HESI RN
HESI RN Med Surg Questions
Extract:
Question 1 of 5
A client who had a biliopancreatic diversion procedure (BDP) 3 months ago is admitted with severe dehydration. Which assessment finding warrants immediate intervention by the nurse?
Correct Answer: B
Rationale: Occult positive emesis indicates vomiting, which can exacerbate dehydration through significant fluid loss, requiring immediate intervention in a post-BDP client already dehydrated.
Question 2 of 5
The nurse is caring for an infant admitted with dehydration, irritability, signs of extreme hunger, and a palpable olive-like mass in the upper right abdominal quadrant. When feeding the infant, the nurse should monitor for which development?
Correct Answer: C
Rationale: Projectile vomiting is a hallmark of pyloric stenosis, indicated by the olive-like mass. Other symptoms are less specific or unrelated.
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 3 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 4 of 5
A child diagnosed with Kawasaki disease is brought to the clinic. The mother reports that her child is irritable, refuses to eat, and has skin peeling on both hands and feet. Which intervention should the nurse instruct the mother to implement first?
Correct Answer: C
Rationale: Placing the child in a quiet environment addresses the irritability and sensitivity to light and sound caused by Kawasaki disease, reducing stress and discomfort. Other interventions, while important, are not the priority.
Question 5 of 5
While assisting a client to the toilet, the client begins to have a seizure and the nurse eases the client to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first?
Correct Answer: A
Rationale: Prolonged apnea during a seizure can lead to hypoxia or cardiac arrest, making it the priority to monitor to ensure respiratory status and client safety post-seizure.