HESI RN
HESI RN Med Surg 3 Questions
Extract:
Question 1 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 2 of 5
A client is admitted to the neurological intensive care unit after having just sustained a C5 spinal cord injury (SCI). Which assessment finding for this client warrants immediate intervention by the nurse?
Correct Answer: A
Rationale: A C5 spinal cord injury can impair diaphragmatic function and respiratory effort, leading to respiratory failure. Shallow and labored breathing suggests that the client is experiencing respiratory compromise, which can quickly progress to hypoventilation, hypoxia, and respiratory arrest. Immediate intervention, such as assisted ventilation or intubation, may be necessary to maintain adequate oxygenation and prevent further complications.
Question 3 of 5
The nurse is caring for a client with massive gastrointestinal bleeding from a gastric ulcer who received 6 units packed red blood cells (PRBCs) and 2 units fresh frozen plasma (FFP). The most recent laboratory results are a hemoglobin of 8.0 g/dL (4.96 mmol/L), platelets of 82,000/gi bleeding, requiring urgent volume replacement to restore perfusion.
Correct Answer: A
Rationale: Administer a PRN bolus normal saline. The client is exhibiting signs of hypovolemic shock, including tachycardia (HR 110 bpm), tachypnea (RR 24), and hypotension (BP 80/50 mmHg) following massive gastrointestinal bleeding and multiple blood transfusions. Immediate fluid resuscitation with a normal saline bolus is the priority to restore intravascular volume, maintain perfusion, and prevent further deterioration.
Question 4 of 5
A client with a gunshot wound is brought to the emergency department (ED) with a bullet entry at the spinal level of C8 and T1. The client is able to move the upper arms. To further assess the client's spinal nerve function, which action should the nurse implement?
Correct Answer: C
Rationale: The C8 and T1 spinal nerves control hand and finger movements. Testing grip strength assesses nerve integrity at the injury level.
Question 5 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.