HESI RN
HESI RN Medical Surgical Exam I Questions
Extract:
Question 1 of 5
A client who was recently diagnosed with Raynaud's disease is concerned about pain management. Which nursing instruction should the nurse provide?
Correct Answer: C
Rationale: Wearing gloves prevents cold-induced spasms, a primary trigger for Raynaud's pain.
Extract:
Nurse's Notes
History and Physical
Initial Assessment
Temperature: 98.9°F
Heart rate: 112 beats per minute
Respirations: 28 breaths per minute
Blood pressure: 130/86 mmHg
Oxygen saturation: 88%
Lung sounds reveal expiratory wheezes
Capillary refill time: 2 seconds
Exhibits
The nurse has completed a client history and initial assessment and is now planning on prioritizing care of the client.
Complete the following sentences by choosing from the list of corresponding options
Based on the history and assessment data, the nurse should prioritize AnxietyImpaired gas exchangeIneffective airway clearanceActivity intolerance as the priority problem for this client, as evidenced by the client's statement, "I was jogging when it started.""I used my rescue inhaler three times, but I couldn’t catch my breath.""My symptoms are worse when outdoors and when exercising.""I noticed my inhaler was expired and was worried the medication was not working."
Question 2 of 5
Based on the history and assessment data, the nurse should prioritize [dropdown] as the priority problem for this client, as evidenced by the client's statement, [dropdown].
Correct Answer: B
Rationale: Impaired gas exchange is prioritized due to low oxygen saturation and ineffective inhaler use.
Extract:
Question 3 of 5
Four days following an abdominal aortic aneurysm repair, the client is exhibiting edema of both lower extremities, and pedal pulses are not palpable. Which action should the nurse implement first?
Correct Answer: C
Rationale: Assessing pulses with a vascular doppler is critical to determine blood flow in the lower extremities, identifying potential vascular complications.
Question 4 of 5
A client with an external fixation device for a fractured left femur is troubled with left foot pain. Which intervention should the nurse implement first?
Correct Answer: C
Rationale: Assessing peripheral pulses is critical to determine if foot pain is due to compromised blood flow, a potential emergency.
Extract:
Nurse's Notes
History and Physical
Initial Assessment
Temperature: 98.9°F
Heart rate: 112 beats per minute
Respirations: 28 breaths per minute
Blood pressure: 130/86 mmHg
Oxygen saturation: 88%
Lung sounds reveal expiratory wheezes
Capillary refill time: 2 seconds
Question 5 of 5
The nurse has identified the priority problem for the client and now needs to determine proper care interventions. Based on the client's history and assessment data, which actions should the nurse anticipate? Select all that apply.
Correct Answer: A,B,E
Rationale: Administering medications (
A), providing teaching (
B), and obtaining medication history (E) address acute asthma and prevent recurrence.