HESI RN
HESI RN Medical Surgical Exam I Questions
Extract:
Nurse's Notes
History and Physical
Initial Assessment
Temperature: 98.9°F
Heart rate: 112 beats per minute
Respirations: 28 breaths per minute
Blood pressure: 130/86 mmHg
Oxygen saturation: 88%
Lung sounds reveal expiratory wheezes
Capillary refill time: 2 seconds
Question 1 of 5
The nurse has identified the priority problem for the client and now needs to determine proper care interventions. Based on the client's history and assessment data, which actions should the nurse anticipate? Select all that apply.
Correct Answer: A,B,E
Rationale: Administering medications (
A), providing teaching (
B), and obtaining medication history (E) address acute asthma and prevent recurrence.
Extract:
Question 2 of 5
A client is recovering from the surgical removal of glass in the right eye. Which intervention should the nurse implement immediately following the procedure?
Correct Answer: C
Rationale: Providing an eye shield to be worn while sleeping protects the operated eye from injury, promoting healing.
Question 3 of 5
A client receives a prescription for 2 liters of lactated Ringer's IV to be infused over 12 hours. The IV administration set delivers 20 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)
Correct Answer: A
Rationale: Calculation: 2 liters = 2000 mL, 2000 mL × 20 gtt/mL = 40,000 gtt, 12 hours = 720 minutes, 40,000 ÷ 720 = 55.56, rounded to 56 gtt/min.
Question 4 of 5
A client who is experiencing a first gouty arthritis attack reports excruciating pain in the right great toe. The nurse inspects the inflamed joint and administers ibuprofen 800mg PO as prescribed. Which instruction should the nurse include in the discharge teaching?
Correct Answer: D
Rationale: Avoiding the consumption of wine, beer, and coffee is crucial for managing gout. Alcohol, particularly beer and wine, contains high levels of purines, which can increase uric acid production and exacerbate gout symptoms. Alcohol also promotes dehydration, which can lead to higher uric acid concentrations in the blood. Both of these factors can trigger gout attacks.
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 tachycardiac, restless, and irritable. Which action should the nurse perform first?
Correct Answer: C
Rationale: Checking for bleeding is critical as symptoms suggest hypovolemic shock, a potential postoperative complication.