HESI RN
HESI RN Med Surg 3 Questions
Extract:
Question 1 of 5
A female client admitted with possible pneumonia and systemic inflammatory response syndrome (SIRS) is manifesting low oxygen saturation rates. Which additional finding(s) associated with SIRS should the nurse report to the health care provider (HCP)? Select all that apply.
Correct Answer: A,B,C,D
Rationale: Respiratory rate -22, heart rate -90, hypothermia <36°C, and WBC >12,000/mm³ meet SIRS criteria, indicating systemic inflammation.
Question 2 of 5
After 15 minutes of cardiopulmonary resuscitation (CPR) and multiple defibrillations, a client has return of spontaneous circulation (ROSC) with a heart rate of 130 beats/minute and ST elevation in leads I,II, III, aVF, aVL, V5, V6. Which serum laboratory values are most important for the nurse to monitor?
Correct Answer: D
Rationale: Troponin is the most specific and sensitive biomarker for myocardial infarction, indicated by ST elevation in multiple leads.
Question 3 of 5
The nurse assesses the telemetry monitor of a client who is 24 hours postoperative from having a permanent pacemaker insertion. The nurse observes that a pacemaker spike is present before each QRS complex in lead II of the electrocardiogram (ECG). Which intervention should the nurse implement?
Correct Answer: A
Rationale: A pacemaker spike before each QRS complex indicates that the pacemaker is functioning properly and triggering ventricular depolarization as intended. Since the client is 24 hours postoperative from a pacemaker insertion, this is an expected finding and should be documented accordingly.
Question 4 of 5
A client who is admitted to the intensive care unit (ICU) with acute decompensated heart failure is receiving a continuous infusion of milrinone via a subclavian venous catheter. Which action should the nurse take when preparing to administer the first dose of IV furosemide?
Correct Answer: D
Rationale: Milrinone and furosemide are incompatible due to pH differences, which can cause precipitation. Administering furosemide through a separate IV line ensures safe delivery.
Question 5 of 5
Based on this rhythm strip, which interpretation should the nurse make?
Correct Answer: D
Rationale: Atrial flutter is characterized by regular, rapid atrial depolarizations (flutter waves) at a rate of 250–350 bpm, creating a 'sawtooth' pattern on the ECG. The ventricular response may be regular or irregular, depending on AV conduction.