HESI RN
Hesi RN Medical Surg Questions
Extract:
History and Physical
Nurses' Notes
Orders
A 34-year-old male client presents to the emergency department (ED) for an acute asthma attack which began after jogging through a local park. The client is able to answer questions, pausing every few words to catch his breath. The client reports using a rescue inhaler three times, but he just couldn't catch his breath. The client reports that symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous. The client reports that it has been a couple of months since he had an asthma attack, and he came to the ED today because he noticed that his inhaler was expired and was worried the medication was not working.
Question 1 of 5
After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen. Which action(s) should the nurse take next? Select all that apply.
Correct Answer: A,B,D,E
Rationale: Additional nebulizer treatment targets persistent wheezing, monitoring vital signs tracks response, increasing oxygen flow addresses low saturation, and raising the bed aids breathing. A nonrebreather is unnecessary at this stage, and incentive spirometry (F) is not indicated during an acute attack.
Extract:
Question 2 of 5
A client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning the client, the wound dehisces and eviscerates. The nurse moistens an available sterile dressing and places it over the wound. Which intervention should the nurse implement next?
Correct Answer: D
Rationale: Evisceration is a surgical emergency requiring immediate operative repair to prevent complications.
Question 3 of 5
The nurse is caring for a client who is receiving teletherapy radiation for a malignant tumor. Which Instruction regarding skin care of the portal site should the nurse provide?
Correct Answer: B
Rationale: Protecting the portal site from sunlight prevents exacerbated skin reactions during radiation therapy.
Question 4 of 5
A client with stage IV bone cancer is admitted to the hospital for pain control. The client verbalizes continuous, severe pain of 8 on a 0 to 10 scale. Which intervention should the nurse implement?
Correct Answer: B
Rationale: Combining opioid and non-opioid medications provides synergistic pain relief, optimizing control while minimizing opioid side effects.
Question 5 of 5
The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?
Correct Answer: D
Rationale: Platelet count is directly related to petechiae and ecchymosis, indicating potential thrombocytopenia causing bleeding tendencies.