HESI RN
HESI RN Med Surg 3 Questions
Extract:
The client is a 29-year-old female with a history of type 1 diabetes mellitus from the age of 6. She controls her blood glucose with an insulin pump and uses a continuous glucose monitor. The client was out of town, and her insulin pump was damaged. She had forgotten her backup long-acting insulin at home, so she took the 6-hour drive home. By the time she arrived at home, she was having nausea and vomiting. Her blood glucose meter read over 500 mg/dL (27.8 mmol/L). She took a dose of insulin glargine and took herself to the emergency department (ED).
The nurse draws the arterial blood gas and waits for results
Question 1 of 5
Based on the client's diagnosis, which results does the nurse expect in the blood gas? Select all that apply.
Correct Answer: C,D
Rationale: Diabetic ketoacidosis (DK
A) causes metabolic acidosis due to ketone accumulation, leading to a pH below 7.35. Bicarbonate is depleted while neutralizing excess acids, resulting in levels below 18 mEq/L.
Extract:
Question 2 of 5
The client is a 43-year-old male who had a surgical removal of a benign tumor from the left hemisphere of his brain. The client's estimated blood loss (EBL) is 100 mL during surgical procedure. There were no complications. Vital signs remained stable throughout the procedure. The client will be admitted to the neurological intensive care unit for monitoring. Complete the diagram by specifying which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
| Actions to Take Choices A. Prepare the client to return to surgery B. Give ibuprofen as ordered C. Place the call light within the client's reach D. Elevate the head of the bed to 45 degrees E. Use a word board to help the client communicate |
| Potential Conditions Choices A. Myasthenia gravis B. Cushing response C. Hydrocephalus D. Broca aphasia |
| Parameters to Monitor Choices A. White blood cell count B. Cerebral perfusion pressure C. Pupil response D. Level of consciousness E. Deep tendon reflexes |
Correct Answer: D,E,F,D,E
Rationale: Surgery in the left hemisphere may cause Broca aphasia. Ensuring call light access and using a word board aid communication. Monitoring cerebral perfusion pressure and level of consciousness detects complications.
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
The nurse is caring for a client who has hemorrhaged postoperatively and is in an early stage of shock. Which cardiopulmonary symptoms are most indicative of progressive hypovolemic shock?
Correct Answer: C
Rationale: Tachycardia, lowered systolic BP, and peripheral mottling are characteristic of progressive hypovolemic shock due to reduced circulating volume.
Question 5 of 5
A client who is admitted to the emergency department (ED) following a motorcycle collision is having difficulty breathing. While assessing the client's chest and lungs, the nurse notes that there are no breath sounds over the left lung fields. Which action(s) should the nurse implement? Select all that apply.
Correct Answer: A,B
Rationale: High-flow oxygen improves oxygenation in suspected pneumothorax or hemothorax. Obtaining a chest tube insertion kit prepares for definitive treatment.