HESI RN
HESI RN Med Surg 3 Questions
Extract:
Question 1 of 5
A client, who is 4 hours postoperative laparotomy, has rapidly increasing abdominal distention with elevated pulse and respiratory rates. The client's skin is cool and pale, and there is no change in the blood pressure. Which intervention should the nurse implement immediately?
Correct Answer: D
Rationale: The client's symptoms suggest early shock, likely due to postoperative internal bleeding. Immediate notification of the HCP ensures rapid assessment and intervention.
Question 2 of 5
A client, who is 4 hours postoperative laparotomy, has rapidly increasing abdominal distention with elevated pulse and respiratory rates. The client's skin is cool and pale, and there is no change in the blood pressure. Which intervention should the nurse implement immediately?
Correct Answer: D
Rationale: The client's symptoms suggest early shock, likely due to postoperative internal bleeding. Immediate notification of the HCP ensures rapid assessment and intervention.
Question 3 of 5
After 15 minutes of cardiopulmonary resuscitation (CPR) and multiple defibrillations, a client has return of spontaneous circulation (ROSC) with a heart rate of 130 beats/minute and ST elevation in leads I,II, III, aVF, aVL, V5, V6. Which serum laboratory values are most important for the nurse to monitor?
Correct Answer: D
Rationale: Troponin is the most specific and sensitive biomarker for myocardial infarction, indicated by ST elevation in multiple leads.
Question 4 of 5
Twelve hours following orthopedic surgery on the right leg, the client begins to have acute chest pain and difficulty breathing. Which action should the nurse take first?
Correct Answer: B
Rationale: Acute chest pain and difficulty breathing suggest a pulmonary embolism. Providing oxygen and increasing IV flow rate support vital functions immediately.
Question 5 of 5
A client is admitted to the intensive care unit (ICU) after a colon resection with the formation of a loop colostomy. The nurse determines the client's abdominal dressing is clean and dry. Vital signs are temperature 100° F (37.8° C) orally, heart rate 132 beats/minute, blood pressure 88/65 mm Hg, and urine output 10 mL/hour. Which intervention should the nurse implement?
Correct Answer: C
Rationale: The client has tachycardia, hypotension, and oliguria, suggesting hypovolemic shock. A fluid bolus is the first-line treatment to restore intravascular volume, improve blood pressure, and increase urine output.