HESI RN
HESI RN Med Surg 3 Questions
Extract:
Question 1 of 5
The nurse is collecting a blood sample for a mixed venous oxygen saturation (SVO2) level from the distal lumen of a pulmonary artery (PA) catheter of a client in cardiogenic shock. Which action should the nurse implement?
Correct Answer: C
Rationale: At least 1 mL of blood is required for an accurate SVOâ‚‚ reading, ensuring sufficient sample volume.
Question 2 of 5
A client is admitted to the neurological intensive care unit after having just sustained a C5 spinal cord injury (SCI). Which assessment finding for this client warrants immediate intervention by the nurse?
Correct Answer: A
Rationale: A C5 spinal cord injury can impair diaphragmatic function and respiratory effort, leading to respiratory failure. Shallow and labored breathing suggests that the client is experiencing respiratory compromise, which can quickly progress to hypoventilation, hypoxia, and respiratory arrest. Immediate intervention, such as assisted ventilation or intubation, may be necessary to maintain adequate oxygenation and prevent further complications.
Question 3 of 5
A female client admitted with possible pneumonia and systemic inflammatory response syndrome (SIRS) is manifesting low oxygen saturation rates. Which additional finding(s) associated with SIRS should the nurse report to the health care provider (HCP)? Select all that apply.
Correct Answer: A,B,C,D
Rationale: Respiratory rate -22, heart rate -90, hypothermia <36°C, and WBC >12,000/mm³ meet SIRS criteria, indicating systemic inflammation.
Question 4 of 5
After an endotracheal tube (ETT) is initially placed for a client requiring mechanical ventilation, which intervention should the nurse implement first?
Correct Answer: D
Rationale: The first action after ETT placement is to auscultate bilateral breath sounds to confirm proper tube positioning. If the tube is misplaced in the esophagus, breath sounds will be absent or diminished bilaterally. If placed too deep, breath sounds may be absent on one side, indicating mainstem bronchus intubation. This immediate assessment helps identify misplacement before obtaining a chest x-ray.
Question 5 of 5
A client, who is 4 hours postoperative laparotomy, has rapidly increasing abdominal distention with elevated pulse and respiratory rates. The client's skin is cool and pale, and there is no change in the blood pressure. Which intervention should the nurse implement immediately?
Correct Answer: D
Rationale: The client's symptoms suggest early shock, likely due to postoperative internal bleeding. Immediate notification of the HCP ensures rapid assessment and intervention.