HESI RN
HESI RN Medical Surgical Nursing Questions
Extract:
History and Physical
Nurses' Notes
Orders
Imaging Studies
The client is a young male who appears to be 25 to 30 years old. He was found unconscious on a sidewalk by a jogger who was passing by. The jogger called an ambulance, and the emergency medical technicians (EMTS) transported the client to the hospital. The client is arousable but unable to say what his name is or what happened to him. A STAT head computed tomography (CT) scan in the emergency department showed no abnormalities, so the client will be admitted to the medical floor for observation and further tests.
Question 1 of 5
The healthcare provider comes to the bedside following the seizure and prescribes phenytoin. The nurse administers the phenytoin as prescribed. Which possible side effect(s) of phenytoin should the nurse assess for after administration? Select all that apply.
Correct Answer: B,C,D,F
Rationale: Phenytoin may cause altered coagulation, visual disturbances, drowsiness, and ataxia, affecting safety and monitoring needs.
Extract:
Question 2 of 5
A middle-aged client reports a sudden onset of seeing flashing lights and floating spots. Which is the best nursing action?
Correct Answer: A
Rationale: Flashing lights and floaters suggest retinal detachment, requiring urgent ophthalmic evaluation.
Question 3 of 5
An older adult client arrives at the outpatient eye surgery clinic for a right cataract extraction and lens implant. During the immediate postoperative period, which intervention should the nurse implement?
Correct Answer: C
Rationale: An eye shield is crucial to protect the operated eye from accidental injury during sleep, preventing rubbing and potential complications. Deep breathing and coughing can increase intraocular pressure, teaching medication administration is not an immediate priority, and frequent vital sign monitoring is excessive for cataract surgery.
Question 4 of 5
Which nursing action is most helpful in promoting circulation in a client with chronic venous insufficiency?
Correct Answer: C
Rationale: Elevating lower extremities reduces venous pressure and promotes blood return, directly improving circulation in chronic venous insufficiency.
Question 5 of 5
A client with type 2 diabetes mellitus (DM) is admitted to the hospital for uncontrolled DM. Insulin therapy is initiated with an initial dose Isophane suspension insulin at 0800. At 1600, the client reports having diaphoresis, rapid heartbeat, and feeling shaky. Which should the nurse do first?
Correct Answer: B
Rationale: Checking glucose confirms hypoglycemia, indicated by symptoms, guiding appropriate treatment.