HESI RN
HESI RN Med Surg Exam 2 Questions
Extract:
Question 1 of 5
The nurse determines that an adult client who is admitted to the postanesthesia care unit (PACU) following abdominal surgery has a tympanic temperature of 94.6°F (34.8°C), a heart rate of 88 beats/minute, a respiratory rate of 14 breaths/minute, and a blood pressure of 94/68 mm Hg. Which action should the nurse implement?
Correct Answer: B
Rationale: The correct answer is B because a low tympanic temperature may result from improper measurement, requiring verification with another method.
Choice A is unrelated to temperature.
Choice C is not the priority.
Choice D is routine but not immediate.
Question 2 of 5
A client with chronic kidney disease (CKD) missed dialysis yesterday to attend a funeral. The client's spouse calls the home health nurse and reports that the client is lethargic and hard to arouse. Which instruction is most important for the nurse to provide?
Correct Answer: B
Rationale: The correct answer is B because missed dialysis can cause severe electrolyte imbalances and fluid overload, requiring urgent medical evaluation.
Choice A is not targeted to the cause.
Choice C assesses access but not the acute issue.
Choice D is a general recommendation, not urgent.
Question 3 of 5
A client with chronic kidney disease on peritoneal dialysis exhibits redness, tenderness, and drainage around the catheter site on the abdominal wall. While planning care, the nurse is most concerned about preventing which complication related to these findings?
Correct Answer: D
Rationale: The correct answer is D because peritonitis, a severe infection, can result from catheter site infections and is life-threatening.
Choice A is unrelated to catheter issues.
Choice B is a dialysis complication but not directly linked to infection.
Choice C is a concern but less severe than peritonitis.
Question 4 of 5
A client with metastatic cancer reports a pain level of 10 on a 0 to 10 scale. Twenty minutes after the nurse administers an IV analgesic, the client states, 'No pain relief yet.' Which intervention is most important for the nurse to include in this client's plan of care?
Correct Answer: B
Rationale: The correct answer is B because a fixed analgesic schedule maintains consistent pain control in severe cases.
Choice A is routine but not immediate.
Choice C is part of management but secondary.
Choice D is essential but not the primary intervention.
Question 5 of 5
The nurse assesses an adult client 24 hours following abdominal surgery and finds the client's blood pressure is 98/40 mm Hg. The client is tachycardic, restless, and irritable. Which action should the nurse perform first?
Correct Answer: A
Rationale: The correct answer is A because low blood pressure and tachycardia suggest bleeding, which checking under the back can confirm.
Choice B is not the priority.
Choice C is secondary.
Choice D follows assessment.