HESI RN
HESI RN Med Surg 3 Questions
Extract:
Question 1 of 5
A client who is admitted to the emergency department (ED) following a motorcycle collision is having difficulty breathing. While assessing the client's chest and lungs, the nurse notes that there are no breath sounds over the left lung fields. Which action(s) should the nurse implement? Select all that apply.
Correct Answer: A,B
Rationale: High-flow oxygen improves oxygenation in suspected pneumothorax or hemothorax. Obtaining a chest tube insertion kit prepares for definitive treatment.
Question 2 of 5
A client is admitted to the neurological intensive care unit after having just sustained a C5 spinal cord injury (SCI). Which assessment finding for this client warrants immediate intervention by the nurse?
Correct Answer: A
Rationale: A C5 spinal cord injury can impair diaphragmatic function and respiratory effort, leading to respiratory failure. Shallow and labored breathing suggests that the client is experiencing respiratory compromise, which can quickly progress to hypoventilation, hypoxia, and respiratory arrest. Immediate intervention, such as assisted ventilation or intubation, may be necessary to maintain adequate oxygenation and prevent further complications.
Question 3 of 5
A client with a gunshot wound is brought to the emergency department (ED) with a bullet entry at the spinal level of C8 and T1. The client is able to move the upper arms. To further assess the client's spinal nerve function, which action should the nurse implement?
Correct Answer: C
Rationale: The C8 and T1 spinal nerves control hand and finger movements. Testing grip strength assesses nerve integrity at the injury level.
Question 4 of 5
A client is admitted to the intensive care unit (ICU) with sepsis and acute respiratory distress syndrome (ARDS). The client is orally intubated and mechanically ventilated. Which intervention is most important for the nurse to include in the client's plan of care (POC)?
Correct Answer: B
Rationale: Using antiseptic solution for oral care reduces bacterial colonization, decreasing the risk of ventilator-associated pneumonia (VAP), a critical intervention in ARDS.
Question 5 of 5
The nurse is evaluating a client's central venous pressure (CVP) also called right atrial pressure (RAP) readings that are trending upwards. Which nursing problem is supported by the pathophysiologic mechanism most likely causing the increases?
Correct Answer: A
Rationale: Increasing CVP indicates fluid overload or impaired right ventricular function, leading to decreased cardiac output.