HESI RN
HESI RN Med Surg 3 Questions
Extract:
Question 1 of 5
The nurse is completing a neurological assessment on a client with a head injury. The Glasgow Coma Scale (GCS) score is 14. Which intervention should the nurse implement?
Correct Answer: D
Rationale: A GSC of 14 indicates mild head injury. Frequent monitoring every 2 hours detects worsening conditions.
Question 2 of 5
Based on this rhythm strip, which interpretation should the nurse make?
Correct Answer: D
Rationale: Atrial flutter is characterized by regular, rapid atrial depolarizations (flutter waves) at a rate of 250–350 bpm, creating a 'sawtooth' pattern on the ECG. The ventricular response may be regular or irregular, depending on AV conduction.
Question 3 of 5
The vital signs for a client with heart failure (HF), who is admitted to the intensive care unit (ICU), are a temperature of 98.6° F (37°C), heart rate 125 beats/minute, respirations 22 breaths/minute, and blood pressure 140/50 mm Hg. The nurse determines the client's central venous pressure (CVP) and pulmonary artery wedge pressure (PAWP) are elevated. Which intervention should the nurse implement?
Correct Answer: C
Rationale: Elevated CVP and PAWP indicate fluid overload. Furosemide reduces preload and promotes diuresis, improving symptoms.
Question 4 of 5
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.
Correct Answer: A,B
Rationale: High-flow oxygen improves oxygenation in suspected pneumothorax or hemothorax. Obtaining a chest tube insertion kit prepares for definitive treatment.
Question 5 of 5
The nurse is caring for a client with massive gastrointestinal bleeding from a gastric ulcer who received 6 units packed red blood cells (PRBCs) and 2 units fresh frozen plasma (FFP). The most recent laboratory results are a hemoglobin of 8.0 g/dL (4.96 mmol/L), platelets of 82,000/gi bleeding, requiring urgent volume replacement to restore perfusion.
Correct Answer: A
Rationale: Administer a PRN bolus normal saline. The client is exhibiting signs of hypovolemic shock, including tachycardia (HR 110 bpm), tachypnea (RR 24), and hypotension (BP 80/50 mmHg) following massive gastrointestinal bleeding and multiple blood transfusions. Immediate fluid resuscitation with a normal saline bolus is the priority to restore intravascular volume, maintain perfusion, and prevent further deterioration.