HESI RN
HESI RN Med Surg 3 Questions
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 1 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 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
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.
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 4 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 5 of 5
The vital signs for a client with heart failure (HF), who is admitted to the intensive care unit (ICU), are a temperature of 98.6° F (37°C), heart rate 125 beats/minute, respirations 22 breaths/minute, and blood pressure 140/50 mm Hg. The nurse determines the client's central venous pressure (CVP) and pulmonary artery wedge pressure (PAWP) are elevated. Which intervention should the nurse implement?
Correct Answer: C
Rationale: Elevated CVP and PAWP indicate fluid overload. Furosemide reduces preload and promotes diuresis, improving symptoms.