HESI RN
HESI RN Medical Surgical Questions
Extract:
Nurses' Notes
A 34-year-old male client presents to the emergency department (ED) for an acute asthma attack which began after jogging through a local park. The client is able to answer questions, pausing every few words to catch his breath. The client reports using a rescue Inhaler three times, but he just couldn't catch his breath. The client reports that symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous. The client reports that it has been a couple of months since he had an asthma attack, and he came to the ED today because he noticed that his inhaler was expired and was worried the medication was not working.
Initial Assessment
Temperature 98.9° F (37.1° C)
Heart rate 112 beats/minute
Respirations 28 breaths/minute
Blood pressure 130/86 mm Hg
Oxygen saturation 88% on room air
Lung sounds reveal expiratory wheezes
Capillary refill time 2 seconds
Question 1 of 5
Complete the following sentences by choosing from the lists of corresponding options. Based on history and assessment data, the nurse should prioritize [condition] as the priority problem for this client, as evidenced by the client's statement, [statement].
Correct Answer: D
Rationale: The client's difficulty breathing, need to pause to catch breath, ineffective rescue inhaler, and oxygen saturation of 88% indicate impaired gas exchange, requiring immediate intervention to improve respiratory function.
Extract:
Question 2 of 5
The nurse is caring for a client who tests positive for the sexually transmitted infection (STI) gonorrhea. The client reports having sex with someone who has many partners. Which response should the nurse provide?
Correct Answer: A
Rationale: Teaching the importance of medication regimen and follow-up protocol is crucial for treating gonorrhea and preventing its spread.
Question 3 of 5
The nurse is caring for a client who is receiving teletherapy radiation for a malignant tumor. Which instruction regarding skin care of the portal site should the nurse provide?
Correct Answer: A
Rationale: Protecting the radiation portal site from sunlight exposure prevents further damage to the sensitive irradiated skin.
Question 4 of 5
Which dietary instruction is most important for the nurse to explain to a client who has had gastric bypass surgery?
Correct Answer: D
Rationale: Eating small frequent meals is crucial after gastric bypass surgery to prevent complications like dumping syndrome and manage portion sizes effectively.
Question 5 of 5
A client receives a prescription for 1 L of lactated Ringers to be infused IV over 8 hours. The IV administration set delivers 15 gtt/mL. How many mL/hr should the nurse program the infusion pump to deliver?
Correct Answer: A
Rationale:
To calculate the infusion rate: 1000 mL / 8 hr = 125 mL/hr. The nurse should program the infusion pump to deliver 125 mL/hr.