HESI RN
HESI RN Medical Surgical Exam I Questions
Extract:
Nurse's Notes
Orders
A 34-year-old male client presents to the emergency department (ED) for an asthma attack that began after jogging through a local park. The client is able to answer questions every few words to catch his breath. He reports using his rescue inhaler three times, but he couldn't catch his breath. He reports that his symptoms are worse when outdoors and when exercising, and episodes like this make him extremely nervous. He says that it has been a couple of months since his last asthma attack, and he came to the ED today because he noticed 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: B,C,D
Rationale: Additional nebulizer treatment (
B), increased oxygen (
C), and raising the bed (
D) address persistent asthma symptoms.
Question 2 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: B,C,D
Rationale: Additional nebulizer treatment (
B), increased oxygen (
C), and raising the bed (
D) address persistent asthma symptoms.
Extract:
Vital Signs
Nurses' Notes
History and Physical
Orders
1030
• Temperature: 99.8°F
• Heart rate: 98 beats/minute
• Respirations: 20 breaths/minute
• Blood pressure: 178/89 mmHg
• Oxygen saturation: 96% on room air
Question 3 of 5
Complete the diagram by choosing from the choices below to specify which condition the client is most likely experiencing, two actions the nurse should take to address the condition, and two parameters the nurse should monitor to assess the client's progress.
| Hypoglycemia |
| Hemorrhagic stroke |
| Urinary tract infection |
| Transient ischemic stroke |
| Actions to take Choices A. Start administering 0.9% sodium chloride IV at a rate of 100 ml/hr B. Administer oxygen at 2 l/min via nasal cannula C. Request a prescription to administer the client's home medication of aspirin D. Request a prescription for a computerized tomography (CT) scan of the client's head and neck E. Perform a National Institute of Health Stroke Scale (NIHSS) assessment |
| Parameters to Monitor Choices A. Neurological status B. Respiratory rate C. Blood pressure D. Urine output E. Oxygen saturation |
Correct Answer: D
Rationale: Condition: Transient ischemic stroke (
D). Actions: Request CT scan (
D), perform NIHSS assessment (E). Parameters: Neurological status (
A), blood pressure (
C).
Rationale: Symptoms and history suggest TIA, requiring imaging and neurological monitoring.
Extract:
Question 4 of 5
During a routine eye examination, an older client reports decreased peripheral vision and is found to have elevated intraocular pressures. Ophthalmic drops are prescribed for primary open-angle glaucoma (POAG). Which intervention(s) should the nurse include in this client's plan of care? Select all that apply.
Correct Answer: B,D,E
Rationale: Teaching strategies for aseptic administration (
B) prevents infections, applying pressure over the inner eye corner (
D) enhances medication efficacy, and explaining lifelong use (E) ensures adherence. A reduced sodium diet (
A) is not directly related to POAG, and eye drops (
C) preserve vision, not improve it.
Question 5 of 5
The nurse observes an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which is the best initial nursing action?
Correct Answer: B
Rationale: Increasing irrigation flow flushes out clots, maintaining catheter patency.