HESI RN
Hesi Med Surg Questions
Extract:
Question 1 of 5
On the third postoperative day, a client who has had a hip replacement surgery becomes anxious and diaphoretic, and begins to experience auditory hallucinations. The client denies having any pain. The client's vital signs are pulse rate is 125 beats/minute, respiratory rate is 36 breaths/minute, and blood pressure is 166/88 mmHg. Which nursing interventions should the nurse implement? (Select all that apply.)
Correct Answer: A,C,E
Rationale: Reorienting, administering lorazepam, and presenting a calm demeanor help manage postoperative delirium symptoms like hallucinations, ensuring patient safety and comfort.
Question 2 of 5
The nurse calls the healthcare provider because a client diagnosed with an abdominal aortic aneurysm (AAA) is reporting of low back pain. Which additional information about the client would be important for the nurse to tell the healthcare provider?
Correct Answer: B
Rationale: Hematocrit and blood pressure are critical for AAA, as low hematocrit may indicate rupture or bleeding, and high blood pressure can exacerbate the aneurysm, necessitating urgent reporting.
Question 3 of 5
A client taking antibiotics for three days to treat a Streptococcal throat infection returns to the clinic reporting a feel itchy rash across the chest and arms. The nurse auscultates pulmonary wheezing and an elevated heart rate. Which action should the nurse implement?
Correct Answer: C
Rationale: Symptoms like rash, wheezing, and tachycardia suggest an allergic reaction to antibiotics, requiring immediate cessation to prevent progression to severe reactions like anaphylaxis.
Question 4 of 5
An older client with cirrhosis of the liver and hepatic failure is placed on a low sodium diet and is receiving periodic albumin infusions. Which assessment finding indicates progress toward the desired effect of this treatment plan?
Correct Answer: D
Rationale: Decreased abdominal girth indicates reduced ascites, a direct result of low sodium diet and albumin infusions, which reduce fluid retention and increase oncotic pressure.
Question 5 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: C
Rationale: A high-pitched sound (stridor) indicates potential airway obstruction, a life-threatening emergency requiring immediate intervention to ensure airway patency.