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HESI RN Med Surg 3 Questions

Extract:


Question 1 of 5

The nurse is caring for a client who has hemorrhaged postoperatively and is in an early stage of shock. Which cardiopulmonary symptoms are most indicative of progressive hypovolemic shock?

Correct Answer: C

Rationale: Tachycardia, lowered systolic BP, and peripheral mottling are characteristic of progressive hypovolemic shock due to reduced circulating volume.

Question 2 of 5

After 15 minutes of cardiopulmonary resuscitation (CPR) and multiple defibrillations, a client has return of spontaneous circulation (ROSC) with a heart rate of 130 beats/minute and ST elevation in leads I,II, III, aVF, aVL, V5, V6. Which serum laboratory values are most important for the nurse to monitor?

Correct Answer: D

Rationale: Troponin is the most specific and sensitive biomarker for myocardial infarction, indicated by ST elevation in multiple leads.

Question 3 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 4 of 5

After intubating a client, correct placement of the endotracheal tube (ETT) is confirmed with a chest x-ray. Which intervention should the nurse implement to ensure that the ETT placement is maintained?

Correct Answer: C

Rationale: After proper ETT placement is confirmed with a chest x-ray, securing the tube with adhesive tape or a commercial ETT holder prevents displacement. Unintentional extubation or tube migration can lead to hypoxia, respiratory distress, or esophageal intubation, making proper tube fixation a priority intervention.

Extract:

Laboratory Results
0600
Laboratory Test
Results
Reference Range
pH
7.23
7.35 to 7.45
Partial pressure of oxygen (PaO2)
89 mm Hg
80 to 100 mm Hg
Partial
37 mm
35 to 45


Question 5 of 5

Based on the ABG values, the nurse knows that the client has [condition] related to [cause].

Correct Answer: D,G

Rationale: Uncompensated metabolic acidosis is characterized by a low pH (7.23) and normal PaCOâ‚‚ (37 mmHg), indicating a primary metabolic problem without respiratory compensation. The lack of insulin in type 1 diabetes leads to ketone formation and metabolic acidosis.

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A client who is admitted to the emergency department (ED) following a motorcycle collision is having difficulty breathing. While assessing the client's chest and lungs, the nurse notes that there are no breath sounds over the left lung fields. Which action(s) should the nurse implement? Select all that apply.
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