HESI RN
HESI RN Med Surg 3 Questions
Extract:
Question 1 of 5
A client was successfully extubated after several days of sedation and mechanical ventilation and is currently receiving 40% oxygen via a face mask. While making rounds, the nurse finds the client confused and attempting to get out of bed. Current vital signs are an oral temperature 99.2°F (37.3° C), heart rate 112 beats/minutes, respirations 16 breaths/minute, blood pressure 100/70 mm Hg, and an oxygen saturation of 98%. Which intervention should the nurse implement?
Correct Answer: C
Rationale: Confusion increases the risk of falls. Restraints are a last resort after non-pharmacological interventions, ensuring safety.
Question 2 of 5
A postoperative client is admitted to the intensive care unit (ICU) with an inflated pressure infuser containing a solution of heparin 2 units/ml attached to an intra-arterial (IA) cannula. Which finding indicates that the heparin infusion has achieved its therapeutic use?
Correct Answer: D
Rationale: Heparinized flush solutions in IA lines prevent clot formation, ensuring patency for continuous monitoring. A patent cannula confirms therapeutic effect.
Extract:
Client is a 61-year-old male with COVID pneumonia. He was on high-flow oxygen for 3 days and was transferred to the intensive care unit (ICU) after being intubated and placed on a mechanical ventilator. Has sedation and a neuromuscular blockade infusing due to the high inspiratory pressures required to ventilate the client.
Question 3 of 5
Click to mark whether the actions are indicated, contraindicated, or nonessential for this client.
| Options | Indicated | Contraindicated | Nonessential |
|---|---|---|---|
| Increase the fraction of inspired oxygen (FiOâ‚‚). | |||
| Collect equipment for a needle aspiration. | |||
| Replace the ventilator. | |||
| Measure the nasogastric tube output. | |||
| Place the client in Trendelenburg. |
Correct Answer: A,D
Rationale: Increasing FiOâ‚‚ is indicated if oxygenation is inadequate. Measuring NG output is essential to assess for gastrointestinal issues. Other actions lack clinical justification.
Extract:
Question 4 of 5
An adult who fell 20 feet (6 meters) from a tree is admitted to the intermediate intensive care unit with a fractured femur. When the cardiac monitor alarms, the nurse finds the client has no palpable carotid pulse and no spontaneous respiration, however, the cardiac monitor displays a sinus rhythm. Which intervention should the nurse implement?
Correct Answer: B
Rationale: No pulse and respirations with a sinus rhythm indicate pulseless electrical activity (PE
A). Immediate chest compressions are essential to maintain perfusion.
Question 5 of 5
A client who is admitted to the intensive care unit (ICU) with acute decompensated heart failure is receiving a continuous infusion of milrinone via a subclavian venous catheter. Which action should the nurse take when preparing to administer the first dose of IV furosemide?
Correct Answer: D
Rationale: Milrinone and furosemide are incompatible due to pH differences, which can cause precipitation. Administering furosemide through a separate IV line ensures safe delivery.