HESI RN
HESI RN Med Surg 3 Questions
Extract:
Question 1 of 5
The nurse identifies the collaborative problem of potential electrolyte imbalance in a client with acute pancreatitis. Which assessment finding should the nurse associate with an electrolyte imbalance related to acute pancreatitis?
Correct Answer: D
Rationale: Hypocalcemia in acute pancreatitis causes neuromuscular excitability, leading to muscle twitching and numbness.
Question 2 of 5
A young male adult walks into the emergency department (ED) holding a dead poisonous snake that bit him on his right calf within the last hour. After killing the snake, he tied a tablecloth about 4 inches (10 cm) above the bite. The client is now reporting numbness and tingling from the right knee to ankle. His heart rate is 123 beats/minute, respirations 28 breaths/minute, blood pressure 86/40 mm Hg, and oxygen saturation 94% on room air. Which intervention should the nurse implement?
Correct Answer: A
Rationale: Signs of shock due to envenomation require rapid IV access for fluid resuscitation and antivenom administration.
Question 3 of 5
A client is brought to the emergency department (ED) following a motor vehicle collision with blunt trauma to the chest. Which finding should the nurse report immediately to the healthcare provider (HCP)?
Correct Answer: A
Rationale: Muffled heart tones suggest cardiac tamponade, a life-threatening emergency requiring immediate intervention.
Question 4 of 5
The nurse is administering low dose dopamine to a client who is in septic shock. Which physiologic parameter should the nurse use to evaluate a therapeutic response to the dopamine?
Correct Answer: C
Rationale: Low-dose dopamine increases renal blood flow, improving urinary output, indicating effective renal perfusion.
Question 5 of 5
The nurse assesses a client postoperatively who has an arterial line in the right radial artery. Assessment findings include pallor, paresthesia, and slow capillary refill in the client's right-hand fingers. Which action should the nurse take?
Correct Answer: D
Rationale: The pallor, paresthesia, and delayed capillary refill suggest arterial insufficiency, possible thrombosis, or arterial spasm, which can lead to tissue ischemia and necrosis if not addressed promptly. The healthcare provider should be notified immediately to assess the need for interventions such as removal of the arterial line, vascular assessment, or anticoagulation therapy.