HESI RN
Hesi Med Surg Questions
Extract:
Question 1 of 5
The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding requires immediate action by the nurse?
Correct Answer: C
Rationale: A high-pitched sound (stridor) indicates potential airway obstruction, a life-threatening emergency requiring immediate intervention to ensure airway patency.
Question 2 of 5
The nurse is caring for a client who is still experiencing light sedation after undergoing an emergency colectomy for bowel obstruction. Which postoperative pain intervention should the nurse implement first?
Correct Answer: A
Rationale: Providing the prescribed pain medication first prevents pain escalation in a sedated client, using behavioral indicators like vital signs to guide administration, as self-reporting may be unreliable.
Question 3 of 5
An adult woman with Grave's disease is admitted with severe dehydration and malnutrition. She is currently restless and refusing to eat. Which action is most important for the nurse to implement?
Correct Answer: C
Rationale: Maintaining a patent IV site allows administration of fluids, electrolytes, and nutrients, addressing the critical dehydration and malnutrition in Grave's disease, which takes precedence over other supportive measures.
Question 4 of 5
During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?
Correct Answer: B
Rationale: Exposure to a new dog may introduce allergens like dander, triggering an eczema flare-up, making this information critical for identifying the cause of the exacerbation.
Question 5 of 5
On the third postoperative day, a client who has had a hip replacement surgery becomes anxious and diaphoretic, and begins to experience auditory hallucinations. The client denies having any pain. The client's vital signs are pulse rate is 125 beats/minute, respiratory rate is 36 breaths/minute, and blood pressure is 166/88 mmHg. Which nursing interventions should the nurse implement? (Select all that apply.)
Correct Answer: A,C,E
Rationale: Reorienting to time, administering lorazepam, and maintaining a calm demeanor address anxiety and hallucinations, reducing distress without increasing stimulation or using restraints unnecessarily.