HESI RN
HESI RN Med Surg 3 Questions
Extract:
Question 1 of 5
The nurse assesses a client postoperatively who has an arterial line in the right radial artery. Assessment findings include pallor, paresthesia, and slow capillary refill in the client's right-hand fingers. Which action should the nurse take?
Correct Answer: D
Rationale: The pallor, paresthesia, and delayed capillary refill suggest arterial insufficiency, possible thrombosis, or arterial spasm, which can lead to tissue ischemia and necrosis if not addressed promptly. The healthcare provider should be notified immediately to assess the need for interventions such as removal of the arterial line, vascular assessment, or anticoagulation therapy.
Question 2 of 5
A pH level of ________ and bicarbonate (HCO3-) level of ________ indicate a resolution of ketoacidosis.
Correct Answer: C
Rationale: A pH of 7.38 and bicarbonate of 24 mEq/L are within normal ranges, indicating resolution of ketoacidosis.
Question 3 of 5
The nurse assesses the telemetry monitor of a client who is 24 hours postoperative from having a permanent pacemaker insertion. The nurse observes that a pacemaker spike is present before each QRS complex in lead II of the electrocardiogram (ECG). Which intervention should the nurse implement?
Correct Answer: A
Rationale: A pacemaker spike before each QRS complex indicates that the pacemaker is functioning properly and triggering ventricular depolarization as intended. Since the client is 24 hours postoperative from a pacemaker insertion, this is an expected finding and should be documented accordingly.
Question 4 of 5
A client is admitted to the intensive care unit with multisystem organ dysfunction syndrome (MODS). The client is restless, febrile, and nauseated. Insulin is infusing at 5 units/hour per protocol to keep blood glucose less than 150 mg/dL (8.3 mmol/L). Dopamine is infusing at 5 mcg/kg/minute per protocol to keep mean arterial pressure (MAP) greater than 65 mm Hg. Serum blood glucose is 160 mg/dL and MAP is 66 mm Hg. The client is receiving oxygen at 50% via face mask and has an oxygen saturation of 92%. Which intervention should the nurse implement?
Correct Answer: B
Rationale: Blood glucose of 160 mg/dL requires increasing insulin by 1 unit/hour per protocol to maintain levels below 150 mg/dL.
Question 5 of 5
After 15 minutes of cardiopulmonary resuscitation (CPR) and multiple defibrillations, a client has return of spontaneous circulation (ROSC) with a heart rate of 130 beats/minute and ST elevation in leads I,II, III, aVF, aVL, V5, V6. Which serum laboratory values are most important for the nurse to monitor?
Correct Answer: D
Rationale: Troponin is the most specific and sensitive biomarker for myocardial infarction, indicated by ST elevation in multiple leads.