HESI RN
HESI RN Med Surg 3 Questions
Extract:
Question 1 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.
Extract:
History and Physical Orders
The client is a 29-year-old female with a history of type 1 diabetes mellitus from the age of 6. She controls her blood glucose with an insulin pump and uses a continuous glucose monitor. The client was out of town, and her insulin pump was damaged. She had forgotten her backup long-acting insulin at home, so she took the 6-hour drive home. By the time she arrived at home, she was having nausea and vomiting. Her blood glucose meter read over 500 mg/dL (27.8 mmol/L). She took a dose of insulin glargine and took herself to the emergency department (ED).
Question 2 of 5
Which other labs would be helpful for the treatment of diabetic ketoacidosis (DKA)? Select all that apply.
Correct Answer: C,E,F
Rationale: Serum electrolytes are crucial for guiding fluid and electrolyte replacement. The anion gap assesses the severity of acidosis, and urine ketones confirm ketoacidosis and monitor treatment response.
Extract:
Question 3 of 5
A client is admitted to the neurological intensive care unit after having just sustained a C5 spinal cord injury (SCI). Which assessment finding for this client warrants immediate intervention by the nurse?
Correct Answer: A
Rationale: A C5 spinal cord injury can impair diaphragmatic function and respiratory effort, leading to respiratory failure. Shallow and labored breathing suggests that the client is experiencing respiratory compromise, which can quickly progress to hypoventilation, hypoxia, and respiratory arrest. Immediate intervention, such as assisted ventilation or intubation, may be necessary to maintain adequate oxygenation and prevent further complications.
Question 4 of 5
The nurse is collecting a blood sample for a mixed venous oxygen saturation (SVO2) level from the distal lumen of a pulmonary artery (PA) catheter of a client in cardiogenic shock. Which action should the nurse implement?
Correct Answer: C
Rationale: At least 1 mL of blood is required for an accurate SVOâ‚‚ reading, ensuring sufficient sample volume.
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.