HESI RN
HESI RN Med Surg Exam 3 Questions
Extract:
Question 1 of 5
A client with a history of emphysema and heart failure is admitted to the emergency department with enema, coughing, and shortness of breath. The client's laboratory value for brain natriuretic peptide is elevated. Which prescription is most important for the nurse to implement?
Correct Answer: Administering IV furosemide is crucial for managing fluid overload, as indicated by enema and elevated BNP levels.
Rationale:
Question 2 of 5
A client who had a biliopancreatic diversion procedure (BDP) 3 months ago is admitted with severe dehydration. Which assessment finding warrants immediate intervention by the nurse?
Correct Answer: Occult positive emesis indicates potential gastrointestinal bleeding, requiring immediate intervention.
Rationale:
Question 3 of 5
A client with type 1 diabetes mellitus calls the home care nurse and reports taking a morning dose of 70/30 insulin before realizing they have a stomach virus and are now unable to eat breakfast due to nausea. Which initial instruction should the nurse provide the client?
Correct Answer: Monitoring blood glucose levels and drinking fluids helps prevent dehydration and maintain glucose control.
Rationale:
Question 4 of 5
A client in the operating room received succinylcholine. The client is experiencing muscle rigidity and has an extremely high temperature. Which action should the nurse implement?
Correct Answer: Preparing ice packs for placement in the client's axillary area is a direct and immediate action to help reduce the client's extremely high temperature. Cooling measures are crucial to manage hyperthermia and prevent further complications.
Rationale:
Question 5 of 5
An older client who is agitated, dyspneic, orthopneic, and using accessory muscles to breathe is admitted for further treatment. Initial assessment includes a heart rate of 128 beats/minute and irregular, respirations of 38 breaths/minute, blood pressure of 168/100 mm Hg, and oxygen saturation of 90% on room air. Wheezes and crackles are noted throughout bilateral lung fields. An hour after the administration of furosemide 60 mg IV push (IVP), which assessments should the nurse obtain to determine the client's response to treatment? Select all that apply.
Correct Answer: Lung sounds, oxygen saturation, and urinary output are direct measures of furosemide's effectiveness in reducing fluid overload and improving respiratory status.
Rationale: