HESI RN
HESI RN Med Surg Questions
Extract:
Question 1 of 5
The nurse is conducting an admission assessment of an infant with heart failure who is scheduled for repair of restenosis of coarctation of the aorta that was repaired 4 days after birth. Findings include blood pressure higher in the arms than the lower extremities, pounding brachial pulses, and slightly palpable femoral pulses. Which pathophysiologic mechanism supports these findings?
Correct Answer: A
Rationale: Coarctation of the aorta narrows the aortic lumen, reducing blood flow to the lower extremities, causing higher blood pressure in the arms and weaker pulses in the legs.
Question 2 of 5
A mother brings her preteen daughter to the clinic for her first female examination. During the health assessment, the nurse should implement which technique to determine if the client has reached the age of menarche?
Correct Answer: B
Rationale: Tanner staging assesses puberty stage, indicating likelihood of menarche. Other techniques are irrelevant or unreliable.
Question 3 of 5
For each client activity, click to indicate whether the activity shows positive or negative health promotion postamputation due to extensive peripheral vascular disease.
| Options | Positive | Negative |
|---|---|---|
| Inquires about blood pressure. (Positive) | ||
| Asks questions about self-care. (Positive) | ||
| Executes pull-ups on a trapeze bar. (Positive) | ||
| Turns side to side. (Positive) | ||
| Requests nurse to perform wound care. (Negative) | ||
| Avoids looking at residual limb. (Negative) |
Correct Answer: Positive: A,B,C,D; Negative: E,F
Rationale: Positive activities (inquiring about blood pressure, self-care questions, physical exercises, mobility) promote recovery and adaptation. Negative activities (relying on nurse for wound care, avoiding residual limb) hinder independence and psychological adjustment.
Question 4 of 5
The nurse calls the healthcare provider because a client diagnosed with an abdominal aortic aneurysm (AAA) is reporting low back pain. Which additional information about the client would be important for the nurse to tell the healthcare provider?
Correct Answer: B
Rationale: Low back pain in AAA may suggest aneurysm expansion or rupture. Hematocrit and blood pressure indicate potential bleeding or hemodynamic instability, critical for the provider's assessment.
Extract:
History and Physical
Nurses’ Notes
Flow sheet
Orders
Imaging Studies
A 19-year-old female client presents to the emergency department reporting tightness in her chest and difficulty breathing. The client's friend, who accompanied the client to the emergency department, reports she was at a park playing soccer with a group of college friends when the symptoms started. The park is close to a residential area where a fire was burning and there was a moderate breeze in the air. The client reported itching eyes and coughing. Approximately 15 minutes into the game, the client stopped running and held her hand on her chest, saying it felt tight. The client had difficulty catching her breath.
Home Medications
Albuterol/ipratropium every 4 hours by inhaler PRN for shortness of breath, last dose 2 days ago
Fluticasone/vilanterol 100/25 mcg inhaled daily, last dose 3 days ago
Ibuprofen 600 mg PO PRN for pain, last dose this morning for headache
Question 5 of 5
What finding(s) are cues for a respiratory problem? Select all that apply.
Correct Answer: A,B,D,E,F,G
Rationale: Sitting upright, chest tightness, tachypnea, restlessness, dyspnea, and low pulse oxygenation (85%) are direct indicators of respiratory distress, unlike medication compliance which is not a symptom.