HESI RN
HESI RN Med Surg 3 Questions
Extract:
Question 1 of 5
A young male adult walks into the emergency department (ED) holding a dead poisonous snake that bit him on his right calf within the last hour. After killing the snake, he tied a tablecloth about 4 inches (10 cm) above the bite. The client is now reporting numbness and tingling from the right knee to ankle. His heart rate is 123 beats/minute, respirations 28 breaths/minute, blood pressure 86/40 mm Hg, and oxygen saturation 94% on room air. Which intervention should the nurse implement?
Correct Answer: A
Rationale: Signs of shock due to envenomation require rapid IV access for fluid resuscitation and antivenom administration.
Question 2 of 5
A client who was involved in a motor vehicle collision while riding a motorcycle without wearing a helmet, is brought the emergency department (ED) by emergency medical services (EMS). Which assessment should the nurse obtain first?
Correct Answer: B
Rationale: Assessing pulse and blood pressure determines hemodynamic stability, a priority in trauma resuscitation following the ABCs (Airway, Breathing, Circulation).
Question 3 of 5
An adult who fell 20 feet (6 meters) from a tree is admitted to the intermediate intensive care unit with a fractured femur. When the cardiac monitor alarms, the nurse finds the client has no palpable carotid pulse and no spontaneous respiration, however, the cardiac monitor displays a sinus rhythm. Which intervention should the nurse implement?
Correct Answer: B
Rationale: No pulse and respirations with a sinus rhythm indicate pulseless electrical activity (PE
A). Immediate chest compressions are essential to maintain perfusion.
Question 4 of 5
Twelve hours following orthopedic surgery on the right leg, the client begins to have acute chest pain and difficulty breathing. Which action should the nurse take first?
Correct Answer: B
Rationale: Acute chest pain and difficulty breathing suggest a pulmonary embolism. Providing oxygen and increasing IV flow rate support vital functions immediately.
Question 5 of 5
The nurse is completing a neurological assessment on a client with a head injury. The Glasgow Coma Scale (GCS) score is 14. Which intervention should the nurse implement?
Correct Answer: D
Rationale: A GSC of 14 indicates mild head injury. Frequent monitoring every 2 hours detects worsening conditions.