HESI RN Medical Surgical Nursing | Nurselytic

Questions 57

HESI RN

Home > HESI RN > HESI Medical Surgical > HESI RN Medical Surgical Nursing
HESI RN Test Bank

HESI RN Medical Surgical Nursing Questions

Extract:

Nurses votes
Skin assessment reveals a stage 2 pressure injury on the right trochanter. Measures 0.79" x 1.57" x 0.39 (2 cm X 4 cm X 1 cm). Minimal drainage noted. Painful to touch. The Braden Scale was utilized during the skin assessment. The score is two for sensory, three for moisture, two for activity, two for mobility, two for nutrition and one for friction and shear.


Question 1 of 5

Complete the diagram by dragging from the choices area to specify 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 A. Begin enteral feedings B. Insert Indwelling urinary catheter C. Ambulate every four D. Apply pressure reduction mattress to bed E. Request service of wound care nurse
Potential Conditions Choices A. Immobility B. Dehydration C. Malnutrition D. Poor healing of stage 2 pressure injury
Parameters to monitor Choices A. Sterile dressing changes B. Adherence to repositioning schedule hours C. Temperature D. Laboratory studies for malnutrition status E. Progression of wound

Correct Answer: D

Rationale: Poor healing of a pressure injury requires a pressure reduction mattress and wound care nurse consultation, monitoring wound progression and repositioning adherence.

Extract:


Question 2 of 5

Correct Answer:

Rationale:

Question 3 of 5

Correct Answer:

Rationale:

Question 4 of 5

Correct Answer:

Rationale:

Question 5 of 5

Correct Answer:

Rationale:

Similar Questions

The nurse establishes a nursing problem of 'Fatigue related to inability to rest comfortably secondary to rheumatoid arthritis.' Which nursing intervention should the nurse include in the plan of care for this client?
A client is admitted with heart failure (HF) and left ventricular hypertrophy. Which intervention is most likely to avert development of cardiomegaly and improve myocardial contractility?
The healthcare provider comes to the bedside following the seizure and prescribes phenytoin. The nurse administers the phenytoin as prescribed. Which possible side effect(s) of phenytoin should the nurse assess for after administration? Select all that apply.
A client with an acute exacerbation of rheumatoid arthritis (RA) has localized pain and inflammation of the fingers and feet, swelling, redness, restricted joint motion, and reports feeling fatigued. Which nursing problem has the highest priority for this client?
A client with pancreatitis is receiving 0.9% normal saline, and the prescribed IV infusion rate was increased from 100 mL/hour to 150 mL/hour. Which assessment finding indicates to the nurse that the prescription has a therapeutic outcome?

Access More Questions!

HESI RN Basic

$89/ 30 days

 

HESI RN Premium

$150/ 90 days