HESI RN
RN Medical Surgical HESI Questions
Extract:
Question 1 of 5
The client is in respiratory distress with an oxygen saturation of 78% on a non-rebreather oxygen mask. His abdomen is distended and tense. His skin is pale with capillary refill of 7 seconds. His pulses are faint. Electrocardiogram reveals heart rate of 88 beats/minute, normal sinus rhythm. Lung sounds are clear and equal bilaterally. The client's temperature is 97 °F (36.1 °C). Drag from the choices area to specify which 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 progress.
Correct Answer: C
Rationale: Abdominal compartment syndrome is indicated by distended abdomen and respiratory distress. Paracentesis and fluid boluses address pressure and perfusion. Monitor oxygen saturation and urine output to assess progress.
Question 2 of 5
A client with gouty arthritis reports tenderness and swelling of the right ankle and great toe. The nurse observes the area of inflammation extends above the ankle area. The client receives prescriptions for colchicine and indomethacin. Which instruction should the nurse include in the discharge teaching?
Correct Answer: A
Rationale: Colchicine and indomethacin can cause liver toxicity, necessitating periodic liver function tests. Massaging joints, limiting mobility aids, or drinking fruit juices (high in fructose) are not advised.
Question 3 of 5
After performing a head-to-toe assessment for a client with Addison's disease, the nurse reports findings to the healthcare provider. The findings include moist mucous membranes, strong palpable peripheral pulses, and blood pressure 132/88 mm Hg. The client verbalizes understanding of the illness and importance of taking medications every day. Which action should the nurse implement?
Correct Answer: C
Rationale: With stable vital signs, adequate hydration, and good self-care knowledge, the client is ready for discharge. The other actions are unnecessary given the client's stable condition.
Question 4 of 5
A client with acquired immune deficiency syndrome (AIDS) and Pneumocystis jiroveci pneumonia has a CD4+ T cell count of 200 cells/mm³ (20%). The client asks the nurse why they have these recurring massive infections. Which pathophysiologic mechanism should the nurse describe in response to this client's question?
Correct Answer: B
Rationale: HIV destroys CD4+ T cells, impairing cellular immunity and macrophage activation, leading to opportunistic infections like Pneumocystis jiroveci pneumonia.
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 airway obstruction, a life-threatening emergency requiring immediate action. Other findings are expected or less urgent post-appendectomy.