoms and history suggest TIA, requiring imaging and neurological monitoring.
Extract:
Nurse's Notes
History and Physical
Orders
Vital Signs
Laboratory Results
Day 2, 0730:
Tolerated the surgical procedure well and has been stable since surgery.
Day 3, 0700:
Client is postoperative below-the-knee amputation of the right leg, sitting up with the right residual limb hanging off the bed. Morphine on demand in the left hand area; there is no redness or drainage at the site, with 50 mL per hour infusing. Assessment.
Exhibits
Data is evaluated to determine possible condition and appropriate interventions. Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.
Question 5 of 5
Data is evaluated to determine possible condition and appropriate interventions. Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
| Surgical rash. |
| Contractures. |
| Postoperative infection. |
| Deep vein thrombosis (DVT). |
| Actions to take Choices A. Culture wound drainage. B. Request NPO prescription. C. Administer prescribed antibiotics. D. Elevate residual limb to reduce swelling. E. Educate on incentive spirometer use. |
| Parameters to monitor Choices A. Adherence to activity prescription. B. Temperature. C. White blood cell count. D. Residual limb redness or swelling. E. Pain intensity and characteristics. |
Correct Answer: C
Rationale: Condition: Postoperative infection (
C). Actions: Administer antibiotics (
C), culture wound drainage (
A). Parameters: Temperature (
B), white blood cell count (
C).
Rationale: Elevated WBC and temperature suggest infection, requiring antibiotics and monitoring.