HESI RN
HESI RN Med Surg Exam 3 Questions
Extract:
Question 1 of 5
After placing a client who is having a seizure in the side-lying position, which intervention should the nurse implement?
Correct Answer: Removing objects that could cause injury ensures a safe environment during a seizure.
Rationale:
Question 2 of 5
An older client who is agitated, dyspneic, orthopneic, and using accessory muscles to breathe is admitted for further treatment. Initial assessment includes a heart rate of 128 beats/minute and irregular, respirations of 38 breaths/minute, blood pressure of 168/100 mm Hg, and oxygen saturation of 90% on room air. Wheezes and crackles are noted throughout bilateral lung fields. An hour after the administration of furosemide 60 mg IV push (IVP), which assessments should the nurse obtain to determine the client's response to treatment? Select all that apply.
Correct Answer: Lung sounds, oxygen saturation, and urinary output are direct measures of furosemide's effectiveness in reducing fluid overload and improving respiratory status.
Rationale:
Question 3 of 5
A client is newly diagnosed with type 2 diabetes mellitus. The nurse is educating the client about self-monitoring blood glucose (SMBG) and haemoglobin A1C. Which statement by the client indicates teaching has been effective?
Correct Answer: Washing hands with warm soapy water prevents infections and ensures accurate glucose readings.
Rationale:
Question 4 of 5
A client with a history of diabetes mellitus and hypertension received new medication prescriptions three days ago. Today the client returns to the clinic reporting a severe headache and blurred vision. Which intervention should the nurse implement first?
Correct Answer: Obtaining a blood pressure reading is critical to rule out hypertensive crisis, a potential cause of severe headache and blurred vision.
Rationale:
Question 5 of 5
A female college student comes to the school's health clinic reporting urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first?
Correct Answer: Measuring temperature and heart rate provides immediate information about potential systemic infection or instability.
Rationale: