HESI RN
HESI RN Medical Surgical Exam I Questions
Extract:
Vital Signs
Nurses' Notes
History and Physical
Orders
1030
• Temperature: 99.8°F
• Heart rate: 98 beats/minute
• Respirations: 20 breaths/minute
• Blood pressure: 178/89 mmHg
• Oxygen saturation: 96% on room air
Question 1 of 5
Complete the diagram by choosing from the choices below to specify which condition the client is most likely experiencing, two actions the nurse should take to address the condition, and two parameters the nurse should monitor to assess the client's progress.
Correct Answer: D
Rationale: Condition: Transient ischemic stroke (
D). Actions: Request CT scan (
D), perform NIHSS assessment (E). Parameters: Neurological status (
A), blood pressure (
C).
Rationale: Symptoms and history suggest TIA, requiring imaging and neurological monitoring.
Extract:
Question 2 of 5
The healthcare provider (HCP) prescribes diazepam 8 mg IM every 4 hours PRN for muscle spasms for a client with a fractured femur. The available vial is labeled 'Diazepam Injection, USP 10 mg/2 mL.' How many mL should the nurse administer to the client? (Enter numerical value only. If rounding is required, round to the nearest tenth.)
Correct Answer: A
Rationale: Calculation: 10 mg/2 mL = 0.2 mL/mg, 8 mg × 0.2 mL/mg = 1.6 mL.
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
Question 3 of 5
The nurse has identified the priority problem for the client and now needs to determine proper care interventions. Based on the client's history and assessment data, which actions should the nurse anticipate? Select all that apply.
Correct Answer: A,B,E
Rationale: Administering medications (
A), providing teaching (
B), and obtaining medication history (E) address acute asthma and prevent recurrence.
Extract:
Question 4 of 5
When teaching a client with Parkinson's disease, which rationale for the prescription of carbidopa-levodopa should the nurse include?
Correct Answer: B
Rationale: Carbidopa-levodopa increases dopamine availability, improving muscle function in Parkinson's disease.
Extract:
History and Physical
Nurses' Notes
Orders
A 34-year-old male client presents to the emergency department (ED) for an asthma attack that began after jogging through a local park. The client is able to answer questions every few words to catch his breath. He reports using his rescue inhaler three times, but he couldn't catch his breath. He reports that his symptoms are worse when outdoors and when exercising, and episodes like this make him extremely nervous. He says that it has been a couple of months since his last asthma attack, and he came to the ED today because he noticed his inhaler was expired and was worried the medication was not working.
Question 5 of 5
The nurse has implemented additional needed actions. Indicate the assessment data which indicate the interventions were successful and which assessment data provide no indication that the interventions were successful.
| Options | No indication that the interventions were successful | Indicated the interventions were successful |
|---|---|---|
| The client can now speak in full sentences without pausing. | ||
| Respirations at 16 breaths per minute | ||
| Blood pressure at 122/84 mmHg | ||
| The client reporting, 'It's a lot easier to breathe now.' | ||
| Heart rate at 105 beats per minute | ||
| Lung sounds being clear |
Correct Answer: A,B,D,F
Rationale: Speaking in sentences (
A), normal respirations (
B), client report (
D), and clear lungs (F) indicate success; blood pressure (
C) and heart rate (E) do not.