HESI RN
HESI RN Medical Surgical Exam I Questions
Extract:
History and Physical
Nurses' Notes
Orders
A 34-year-old male client presents to the emergency department (ED) for an asthma attack that began after jogging through a local park. The client is able to answer questions every few words to catch his breath. He reports using his rescue inhaler three times, but he couldn't catch his breath. He reports that his symptoms are worse when outdoors and when exercising, and episodes like this make him extremely nervous. He says that it has been a couple of months since his last asthma attack, and he came to the ED today because he noticed his inhaler was expired and was worried the medication was not working.
Question 1 of 5
The nurse has implemented additional needed actions. Indicate the assessment data which indicate the interventions were successful and which assessment data provide no indication that the interventions were successful.
| Options | No indication that the interventions were successful | Indicated the interventions were successful |
|---|---|---|
| The client can now speak in full sentences without pausing. | ||
| Respirations at 16 breaths per minute | ||
| Blood pressure at 122/84 mmHg | ||
| The client reporting, 'It's a lot easier to breathe now.' | ||
| Heart rate at 105 beats per minute | ||
| Lung sounds being clear |
Correct Answer: A,B,D,F
Rationale: Speaking in sentences (
A), normal respirations (
B), client report (
D), and clear lungs (F) indicate success; blood pressure (
C) and heart rate (E) do not.
Extract:
Vital Signs
Nurses Notes
History and Physical
Imaging Studies
Laboratory Results
Orders
0930
• Temperature: 100.8°F (38.2°C) orally
• Heart rate: 121 bpm
• Respirations: 28 bpm
• Blood pressure: 115/76
• Oxygen saturation: 95% on room air
Question 2 of 5
The nurse is stabilizing the client and preparing her for surgery. Which goals should the nurse prioritize in the plan of care for the client while in the emergency department (ED)? Select all that apply.
Correct Answer: A,B,C,D,G
Rationale: Infection prevention (
A), pain relief (
B), education (
C), anxiety coping (
D), and fluid management (G) are critical for appendicitis surgery preparation.
Extract:
Question 3 of 5
A client with Addison's disease started taking hydrocortisone in a divided daily dose last week. It is most important for the nurse to monitor which serum laboratory value?
Correct Answer: D
Rationale: Glucose levels are crucial to monitor in clients with Addison's disease on hydrocortisone therapy. Hydrocortisone can affect glucose metabolism, potentially leading to hyperglycemia. Monitoring glucose levels helps ensure that the client's blood sugar remains within a safe range and allows for timely intervention if necessary.
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
During a routine eye examination, an older client reports decreased peripheral vision and is found to have elevated intraocular pressures. Ophthalmic drops are prescribed for primary open-angle glaucoma (POAG). Which intervention(s) should the nurse include in this client's plan of care? Select all that apply.
Correct Answer: B,D,E
Rationale: Teaching strategies for aseptic administration (
B) prevents infections, applying pressure over the inner eye corner (
D) enhances medication efficacy, and explaining lifelong use (E) ensures adherence. A reduced sodium diet (
A) is not directly related to POAG, and eye drops (
C) preserve vision, not improve it.