HESI RN Med Surg | Nurselytic

Questions 176

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HESI RN Med Surg Questions

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Question 1 of 5

The nurse is assessing the lung sounds of a preschooler. Which action should the nurse implement to ensure the child's cooperation?

Correct Answer: B

Rationale: Allowing the child to use a stethoscope on a stuffed animal helps the child understand the purpose of the stethoscope, reduces fear of the unfamiliar device, and encourages cooperation. Other options may distract the child or alter breathing patterns, interfering with the assessment.

Question 2 of 5

Lactulose was prescribed two days ago for a client who was recently diagnosed with hepatic encephalopathy. The client is confused and experiencing frequent loose stools. Laboratory findings show an elevated serum ammonia (NH) level of 220 μg/dL (157.1 μmol/dL). Which action should the nurse take?

Correct Answer: B

Rationale: Lactulose reduces ammonia levels by promoting its excretion, and the elevated ammonia level indicates the need to continue therapy. Loose stools are an expected effect, and continuing the dose addresses the underlying hepatic encephalopathy.

Question 3 of 5

In providing discharge teaching to a client with chronic obstructive pulmonary disease (COPD), which instruction is most important for the nurse to emphasize?

Correct Answer: A

Rationale: Changes in sputum color may indicate infection or exacerbation in COPD, requiring prompt reporting to the healthcare provider for timely management to prevent worsening respiratory status.

Question 4 of 5

A client with metastatic cancer reports a pain level of 10 on a scale of 0 to 10. Twenty minutes after the nurse administers an IV analgesic, the client reports no pain relief. Which intervention is most important for the nurse to include in this client's plan of care?

Correct Answer: C

Rationale: Persistent pain despite IV analgesia suggests breakthrough pain, requiring monitoring to adjust the pain management regimen promptly, addressing exacerbations effectively.

Question 5 of 5

The nurse is performing a routine assessment of a 3-year-old at a community health center. Which behavior by the child should alert the nurse to request a follow-up for a possible autism spectrum disorder (ASD)?

Correct Answer: D

Rationale: Odd repetitive behaviors are specific to ASD, indicating a need for follow-up. Other behaviors are less specific or normal.

Similar Questions

A client presents with the onset of a severe headache, fever, nuchal rigidity, and a petechial rash on arms and legs. The nurse recognizes the client is exhibiting symptoms of which condition?
A 9-year-old boy is diagnosed with type 1 diabetes mellitus (DM). Which stage of Erikson’s theory of psychosocial development is the nurse addressing when teaching this client about insulin injections?
While assisting a client to the toilet, the client begins to have a seizure and the nurse eases the client to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first?
An adolescent client reports to the nurse of walking with a limp due to pain localized in the right knee which worsens at night but denies any recent injury or trauma. The nurse observes swelling and tenderness in the right lower thigh and imaging results reveal radial ossification in the soft tissues. Which condition should the nurse consider as the probable cause of the findings?
The nurse is evaluating a client's understanding of diet teaching about the DASH (Dietary Approaches to Stop Hypertension) eating plan. Which behavior indicates that the client is adhering to the eating plan?

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