HESI RN
HESI RN Med Surg 3 Questions
Extract:
Question 1 of 5
After intubating a client, correct placement of the endotracheal tube (ETT) is confirmed with a chest x-ray. Which intervention should the nurse implement to ensure that the ETT placement is maintained?
Correct Answer: C
Rationale: After proper ETT placement is confirmed with a chest x-ray, securing the tube with adhesive tape or a commercial ETT holder prevents displacement. Unintentional extubation or tube migration can lead to hypoxia, respiratory distress, or esophageal intubation, making proper tube fixation a priority intervention.
Extract:
History and Physical
Flow Sheet
Laboratory Results
The client is a 59-year-old female with hyperosmolar hyperglycemic syndrome (HHS). She developed abdominal pain several days ago and nausea starting yesterday. This morning, she was extremely drowsy and confused at work. Her coworker brought her to the hospital.
Question 2 of 5
Based on the client's laboratory values at 1600, which are appropriate nursing actions? Select all that apply.
Correct Answer: D,E,F
Rationale: Once circulatory volume is restored, fluids should be switched to 0.45% sodium chloride to correct hypernatremia and intracellular dehydration. Glucose levels are improving but still high (250 mg/dL), requiring adjustments in fluid and insulin therapy, so the provider should be informed. Insulin therapy drives potassium into cells, leading to hypokalemia (K⺠= 3.2 mEq/L), which can cause cardiac arrhythmias and muscle weakness, necessitating potassium replacement.
Extract:
Question 3 of 5
After intubating a client, correct placement of the endotracheal tube (ETT) is confirmed with a chest x-ray. Which intervention should the nurse implement to ensure that the ETT placement is maintained?
Correct Answer: C
Rationale: After proper ETT placement is confirmed with a chest x-ray, securing the tube with adhesive tape or a commercial ETT holder prevents displacement. Unintentional extubation or tube migration can lead to hypoxia, respiratory distress, or esophageal intubation, making proper tube fixation a priority intervention.
Question 4 of 5
A client has a chest tube connected to a closed water-seal drainage system with suction. Which equipment should the nurse always have available at the client's bedside?
Correct Answer: C
Rationale: If the chest tube accidentally dislodges, an occlusive dressing (such as sterile gauze with petroleum jelly) should be applied immediately to prevent air from re-entering the pleural space, which could lead to a tension pneumothorax. Keeping sterile gauze at the bedside ensures rapid intervention in case of accidental chest tube removal.
Question 5 of 5
The nurse assesses the telemetry monitor of a client who is 24 hours postoperative from having a permanent pacemaker insertion. The nurse observes that a pacemaker spike is present before each QRS complex in lead II of the electrocardiogram (ECG). Which intervention should the nurse implement?
Correct Answer: A
Rationale: A pacemaker spike before each QRS complex indicates that the pacemaker is functioning properly and triggering ventricular depolarization as intended. Since the client is 24 hours postoperative from a pacemaker insertion, this is an expected finding and should be documented accordingly.