HESI RN
HESI RN Med Surg Questions
Extract:
Question 1 of 5
A client with rheumatoid arthritis has an elevated serum rheumatoid factor. Which interpretation of this finding should the nurse make?
Correct Answer: A
Rationale: Elevated rheumatoid factor is an autoantibody indicating the autoimmune nature of rheumatoid arthritis, confirming the disease process, not necessarily its severity or organ involvement.
Question 2 of 5
The nurse is preparing to administer medications for an eight-month-old infant with heart failure. The infant has a blood pressure of 114/66 mm Hg, apical pulse of 88 beats/minute, and respirations of 30 breaths/minute. Which medication should the nurse withhold until the health care provider is notified?
Correct Answer: B
Rationale: Digoxin is withheld if the apical pulse is below 90 beats/minute in infants to prevent toxicity. Other medications are not contraindicated.
Question 3 of 5
The nurse calls the healthcare provider because a client diagnosed with an abdominal aortic aneurysm (AAA) is reporting low back pain. Which additional information about the client would be important for the nurse to tell the healthcare provider?
Correct Answer: B
Rationale: Low back pain in AAA may suggest aneurysm expansion or rupture. Hematocrit and blood pressure indicate potential bleeding or hemodynamic instability, critical for the provider's assessment.
Question 4 of 5
An adult client newly diagnosed with left ventricular dysfunction is admitted to the hospital with fine rales and wheezing. When assessing this client, which additional finding is the nurse likely to obtain?
Correct Answer: A
Rationale: Left ventricular dysfunction reduces cardiac output, leading to fatigue due to inadequate systemic perfusion, unlike other findings which are more associated with right ventricular dysfunction.
Question 5 of 5
Lactulose was prescribed two days ago for a client who was recently diagnosed with hepatic encephalopathy. The client is confused and experiencing frequent loose stools. Laboratory findings show an elevated serum ammonia (NH) level of 220 μg/dL (157.1 μmol/dL). Which action should the nurse take?
Correct Answer: B
Rationale: Lactulose reduces ammonia levels by promoting its excretion, and the elevated ammonia level indicates the need to continue therapy. Loose stools are an expected effect, and continuing the dose addresses the underlying hepatic encephalopathy.