HESI RN
HESI RN Medical Surgical Questions
Extract:
History and Physical
Nurses' Notes
Laboratory Results
The client is a 38-year-old male with a history of type 1 diabetes mellitus. The client was diagnosed at the age of 8. The client reports that he has stopped testing his blood glucose regularly since losing his insurance 4 years ago and has been in the hospital 2 times for diabetic ketoacidosis
Question 1 of 5
A client reports to the clinic nurse of recently experiencing symptoms of frequent urination, hunger, and great thirst. What finding(s) would the nurse consider as most significant to report to the healthcare provider? Select all that apply.
Correct Answer: B,E
Rationale: Hemoglobin A1C of 7% and random plasma glucose of 200 mg/dL indicate poor glycemic control, suggestive of diabetes, requiring immediate reporting.
Extract:
Initial Assessment
Orders
A 34-year-old male client presents to the emergency department (ED) for an acute asthma attack which began after jogging through a local park. The client is able to answer questions, pausing every few words to catch his breath. The client reports using a rescue Inhaler three times, but he just couldn't catch his breath. The client reports that symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous. The client reports that it has been a couple of months since he had an asthma attack, and he came to the ED today because he noticed that his inhaler was expired and was worried the medication was not working.
Question 2 of 5
The nurse has identified the priority problem for the client and now must determine proper care interventions. Based on the client history and the assessment data, what action(s) should the nurse anticipate? Select all that apply.
Correct Answer: A,B,C,F
Rationale: Client education, oxygen therapy, obtaining medication history, and administering ordered medications address the client's asthma exacerbation and promote effective management.
Extract:
Question 3 of 5
The nurse is caring for a client that is unconscious and having seizures. Which nursing intervention is most essential in this client's plan of care?
Correct Answer: A
Rationale: Ensuring oral suction is available is the most essential intervention to maintain a clear airway and prevent aspiration during and after seizures, particularly in an unconscious client.
Question 4 of 5
The nurse is caring for a client in the post anesthesia care unit (PACU) who underwent a thoracotomy two hours ago. The nurse observes vital signs of a heart rate of 140 beats/minute, a respiratory rate of 26 breaths/minute, and a blood pressure of 140/90 mm Hg. Which intervention is most important for the nurse to implement?
Correct Answer: B
Rationale: Medicating for pain and monitoring vital signs is the most important intervention, as the elevated vital signs are likely due to inadequate pain control following a thoracotomy, which can lead to increased sympathetic activity.
Question 5 of 5
The nurse reviews discharge instructions with a client who has gastroesophageal reflux disease (GERD). Which instruction is most important for the nurse to emphasize?
Correct Answer: D
Rationale: Remaining upright following meals is essential to prevent gastric reflux by reducing pressure on the lower esophageal sphincter, minimizing reflux episodes.