HESI RN
HESI RN Med Surg Questions
Extract:
Question 1 of 5
During a follow-up clinic visit, a mother tells the nurse that her 5-month-old son who had surgical correction for tetralogy of Fallot (TOF) has rapid breathing, often takes a long time to eat, and requires frequent rest periods. The infant is not crying while being held and his growth is in the expected range. Which intervention should the nurse implement?
Correct Answer: C
Rationale: Auscultating heart and lungs while the infant is held is a noninvasive way to assess respiratory and cardiac status, monitoring for abnormal sounds or changes in heart rate and oxygen saturation. Other options are not prioritized or appropriate.
Question 2 of 5
A client with type 2 diabetes mellitus arrives to the clinic reporting episodes of weakness and palpitations. Which finding is most important for the nurse to monitor?
Correct Answer: C
Rationale: Weakness and palpitations suggest hypoglycemia, with excessive perspiration (diaphoresis) being a classic symptom, indicating the body's response to low blood sugar, requiring immediate monitoring.
Question 3 of 5
The clinic nurse receives a call from a parent of a 10-year-old who reports that their child just returned from summer camp and has developed an expanding circular red rash on the arm. The parent asks the nurse which over-the-counter (OTC) product is safe to use. How should the nurse respond?
Correct Answer: D
Rationale: An expanding circular rash may indicate Lyme disease, requiring urgent medical evaluation. OTC products may be ineffective or harmful.
Question 4 of 5
The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding requires immediate action by the nurse?
Correct Answer: A
Rationale: A high-pitched sound (stridor) upon inspiration suggests airway obstruction, a life-threatening emergency requiring immediate action to ensure airway patency and adequate oxygenation post-surgery.
Question 5 of 5
The nurse is admitting a client with possible tuberculosis (TB). The client is placed in a private room with airborne precautions pending diagnostic test results. Which diagnostic test should the nurse review to confirm the diagnosis of TB?
Correct Answer: A
Rationale: A sputum culture positive for Mycobacterium tuberculosis is the gold standard for confirming TB diagnosis, as it directly identifies the causative bacterium, unlike other tests which may suggest but not confirm TB.