HESI RN
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.
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
A middle-aged client reports a sudden onset of seeing flashing lights and floating spots. Which is the best nursing action?
Correct Answer: A
Rationale: Flashing lights and floaters suggest retinal detachment, requiring urgent ophthalmic evaluation.
Question 3 of 5
The nurse assesses an adult client 24 hours following abdominal surgery and finds the client's blood pressure is 98/40 mm Hg. The client is tachycardiac, restless, and irritable. Which action should the nurse perform first?
Correct Answer: D
Rationale: Checking for bleeding addresses potential hypovolemic shock, indicated by low blood pressure and tachycardia, prioritizing over IV rate or notification.
Question 4 of 5
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?
Correct Answer: C
Rationale: A decrease in BUN indicates improved renal perfusion, a therapeutic outcome of increased IV fluids. Increased hematocrit suggests fluid volume deficit, increased blood glucose is undesirable, and amylase decrease is not directly related to fluid increase.
Question 5 of 5
A client with heart failure (HF) returns to the clinic two weeks after adjustments were made to the prescribed cardiac glycoside, diuretic, and potassium supplement. The client's lungs are clear, heart rate is 58 beats/minute, and serum potassium level is 2.9 mEq/L (2.9 mmol/L). Which action is most important for the nurse to implement?
Correct Answer: B
Rationale: Reporting hypokalemia (2.9 mEq/L) is critical to prevent arrhythmias, especially with cardiac glycosides.