HESI RN
HESI RN Med Surg 3 Questions
Extract:
Medical History
Vital Signs
Physical Examination
Chronic use of hydrocortisone and fludrocortisone
History of hypertension
Recent viral illness with vomiting and diarrhea
A 55-year-old male client is brought to the emergency department by his spouse due to sudden weakness, dizziness, and confusion. The spouse states that the client has had persistent fatigue and nausea for the past few days but suddenly became disoriented and lethargic this morning. The client also reports severe abdominal pain and muscle cramps
Question 1 of 5
Complete the diagram by specifying 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,E,F,A,D
Rationale: The client's symptoms and history of steroid use suggest acute adrenal crisis. Fluid resuscitation and glucose monitoring are critical actions, while blood pressure and electrolytes are key parameters to monitor.
Extract:
Question 2 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.
Question 3 of 5
A client is admitted to the intensive care unit (ICU) after a colon resection with the formation of a loop colostomy. The nurse determines the client's abdominal dressing is clean and dry. Vital signs are temperature 100° F (37.8° C) orally, heart rate 132 beats/minute, blood pressure 88/65 mm Hg, and urine output 10 mL/hour. Which intervention should the nurse implement?
Correct Answer: C
Rationale: The client has tachycardia, hypotension, and oliguria, suggesting hypovolemic shock. A fluid bolus is the first-line treatment to restore intravascular volume, improve blood pressure, and increase urine output.
Question 4 of 5
A client is brought to the emergency department (ED) following a motor vehicle collision with blunt trauma to the chest. Which finding should the nurse report immediately to the healthcare provider (HCP)?
Correct Answer: A
Rationale: Muffled heart tones suggest cardiac tamponade, a life-threatening emergency requiring immediate intervention.
Question 5 of 5
The healthcare provider (HCP) changes a prescription for a nitroglycerin IV infusion from 10 mcg/min to 15 mcg/min. The IV bag contains nitroglycerin 50 mg in dextrose 5% in water (DW) 250 mL. The nurse should program the infusion pump to deliver how many mL/hr? (Enter numerical value only. If rounding is required, round to the nearest whole number.)
Correct Answer: A
Rationale: Calculation: 15 mcg/min × 60 min/hour = 900 mcg/hour. 900 mcg/hour / 1000 = 0.9 mg/hour. Concentration = 50 mg / 250 mL = 0.2 mg/mL. Infusion rate = 0.9 mg/hour / 0.2 mg/mL = 4.5 mL/hour, rounded to 5 mL/hour.