HESI RN
HESI RN Medical Surgical Exam I Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a history of type 2 diabetes mellitus (DM) and hypertension who arrived at the clinic for a scheduled visit. Which finding should the nurse recognize as a possible complication?
Correct Answer: C
Rationale: A serum creatinine level of 1.6 mg/dL indicates impaired kidney function, a significant complication in clients with type 2 diabetes and hypertension, suggesting diabetic or hypertensive nephropathy.
Question 2 of 5
Four days following an abdominal aortic aneurysm repair, the client is exhibiting edema of both lower extremities, and pedal pulses are not palpable. Which action should the nurse implement first?
Correct Answer: C
Rationale: Assessing pulses with a vascular doppler is critical to determine blood flow in the lower extremities, identifying potential vascular complications.
Extract:
Nurse's Notes
History and Physical
Initial Assessment
Temperature: 98.9°F
Heart rate: 112 beats per minute
Respirations: 28 breaths per minute
Blood pressure: 130/86 mmHg
Oxygen saturation: 88%
Lung sounds reveal expiratory wheezes
Capillary refill time: 2 seconds
Question 3 of 5
The nurse has identified the priority problem for the client and now needs to determine proper care interventions. Based on the client's history and assessment data, which actions should the nurse anticipate? Select all that apply.
Correct Answer: A,B,E
Rationale: Administering medications (
A), providing teaching (
B), and obtaining medication history (E) address acute asthma and prevent recurrence.
Extract:
Question 4 of 5
The nurse obtains a fingerstick blood glucose level using a bedside glucose meter from a client with a prescribed sliding scale insulin protocol. The meter indicates 56 mg/dL (3.12 mmol/L). At this time, which intervention should the nurse implement first?
Correct Answer: B
Rationale: Giving the client six ounces of non-diet carbonated soda is the correct first intervention. The client's blood glucose level is significantly below the normal range (hypoglycemia). Administering a fast-acting carbohydrate, such as non-diet soda, helps to quickly increase the blood glucose level to a safer range.
Question 5 of 5
The nurse assesses an adult client 24 hours after a bowel exploration and formation of a sigmoid colostomy. Which assessment finding should be reported to the surgeon immediately?
Correct Answer: D
Rationale: Purple stoma mucosa indicates possible ischemia, requiring immediate reporting to prevent tissue necrosis.