HESI RN
HESI RN Med Surg Exam 2 Questions
Extract:
Question 1 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: A
Rationale: The correct answer is A because swelling may indicate compartment syndrome, a serious complication requiring immediate assessment.
Choice B is unrelated to the pain or fixation device.
Question 2 of 5
The nurse observes an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which is the best initial nursing action?
Correct Answer: B
Rationale: The correct answer is B because increasing irrigation flow helps clear blood clots and maintain catheter patency.
Choice A is routine but not immediate.
Choice C supports hydration but is secondary.
Choice D addresses spasms, not clots.
Question 3 of 5
The nurse assesses an adult client 24 hours following abdominal surgery and finds the client's blood pressure is 98/40 mm Hg. The client is tachycardic, restless, and irritable. Which action should the nurse perform first?
Correct Answer: A
Rationale: The correct answer is A because low blood pressure and tachycardia suggest bleeding, which checking under the back can confirm.
Choice B is not the priority.
Choice C is secondary.
Choice D follows assessment.
Question 4 of 5
The nurse is caring for a client with acute kidney injury (AKI). Which assessment finding warrants immediate intervention?
Correct Answer: A
Rationale: The correct answer is A because dyspnea and sinus tachycardia may indicate fluid overload or heart failure, requiring immediate intervention to prevent complications.
Choice B is a minor symptom not requiring urgent action.
Choice C is expected in AKI but less urgent.
Choice D suggests infection, which is less critical than respiratory and cardiac symptoms.
Question 5 of 5
A client who suffered an electrical injury with the entrance site on the left hand and the exit site on the left foot is admitted to the burn unit. Which intervention is most important for the nurse to include in this client's plan of care?
Correct Answer: C
Rationale: The correct answer is C because electrical injuries can cause cardiac arrhythmias, making continuous monitoring critical.
Choice A supports mobility but is not urgent.
Choice B is routine but less critical.
Choice D is important but secondary to cardiac monitoring.