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
When providing care for a child who is in balanced suspension skeletal traction using a Thomas splint and Pearson attachment to the right femur, which intervention is most important for the nurse to implement?
Correct Answer: D
Rationale: Monitoring pulses and sensation prevents complications like compartment syndrome or nerve damage, which are critical in traction. Other interventions are secondary.
Question 3 of 5
The nurse observes a mother giving her 11-month-old ferrous sulfate (iron drops), followed by 2 ounces (60 mL) of orange juice. What should the nurse do next?
Correct Answer: D
Rationale: Following iron drops with orange juice enhances iron absorption due to vitamin C, warranting positive feedback. Other actions are incorrect.
Question 4 of 5
The nurse is caring for a client with chemotherapy induced mucositis who is describing soreness of the tongue and oral tissues. Which is the best initial nursing action?
Correct Answer: D
Rationale: Frequent mouth care maintains oral hygiene, reduces infection risk, and soothes irritated tissues in mucositis, serving as the initial step before other interventions like analgesics.
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.