HESI RN
RN Medical Surgical HESI Questions
Extract:
Question 1 of 5
Following a motor vehicle accident, a client with chest trauma receives a chest tube to relieve a hemothorax. Two hours following the chest tube insertion, the nurse observes the water level in the water-seal chamber is rising during inspiration and falling during expiration. Which action should the nurse implement?
Correct Answer: C
Rationale: Water level fluctuations in the water-seal chamber are normal, indicating a functioning chest tube. The nurse should continue monitoring unless signs of complications arise.
Question 2 of 5
While completing a health assessment for a young adult female with acute appendicitis, the client informs the nurse that there is a chance that she may be pregnant. The operating team is preparing to take the client to surgery. Which intervention should the nurse implement immediately?
Correct Answer: A
Rationale: A bedside pregnancy test confirms pregnancy status, critical for surgical planning to avoid risks to the fetus.
Question 3 of 5
A client is hospitalized with an inflammatory bowel disease (IBD) exacerbation and is being treated with a corticosteroid. The client develops a rigid abdomen with rebound tenderness. Which action should the nurse take?
Correct Answer: D
Rationale: A rigid abdomen with rebound tenderness suggests peritonitis, a serious IBD complication. Obtaining vital signs is the priority to assess for infection, shock, or organ failure.
Extract:
Flow sheets
1915
Arrival at emergency department
1920
Vital Signs:
- Temperature: 98.2° F (36.8° C)
- Heart rate: 92 beats/minute
- Respirations: 24 breaths/minute
- Blood pressure: 210/98 mmHg
- Oxygen saturation: 95% on room air
Imaging studies
1935
Head CT scan results:
- No evidence of intracranial hemorrhage
- No evidence of acute disease
Orders
- Obtain CT scan of the head.
- Insert a large bore peripheral IV.
- Start normal saline infusion at 50 mL/hour.
Question 4 of 5
The client continues to have stable neurologic assessments. The nurse provides interventions to promote client safety while in the hospital. Of the interventions below, explain if it promotes clients safety or not, or does both.
| Options | Promotes client safety'Does not promote client safety |
|---|---|
| Place the client in a room near the elevator | |
| Complete a swallow study before giving anything by mouth | |
| Provide a call button kept within reach | |
| Initiate use of the bed alarm | |
| Place client belongings out of reach | |
| Instruct the client to call before getting up |
Correct Answer: B,C,D,F
Rationale: Swallow study, call button, bed alarm, and instructing to call promote safety by preventing aspiration, falls, and ensuring assistance. Elevator proximity and unreachable belongings do not.
Extract:
Question 5 of 5
A client who had a biliopancreatic diversion procedure (BPD) 3 months ago is admitted with severe dehydration. Which assessment finding warrants immediate intervention by the nurse?
Correct Answer: A
Rationale: Gastroccult positive emesis indicates gastrointestinal bleeding, a serious complication requiring immediate intervention. Other findings are common BPD side effects or less urgent.