HESI RN
Hesi RN Medical Surg Questions
Extract:
History and Physical Nurses' Notes
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
Based on the client's history and assessment data, the nurse's hypothesis is that the client's vital signs are most likely the result of disease process, medication use, or neither. Each column must have at least one, but may have more than one answer selected.
Correct Answer: A,B
Rationale: Tachypnea results from bronchospasm in asthma, impairing ventilation. Elevated heart rate is a side effect of beta-agonist inhalers used during the attack.
Question 2 of 5
Based on the client's history and assessment data, the nurse's hypothesis is that the client's vital signs are most likely the result of disease process, medication use, or neither. Each column must have at least one, but may have more than one answer selected.
| Options | Neither disease process nor medication use | Disease process | Medication use |
|---|---|---|---|
| Blood pressure 130/86 mmHg | |||
| Respirations 28 breaths/minute | |||
| Temperature 98.9" F (37.1°C) | |||
| Heart rate 112 beats/minute | |||
| Oxygen saturation 88% on room air |
Correct Answer: A,B
Rationale: Tachypnea results from bronchospasm in asthma, impairing ventilation. Elevated heart rate is a side effect of beta-agonist inhalers used during the attack.
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 3 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 4 of 5
The nurse is providing teaching to a client about self-management of type 2 diabetes mellitus. Which information provided by the client indicates understanding?
Correct Answer: B
Rationale: Using herbs and spices reduces reliance on sugars and fats, supporting glycemic control in diabetes.
Question 5 of 5
A client with leukemia is receiving chemotherapy. The nurse observes the client is weak, pale, and febrile. After reviewing the client's most recent laboratory data which reveals a platelet count of 25,000/mm3 (25 x 109/L), which intervention should the nurse include in the plan of care?
Correct Answer: B
Rationale: Monitoring for occult blood is critical with severe thrombocytopenia to detect internal bleeding early, preventing life-threatening complications.