HESI RN Medical Surgical Nursing | Nurselytic

Questions 57

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HESI RN Medical Surgical Nursing Questions

Extract:

History and Physical
Nurses' Notes
Orders
Imaging Studies
The client is a young male who appears to be 25 to 30 years old. He was found unconscious on a sidewalk by a jogger who was passing by. The jogger called an ambulance, and the emergency medical technicians (EMTS) transported the client to the hospital. The client is arousable but unable to say what his name is or what happened to him. A STAT head computed tomography (CT) scan in the emergency department showed no abnormalities, so the client will be admitted to the medical floor for observation and further tests.


Question 1 of 5

The nurse identifies that the client is having a tonic clonic seizure. The oxygen saturation is 40% and the respiratory rate is 4 breaths/minute. The nurse calls for help and 2 other nurses enter the room. Which 3 interventions should be performed first?

Correct Answer: B,C,E

Rationale: Ventilation, oxygen increase, and seizure monitoring address hypoxia and safety during a tonic-clonic seizure.

Extract:


Question 2 of 5

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?

Correct Answer: B

Rationale: C-reactive protein (CRP) is a sensitive marker of inflammation, which often accompanies worsening wound size. Neutrophils indicate acute infection, platelets relate to clotting, and electrolytes are not directly related to wound healing.

Extract:

Nurses' Notes
0900
The 54-year-old female client returned to room from postanesthesia care unit (PACU). Situation- background-assessment-recommendation (SBAR) communication reveals client has had no urine output during the anesthesia recovery period. Last void was 8 hours ago. Client positioned in bed. Warm blanket applied for comfort. IV fluids infusing.
1045
Client requesting pain medication and says has the urge to void. Wishes to use bedpan. Voided 75 mL.
1130
Client informs she continues to have the urge to void and feels, "Wet." Placed on bedpan. Voided 50 mL. Bladder palpated and feels full. Bladder scanner applied and revealed 600 mL residual urine.


Question 3 of 5

The nurse is planning care for the client. Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Actions to Take Choices A. Request prescription for external catheter device B. Request prescription for straight catheter C. Insert indwelling urinary catheter D. Assist client to bathroom for voiding E. Increase the IV fluid rate
Potential Condition Choices A. Urinary Retention B. Urinary tract obstruction C. Overflow Urinary Incontinence D. IV fluid intake E. Frequency of voiding
Parameters to monitor Choices A. Amount of urine output B. Residual urine C. Pain medication effects D. IV fluid intake E. Frequency of voiding

Correct Answer: A

Rationale: Urinary retention, indicated by high residual urine, requires straight and indwelling catheters, with monitoring of urine output and residual urine.

Extract:


Question 4 of 5

A client with chronic venous insufficiency is being discharged from the hospital, and plans to return home. Which client statement indicates an understanding of home care instructions?

Correct Answer: C

Rationale: Avoiding prolonged sitting and leg crossing improves venous return, aligning with chronic venous insufficiency management.

Question 5 of 5

A client is receiving a secondary infusion of vancomycin 1,500 mg in 250 ml to be infused over two hours. The IV administration set delivers 15 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: 31

Rationale: Using the formula (250 mL x 15 gtt/mL) / 120 min = 31.25 gtt/min, rounded to 31 gtt/min.

Similar Questions

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The nurse reviews client data. Select the 3 possible conditions that could have the clinical manifestation of clubbed nails for this client.
The nurse has determined that a client with trigeminal neuralgia has the nursing problem, 'Imbalanced nutrition, less than body requirements.' Which cause is most likely contributing to the problem?
The nurse is evaluating a client's symptoms, and formulates the nursing problem, 'High risk for injury due to potential urinary tract infection.' Which symptoms indicate the need for this nursing problem?
The nurse provides education about seizures to the client and asks the client to explain what he understands about his condition. For each statement click to specify if the client demonstrates an understanding or no understanding.

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