HESI RN
HESI RN Medical Surgical Questions
Extract:
Question 1 of 5
The nurse is caring for a client that is unconscious and having seizures. Which nursing intervention is most essential in this client's plan of care?
Correct Answer: A
Rationale: Ensuring oral suction is available is the most essential intervention to maintain a clear airway and prevent aspiration during and after seizures, particularly in an unconscious client.
Extract:
Initial Assessment
Orders
A 34-year-old male client presents to the emergency department (ED) for an acute asthma attack which began after jogging through a local park. The client is able to answer questions, pausing every few words to catch his breath. The client reports using a rescue Inhaler three times, but he just couldn't catch his breath. The client reports that symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous. The client reports that it has been a couple of months since he had an asthma attack, and he came to the ED today because he noticed that his inhaler was expired and was worried the medication was not working.
Question 2 of 5
The nurse has identified the priority problem for the client and now must determine proper care interventions. Based on the client history and the assessment data, what action(s) should the nurse anticipate? Select all that apply.
Correct Answer: A,B,C,F
Rationale: Client education, oxygen therapy, obtaining medication history, and administering ordered medications address the client's asthma exacerbation and promote effective management.
Question 3 of 5
After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen. Which action(s) should the nurse take next? Select all that apply.
Correct Answer: A,B,C,D,F
Rationale: Increasing oxygen flow, administering additional nebulizer treatment, raising the head of the bed, applying a nonrebreather mask, and monitoring vital signs address persistent respiratory distress and low oxygen saturation.
Extract:
History and Physical Nurses' Notes
A 34-year-old male client presents to the emergency department (ED) for an acute asthma attack which began after jogging through a local park. The client is able to answer questions, pausing every few words to catch his breath. The client reports using a rescue Inhaler three times, but he just couldn't catch his breath. The client reports that symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous. The client reports that it has been a couple of months since he had an asthma attack, and he came to the ED today because he noticed that his inhaler was expired and was worried the medication was not working.
Initial Assessment
Temperature 98.9° F (37.1° C)
Heart rate 112 beats/minute
Respirations 28 breaths/minute
Blood pressure 130/86 mm Hg
Oxygen saturation 88% on room air
Lung sounds reveal expiratory wheezes
Capillary refill time 2 seconds
Orders
Administer albuterol 2.5 mg/ipratropium bromide 0.5 mg in 3 mL solution via nebulizer four times a day and PRN.
Administer prednisone 60 mg PO
Administer oxygen to keep oxygen saturation greater than 94%, titrate as needed.
Question 4 of 5
The nurse has implemented additional needed actions. Click the assessment data which indicates the interventions were successful and which assessment data provides no indication that the interventions were successful.
| Options | Indicates the Interventions Were Successful | No Indication that the Interventions Were Successful |
|---|---|---|
| Decrease in heart rate from 112 to 105 beats per minute. | ||
| Client able to speak in full sentences without pausing. | ||
| Clear lung sounds. | ||
| Reduction in respiratory rate to 16 breaths per minute. | ||
| Client reports breathing is eased. | ||
| Blood pressure within normal limits. |
Correct Answer: A,B,C,D,E,F
Rationale: The assessment data showing decreased heart rate, ability to speak in full sentences, clear lung sounds, reduced respiratory rate, eased breathing, and stable blood pressure all indicate successful interventions for the asthma attack.
Extract:
Nurses' Notes
A 34-year-old male client presents to the emergency department (ED) for an acute asthma attack which began after jogging through a local park. The client is able to answer questions, pausing every few words to catch his breath. The client reports using a rescue Inhaler three times, but he just couldn't catch his breath. The client reports that symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous. The client reports that it has been a couple of months since he had an asthma attack, and he came to the ED today because he noticed that his inhaler was expired and was worried the medication was not working.
Initial Assessment
Temperature 98.9° F (37.1° C)
Heart rate 112 beats/minute
Respirations 28 breaths/minute
Blood pressure 130/86 mm Hg
Oxygen saturation 88% on room air
Lung sounds reveal expiratory wheezes
Capillary refill time 2 seconds
Question 5 of 5
Complete the following sentences by choosing from the lists of corresponding options. Based on history and assessment data, the nurse should prioritize [condition] as the priority problem for this client, as evidenced by the client's statement, [statement].
Correct Answer: D
Rationale: The client's difficulty breathing, need to pause to catch breath, ineffective rescue inhaler, and oxygen saturation of 88% indicate impaired gas exchange, requiring immediate intervention to improve respiratory function.