HESI RN
HESI RN Med Surg 3 Questions
Extract:
Client is a 61-year-old male with COVID pneumonia. He was on high-flow oxygen for 3 days and was transferred to the intensive care unit (ICU) after being intubated and placed on a mechanical ventilator. Has sedation and a neuromuscular blockade infusing due to the high inspiratory pressures required to ventilate the client.
Question 1 of 5
Click to mark whether the actions are indicated, contraindicated, or nonessential for this client.
Correct Answer: A,D
Rationale: Increasing FiOâ‚‚ is indicated if oxygenation is inadequate. Measuring NG output is essential to assess for gastrointestinal issues. Other actions lack clinical justification.
Extract:
Question 2 of 5
A client is admitted to the intensive care unit (ICU) with sepsis and acute respiratory distress syndrome (ARDS). The client is orally intubated and mechanically ventilated. Which intervention is most important for the nurse to include in the client's plan of care (POC)?
Correct Answer: B
Rationale: Using antiseptic solution for oral care reduces bacterial colonization, decreasing the risk of ventilator-associated pneumonia (VAP), a critical intervention in ARDS.
Question 3 of 5
A female client admitted with possible pneumonia and systemic inflammatory response syndrome (SIRS) is manifesting low oxygen saturation rates. Which additional finding(s) associated with SIRS should the nurse report to the health care provider (HCP)? Select all that apply.
Correct Answer: A,B,C,D
Rationale: Respiratory rate -22, heart rate -90, hypothermia <36°C, and WBC >12,000/mm³ meet SIRS criteria, indicating systemic inflammation.
Question 4 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.
Question 5 of 5
An adult with head and facial injuries from a motor vehicle collision is fully immobilized and has a Glasgow coma score of 6. The client is intubated, sedated, and is being prepared for transfer to a regional trauma center. Which intervention(s) should the nurse implement? Select all that apply.
Correct Answer: A,B,C,D
Rationale: Family presence provides emotional support. Reassessing vascular access ensures functionality. Frequent neurological assessments monitor for deterioration. Ophthalmic ointment prevents corneal abrasions.