HESI RN
HESI RN Med Surg 3 Questions
Extract:
Question 1 of 5
The nurse is evaluating a client's central venous pressure (CVP) also called right atrial pressure (RAP) readings that are trending upwards. Which nursing problem is supported by the pathophysiologic mechanism most likely causing the increases?
Correct Answer: A
Rationale: Increasing CVP indicates fluid overload or impaired right ventricular function, leading to decreased cardiac output.
Extract:
History and Physical
The client is a 29-year-old female with a history of type 1 diabetes mellitus from the age of 6. She controls her blood glucose with an insulin pump and uses a continuous glucose monitor. The client was out of town, and her insulin pump was damaged. She had forgotten her backup long-acting insulin at home, so she took the 6-hour drive home. By the time she arrived at home, she was having nausea and vomiting. Her blood glucose meter read over 500 mg/dL (27.8 mmol/L). She took a dose of insulin glargine and took herself to the emergency department (ED).
Question 2 of 5
Which are three goals of therapy for this client?
| Promote oxygenation to tissues. |
| Reverse dehydration. |
| Replace insulin. |
| Correct electrolytes that are out of normal range. |
| Provide respiratory support. |
| Prevent hyperventilation. |
Correct Answer: B,C,D
Rationale: Reversing dehydration with IV fluids, replacing insulin to suppress ketogenesis, and correcting electrolyte imbalances are primary goals in DKA management.
Extract:
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
Twelve hours following orthopedic surgery on the right leg, the client begins to have acute chest pain and difficulty breathing. Which action should the nurse take first?
Correct Answer: B
Rationale: Acute chest pain and difficulty breathing suggest a pulmonary embolism. Providing oxygen and increasing IV flow rate support vital functions immediately.
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.