HESI RN
HESI RN Med Surg 3 Questions
Extract:
Question 1 of 5
Based on this rhythm strip, which interpretation should the nurse make?
Correct Answer: D
Rationale: Atrial flutter is characterized by regular, rapid atrial depolarizations (flutter waves) at a rate of 250–350 bpm, creating a 'sawtooth' pattern on the ECG. The ventricular response may be regular or irregular, depending on AV conduction.
Question 2 of 5
An adult who fell 20 feet (6 meters) from a tree is admitted to the intermediate intensive care unit with a fractured femur. When the cardiac monitor alarms, the nurse finds the client has no palpable carotid pulse and no spontaneous respiration, however, the cardiac monitor displays a sinus rhythm. Which intervention should the nurse implement?
Correct Answer: B
Rationale: No pulse and respirations with a sinus rhythm indicate pulseless electrical activity (PE
A). Immediate chest compressions are essential to maintain perfusion.
Question 3 of 5
Twelve hours following orthopedic surgery on the right leg, the client begins to have acute chest pain and difficulty breathing. Which action should the nurse take first?
Correct Answer: B
Rationale: Acute chest pain and difficulty breathing suggest a pulmonary embolism. Providing oxygen and increasing IV flow rate support vital functions immediately.
Question 4 of 5
A client with a gunshot wound is brought to the emergency department (ED) with a bullet entry at the spinal level of C8 and T1. The client is able to move the upper arms. To further assess the client's spinal nerve function, which action should the nurse implement?
Correct Answer: C
Rationale: The C8 and T1 spinal nerves control hand and finger movements. Testing grip strength assesses nerve integrity at the injury level.
Question 5 of 5
A young male adult walks into the emergency department (ED) holding a dead poisonous snake that bit him on his right calf within the last hour. After killing the snake, he tied a tablecloth about 4 inches (10 cm) above the bite. The client is now reporting numbness and tingling from the right knee to ankle. His heart rate is 123 beats/minute, respirations 28 breaths/minute, blood pressure 86/40 mm Hg, and oxygen saturation 94% on room air. Which intervention should the nurse implement?
Correct Answer: A
Rationale: Signs of shock due to envenomation require rapid IV access for fluid resuscitation and antivenom administration.