HESI RN
Samuel Merrit University Hesi Med Surg Questions
Extract:
Question 1 of 5
After a long bed rest, a client with a Foley catheter and wrist restraints has repeatedly removed the antibiotic (G) tube and NG tube.At checking the restraints, which action is most important for the nurse to take?
Correct Answer: C
Rationale: When checking the restraints, the most important action for the nurse to take is to assess capillary refill distal to the restraints. This helps to ensure that the restraints are not too tight and that blood flow to the extremities is not compromised.
Question 2 of 5
After a week of bed rest, a client is being assisted to a chair for the first time.The nurse raises the head of the bed and moves the client to a sitting position. What should the nurse implement next?
Correct Answer: A
Rationale: After moving the client to a sitting position, the next step the nurse should implement is to determine how the client feels. This allows the nurse to assess for any dizziness, lightheadedness, or other symptoms that may indicate orthostatic hypotension or other issues.
Question 3 of 5
While teaching a client how to perform a skill, the nurse determines that the client is experiencing sensory overload and is unable to learn effectively.Which action should the nurse implement?
Correct Answer: C
Rationale: Sensory overload happens when an individual is getting more input from their senses than their brain can sort through and process.
Therefore, reducing the stimuli in the area can help the client's brain to better process the information being taught.
Question 4 of 5
A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?
Correct Answer: A
Rationale: Charting by exception means that the nurse only documents findings that deviate from the established norm or expected outcome. In this case, the nurse should document the assessment that is not within normal limits, which is 'Basilar lung sounds that are diminished in the left lung.'
Question 5 of 5
Which descriptions of stool warrant additional follow-up by the nurse? (Select all that apply.).
Correct Answer: A,C,D,E
Rationale: Solid stool with red streaks may indicate lower gastrointestinal bleeding and requires further evaluation. Brown liquid stool may suggest diarrhea or malabsorption issues, warranting further assessment. A tarry appearance can indicate upper gastrointestinal bleeding and requires prompt follow-up. Multiple hard pellets may indicate constipation or dehydration and should be addressed.