HESI RN
Hesi RN Medical Surg Questions
Extract:
Question 1 of 5
A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing care plan?
Correct Answer: D
Rationale: Assessing pin sites for infection is critical in skeletal traction to prevent complications like osteomyelitis, which could delay healing.
Extract:
History & Physical
Initial Assessment Findings
Chief Complaint: Acute asthma attack after jogging; worsened by outdoor activity and exercise.
Current Treatment: Used rescue inhaler three times, expired inhaler, worried about effectiveness.
Patient Data
Exhibits
The nurse has identified the priority problem for the client and now must determine proper care interventions.
Question 2 of 5
Based on the client's history and the assessment data, what action(s) should the nurse anticipate? Select all that apply.
Correct Answer: A,B,D,F
Rationale: Administering medications and oxygen (F) address the acute asthma attack. Obtaining a medication list ensures safe treatment, and teaching prevents future exacerbations. Trendelenburg position is inappropriate, and intubation is premature without further assessment.
Extract:
Question 3 of 5
The nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendation should the nurse encourage the client to follow?
Correct Answer: B
Rationale: Restricting protein reduces kidney workload and proteinuria, preserving function in glomerulonephritis.
Extract:
Orders
Laboratory Results
Day 1, 1000
Serum uric acid, blood urea nitrogen (BUN), creatinine (Cr)
X-ray of right foot
Day 1, 1015
Acetaminophen 650 mg PO now
Question 4 of 5
Based on the client's laboratory findings, the nurse recognizes that the client is having an acute gout attack and is most at risk for SwellingBruisingInfectionInflammationRash and DiscolorationErythemaCyanosisPallorEcchymosis in his affected joint.
Correct Answer: A,B
Rationale: Inflammation and discoloration are hallmark symptoms of gout due to urate crystal-induced immune response and increased blood flow.
Extract:
History and Physical Nurses' Notes
A 34-year-old male client presents to the emergency department (ED) for an acute asthma attack which began after jogging through a local park. The client is able to answer questions, pausing every few words to catch his breath. The client reports using a rescue inhaler three times, but he just couldn't catch his breath. The client reports that symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous. The client reports that it has been a couple of months since he had an asthma attack, and he came to the ED today because he noticed that his inhaler was expired and was worried the medication was not working.
Question 5 of 5
Based on the client's history and assessment data, the nurse's hypothesis is that the client's vital signs are most likely the result of disease process, medication use, or neither. Each column must have at least one, but may have more than one answer selected.
| Options | Neither disease process nor medication use | Disease process | Medication use |
|---|---|---|---|
| Blood pressure 130/86 mmHg | |||
| Respirations 28 breaths/minute | |||
| Temperature 98.9" F (37.1°C) | |||
| Heart rate 112 beats/minute | |||
| Oxygen saturation 88% on room air |
Correct Answer: A,B
Rationale: Tachypnea results from bronchospasm in asthma, impairing ventilation. Elevated heart rate is a side effect of beta-agonist inhalers used during the attack.