HESI RN
HESI RN Medical Surgical Exam I Questions
Extract:
Question 1 of 5
A client with oral cancer is receiving radiotherapy (RT) prior to surgery. Which intervention should the nurse teach the client to implement in managing mucositis related to RT?
Correct Answer: B
Rationale: Normal saline mouth rinses as swish and spit after meals and bedtime is an effective intervention for managing mucositis. Rinsing with saline helps to keep the mouth clean, reduce bacterial load, and soothe inflamed tissues.
Extract:
Vital Signs
Nurses Notes
History and Physical
Imaging Studies
Laboratory Results
Orders
0930
• Temperature: 100.8°F (38.2°C) orally
• Heart rate: 121 bpm
• Respirations: 28 bpm
• Blood pressure: 115/76
• Oxygen saturation: 95% on room air
Question 2 of 5
The nurse is stabilizing the client and preparing her for surgery. Which goals should the nurse prioritize in the plan of care for the client while in the emergency department (ED)? Select all that apply.
Correct Answer: A,B,C,D,G
Rationale: Infection prevention (
A), pain relief (
B), education (
C), anxiety coping (
D), and fluid management (G) are critical for appendicitis surgery preparation.
Extract:
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 tachycardiac, restless, and irritable. Which action should the nurse perform first?
Correct Answer: C
Rationale: Checking for bleeding is critical as symptoms suggest hypovolemic shock, a potential postoperative complication.
Extract:
Vital Signs
Nurses' Notes
History and Physical
Orders
1030
• Temperature: 99.8°F
• Heart rate: 98 beats/minute
• Respirations: 20 breaths/minute
• Blood pressure: 178/89 mmHg
• Oxygen saturation: 96% on room air
Question 4 of 5
Complete the diagram by choosing from the choices below to specify which condition the client is most likely experiencing, two actions the nurse should take to address the condition, and two parameters the nurse should monitor to assess the client's progress.
| Hypoglycemia |
| Hemorrhagic stroke |
| Urinary tract infection |
| Transient ischemic stroke |
| Actions to take Choices A. Start administering 0.9% sodium chloride IV at a rate of 100 ml/hr B. Administer oxygen at 2 l/min via nasal cannula C. Request a prescription to administer the client's home medication of aspirin D. Request a prescription for a computerized tomography (CT) scan of the client's head and neck E. Perform a National Institute of Health Stroke Scale (NIHSS) assessment |
| Parameters to Monitor Choices A. Neurological status B. Respiratory rate C. Blood pressure D. Urine output E. Oxygen saturation |
Correct Answer: D
Rationale: Condition: Transient ischemic stroke (
D). Actions: Request CT scan (
D), perform NIHSS assessment (E). Parameters: Neurological status (
A), blood pressure (
C).
Rationale: Symptoms and history suggest TIA, requiring imaging and neurological monitoring.
Extract:
Question 5 of 5
The healthcare provider prescribes 100 mL of 0.9% normal saline to be infused within 15 minutes. The nurse should program the infusion pump to deliver how many mL/hr? (Enter numerical value only.)
Correct Answer: A
Rationale: Calculation: 100 mL ÷ 0.25 hours (15 minutes) = 400 mL/hr.