HESI RN
RN Medical Surgical HESI Questions
Extract:
Question 1 of 5
The client is a 19-year-old male who sustained a closed skull fracture and a humerus fracture while skateboarding. A cast was applied to the right arm to stabilize the humerus, and the client will be admitted to monitor his neurological status. Specify which potential condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's response.
Correct Answer: D
Rationale: Compartment syndrome is likely due to cast-related pressure. Elevate the extremity and remove the cast to relieve pressure. Monitor capillary refill and blood pressure for perfusion.
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.
The nurse administered tPA and conducted neurologic assessments every 15 minutes during the infusion.
The tPA infusion finished and the nurse performed neurologic assessments every 30 minutes for the 6 hours following the administration.
The client was noted to be stable with unchanged neurologic assessments.
The nurse begins to plan care for the client's recovery and identifies interdisciplinary team members who can assist with the client's recovery.
Question 2 of 5
The nurse begins to plan care for the client's recovery and identifies interdisciplinary team members who can assist with the client's recovery. Select the interdisciplinary team members who should assist the client in recovery.
| Occupational Therapist |
| Speech Therapist |
| Case manager |
| Physical therapist |
| Chief Nursing Officer |
Correct Answer: A,B,C,D
Rationale: Occupational, speech, and physical therapists address functional and communication deficits post-stroke, while a case manager coordinates care.
Extract:
Question 3 of 5
A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA), which information should the nurse include in the discharge instructions?
Correct Answer: B
Rationale: Monitoring urinary stream for decreased output detects complications like urinary retention post-TUNA, a priority for discharge teaching.
Question 4 of 5
The healthcare provider prescribes 1 liter of 0.9% sodium chloride, USP intravenously (IV) to be infused over 10 hours for a client. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only.)
Correct Answer: 100
Rationale: 1000 mL divided by 10 hours equals 100 mL/hr.
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 5 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.