HESI RN
HESI RN Med Surg Questions
Extract:
Question 1 of 5
A client who fractured the right femur from a fall at home is placed in traction while awaiting surgery. When the client informs the nurse of the need to urinate, which intervention should the nurse implement?
Correct Answer: D
Rationale: Maintaining traction while using a urinal prevents disruption of fracture alignment, ensuring stability and minimizing complications, while addressing the client's need to urinate.
Extract:
History and Physical
Nurses’ Notes
Flow sheet
Orders
Imaging Studies
A 19-year-old female client presents to the emergency department reporting tightness in her chest and difficulty breathing. The client's friend, who accompanied the client to the emergency department, reports she was at a park playing soccer with a group of college friends when the symptoms started. The park is close to a residential area where a fire was burning and there was a moderate breeze in the air. The client reported itching eyes and coughing. Approximately 15 minutes into the game, the client stopped running and held her hand on her chest, saying it felt tight. The client had difficulty catching her breath.
Home Medications
Albuterol/ipratropium every 4 hours by inhaler PRN for shortness of breath, last dose 2 days ago
Fluticasone/vilanterol 100/25 mcg inhaled daily, last dose 3 days ago
Ibuprofen 600 mg PO PRN for pain, last dose this morning for headache
Question 2 of 5
What finding(s) are cues for a respiratory problem? Select all that apply.
Correct Answer: A,B,D,E,F,G
Rationale: Sitting upright, chest tightness, tachypnea, restlessness, dyspnea, and low pulse oxygenation (85%) are direct indicators of respiratory distress, unlike medication compliance which is not a symptom.
Extract:
Question 3 of 5
Lactulose was prescribed two days ago for a client who was recently diagnosed with hepatic encephalopathy. The client is confused and experiencing frequent loose stools. Laboratory findings show an elevated serum ammonia (NH) level of 220 μg/dL (157.1 μmol/dL). Which action should the nurse take?
Correct Answer: B
Rationale: Lactulose reduces ammonia levels by promoting its excretion, and the elevated ammonia level indicates the need to continue therapy. Loose stools are an expected effect, and continuing the dose addresses the underlying hepatic encephalopathy.
Question 4 of 5
A client with metastatic cancer reports a pain level of 10 on a scale of 0 to 10. Twenty minutes after the nurse administers an IV analgesic, the client reports no pain relief. Which intervention is most important for the nurse to include in this client's plan of care?
Correct Answer: C
Rationale: Persistent pain despite IV analgesia suggests breakthrough pain, requiring monitoring to adjust the pain management regimen promptly, addressing exacerbations effectively.
Question 5 of 5
An infant born 2 days ago has not passed a meconium stool and begins to vomit bilious secretions. Which action should the nurse take first?
Correct Answer: B
Rationale: Gathering IV supplies addresses the risk of dehydration and shock from vomiting and possible bowel obstruction, which is the priority. Other actions are less urgent.