HESI RN
HESI RN Med Surg Exam 3 Questions
Extract:
Question 1 of 5
A client with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the client's fluid balance?
Correct Answer: Weight is the most accurate and direct measure of fluid balance, as fluctuations reflect changes in body fluid.
Rationale:
Question 2 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:
Question 3 of 5
The nurse completes the admission assessment of a client with systemic lupus erythematosus. Which finding requires immediate follow-up by the nurse?
Correct Answer: Haematuria requires immediate follow-up because it can indicate serious renal involvement or a possible flare-up of lupus nephritis.
Rationale:
Question 4 of 5
The nurse is caring for a client admitted to the unit for possible hyperthyroidism. The client describes weakness, nervousness, a racing heartbeat, and recent weight loss of 15 pounds (6.8 kg). Which action should the nurse implement first?
Correct Answer: Monitoring the client's vital signs frequently is the first action the nurse should take. This helps assess the client's current condition, detect any immediate complications, and guide further interventions. It is crucial to ensure the client's stability before implementing other care measures.
Rationale:
Question 5 of 5
The nurse is teaching the client about incentive spirometry in the preoperative unit. Which statement regarding incentive spirometry should the nurse include with preoperative teaching?
Correct Answer: This statement explains the purpose and benefits of deep breathing exercises, providing a clear rationale for the intervention.
Rationale: