HESI RN
HESI RN Med Surg Exam 3 Questions
Extract:
Question 1 of 5
A client who is receiving normal saline IV at 75 mL/hour has dry, sticky mucous membranes, and inelastic skin turgor. Which action should the nurse implement?
Correct Answer: Continuing the IV and encouraging oral fluid intake addresses dehydration indicated by dry mucous membranes and inelastic skin turgor.
Rationale:
Question 2 of 5
A client with a bowel obstruction is experiencing intractable vomiting for the last several hours despite the administration of prescribed antiemetics. The nurse obtains the client's arterial blood gas (ABG) results which identify a pH of 7.50, a PaCO2 of 42 mm Hg, and an HCO3 of 33 me/L (33 mmol/L). The nurse should interpret these results as confirming which acid-base imbalance?
Correct Answer: Metabolic alkalosis is characterized by a high pH and elevated HCO3, resulting from loss of stomach acid due to vomiting.
Rationale:
Question 3 of 5
A client with heart failure (HF) is waiting in the preoperative area for a scheduled procedure and tells the nurse, 'My heart feels like it is beating too fast and I feel faint.' After initiating a call for an electrocardiogram (ECG), which assessment data is most important for the nurse to obtain?
Correct Answer: The rhythm of the apical pulse is critical to identify possible arrhythmias causing palpitations and faintness.
Rationale:
Question 4 of 5
During the evening shift, a client with Alzheimer's disease becomes agitated, restless, and repeatedly attempts to leave the room unattended. Which intervention should the nurse implement?
Correct Answer: Taking a walk with the client helps reduce agitation and restlessness through physical activity and supervision.
Rationale:
Question 5 of 5
A client with hyperthyroidism tells the home health nurse, 'I stopped taking my antithyroid medication and now I feel anxious. I can feel my heart racing and pounding.' Which assessment is most important for the nurse to obtain?
Correct Answer: Obtaining vital signs is critical to evaluate for thyrotoxic crisis, indicated by anxiety and heart racing.
Rationale: