HESI RN
HESI RN Med Surg Exam 2 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: C
Rationale: The correct answer is C because elevated rheumatoid factor confirms the autoimmune process in rheumatoid arthritis.
Choice A does not indicate decline.
Choice B is unrelated to kidney spread.
Choice D is not specific to joint degeneration onset.
Question 2 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: C
Rationale: The correct answer is C because jugular vein distension is a hallmark of left ventricular dysfunction and heart failure.
Choice A is less common.
Choice B is secondary to other signs.
Choice D is non-specific.
Question 3 of 5
A client is recovering from the surgical removal of glass in the right eye. Which intervention should the nurse implement immediately following the procedure?
Correct Answer: C
Rationale: The correct answer is C because an eye shield protects the surgical site from trauma and infection, which is critical immediately post-procedure.
Choice A is unrelated to eye surgery.
Choice B is routine but not immediate.
Choice D is important for ongoing care but not the priority.
Question 4 of 5
A client reports to the nurse of recently visiting someone who has a shingles infection. The client believes that having had chickenpox as a child will be protective against shingles. How should the nurse respond? Select all that apply.
Correct Answer: B,E
Rationale: The correct answers are B and E for the same reasons as Question 1: affirming the link between chickenpox and shingles (
B) and distinguishing herpes varicella from herpes zoster (E) address the client's misconception.
Choice A does not clarify the client's risk.
Choice C is unrelated to the question about protection.
Choice D is incorrect as the risk of shingles increases with age.
Question 5 of 5
A nurse is caring for a client with diabetes insipidus (DI). Which data warrants the most immediate intervention by the nurse?
Correct Answer: A
Rationale: The correct answer is A because severe hypernatremia (185 mEq/L) can cause neurological damage and requires urgent correction.
Choice B is a symptom of DI but less urgent.
Choice C indicates dehydration but is secondary.
Choice D is elevated but not as critical.