HESI RN
HESI RN Medical Surgical Exam I Questions
Extract:
Nurse's Notes
History and Physical
Initial Assessment
Temperature: 98.9°F
Heart rate: 112 beats per minute
Respirations: 28 breaths per minute
Blood pressure: 130/86 mmHg
Oxygen saturation: 88%
Lung sounds reveal expiratory wheezes
Capillary refill time: 2 seconds
Exhibits
The nurse has completed a client history and initial assessment and is now planning on prioritizing care of the client.
Complete the following sentences by choosing from the list of corresponding options
Based on the history and assessment data, the nurse should prioritize AnxietyImpaired gas exchangeIneffective airway clearanceActivity intolerance as the priority problem for this client, as evidenced by the client's statement, "I was jogging when it started.""I used my rescue inhaler three times, but I couldn’t catch my breath.""My symptoms are worse when outdoors and when exercising.""I noticed my inhaler was expired and was worried the medication was not working."
Question 1 of 5
Based on the history and assessment data, the nurse should prioritize [dropdown] as the priority problem for this client, as evidenced by the client's statement, [dropdown].
Correct Answer: B
Rationale: Impaired gas exchange is prioritized due to low oxygen saturation and ineffective inhaler use.
Extract:
Question 2 of 5
The nurse is assessing a client who is one day postoperative parathyroidectomy and finds that the client is experiencing stridor. After notifying the healthcare provider (HCP), the nurse should prepare for which procedure:
Correct Answer: C
Rationale: Tracheostomy placement is necessary to manage stridor, which indicates airway obstruction in a postoperative parathyroidectomy patient.
Question 3 of 5
The nurse is caring for a client with a history of type 2 diabetes mellitus (DM) and hypertension who arrived at the clinic for a scheduled visit. Which finding should the nurse recognize as a possible complication?
Correct Answer: C
Rationale: A serum creatinine level of 1.6 mg/dL indicates impaired kidney function, a significant complication in clients with type 2 diabetes and hypertension, suggesting diabetic or hypertensive nephropathy.
Question 4 of 5
During a routine eye examination, an older client reports decreased peripheral vision and is found to have elevated intraocular pressures. Ophthalmic drops are prescribed for primary open-angle glaucoma (POAG). Which intervention(s) should the nurse include in this client's plan of care? Select all that apply.
Correct Answer: B,D,E
Rationale: Teaching strategies for aseptic administration (
B) prevents infections, applying pressure over the inner eye corner (
D) enhances medication efficacy, and explaining lifelong use (E) ensures adherence. A reduced sodium diet (
A) is not directly related to POAG, and eye drops (
C) preserve vision, not improve it.
Question 5 of 5
A nurse is developing home care instructions for a client with peripheral artery disease (PAD). Which intervention should the nurse include?
Correct Answer: B
Rationale: Structured exercise, such as walking, improves blood flow and reduces symptoms in PAD.