HESI RN
HESI RN Med Surg Questions
Extract:
Question 1 of 5
After administering varicella vaccine to a five-year-old child, which instruction should the nurse provide the child's parent?
Correct Answer: A
Rationale: Applying a cool pack reduces discomfort at the injection site. Other instructions are incorrect or unnecessary.
Question 2 of 5
While caring for a client with full thickness burns covering 40% of the body, the nurse observes purulent drainage from the wounds. Before reporting this finding to the healthcare provider, the nurse should evaluate which laboratory value?
Correct Answer: A
Rationale: Purulent drainage suggests infection. An elevated neutrophil count indicates an immune response to bacterial infection, critical to evaluate before reporting to confirm the infection's presence.
Question 3 of 5
A 9-month-old with Tay-Sachs disease is admitted due to seizures. Which assessment is most important for the nurse to obtain?
Correct Answer: D
Rationale: Exaggerated startle reaction is specific to Tay-Sachs and may trigger seizures, making it critical to assess. Other findings are less urgent.
Extract:
History and Physical
Nurses’ Notes
Flow sheet
Orders
Imaging Studies
A 19-year-old female client presents to the emergency department reporting tightness in her chest and difficulty breathing. The client's friend, who accompanied the client to the emergency department, reports she was at a park playing soccer with a group of college friends when the symptoms started. The park is close to a residential area where a fire was burning and there was a moderate breeze in the air. The client reported itching eyes and coughing. Approximately 15 minutes into the game, the client stopped running and held her hand on her chest, saying it felt tight. The client had difficulty catching her breath.
Home Medications
Albuterol/ipratropium every 4 hours by inhaler PRN for shortness of breath, last dose 2 days ago
Fluticasone/vilanterol 100/25 mcg inhaled daily, last dose 3 days ago
Ibuprofen 600 mg PO PRN for pain, last dose this morning for headache
Question 4 of 5
What finding(s) are cues for a respiratory problem? Select all that apply.
Correct Answer: A,B,D,E,F,G
Rationale: Sitting upright, chest tightness, tachypnea, restlessness, dyspnea, and low pulse oxygenation (85%) are direct indicators of respiratory distress, unlike medication compliance which is not a symptom.
Extract:
Question 5 of 5
In providing discharge teaching to a client with chronic obstructive pulmonary disease (COPD), which instruction is most important for the nurse to emphasize?
Correct Answer: A
Rationale: Changes in sputum color may indicate infection or exacerbation in COPD, requiring prompt reporting to the healthcare provider for timely management to prevent worsening respiratory status.