HESI RN
HESI RN Med Surg 3 Questions
Extract:
Question 1 of 5
The nurse is monitoring for signs of increased intracranial pressure (ICP) in a client who attempted suicide by jumping from a tenth floor balcony. The client is intubated and mechanically ventilated. Which intervention should the nurse implement to minimize rises in ICP?
Correct Answer: C
Rationale: Clustering too many nursing interventions together can overstimulate the client and cause spikes in ICP. Providing adequate rest periods between activities such as repositioning, suctioning, and assessments allows intracranial pressure to return to baseline levels, helping to prevent sustained increases.
Question 2 of 5
The healthcare provider (HCP) changes a prescription for a nitroglycerin IV infusion from 10 mcg/min to 15 mcg/min. The IV bag contains nitroglycerin 50 mg in dextrose 5% in water (DW) 250 mL. The nurse should program the infusion pump to deliver how many mL/hr? (Enter numerical value only. If rounding is required, round to the nearest whole number.)
Correct Answer: A
Rationale: Calculation: 15 mcg/min × 60 min/hour = 900 mcg/hour. 900 mcg/hour / 1000 = 0.9 mg/hour. Concentration = 50 mg / 250 mL = 0.2 mg/mL. Infusion rate = 0.9 mg/hour / 0.2 mg/mL = 4.5 mL/hour, rounded to 5 mL/hour.
Question 3 of 5
The nurse assesses the telemetry monitor of a client who is 24 hours postoperative from having a permanent pacemaker insertion. The nurse observes that a pacemaker spike is present before each QRS complex in lead II of the electrocardiogram (ECG). Which intervention should the nurse implement?
Correct Answer: A
Rationale: A pacemaker spike before each QRS complex indicates that the pacemaker is functioning properly and triggering ventricular depolarization as intended. Since the client is 24 hours postoperative from a pacemaker insertion, this is an expected finding and should be documented accordingly.
Extract:
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).
The nurse draws the arterial blood gas and waits for results
Question 4 of 5
Based on the client's diagnosis, which results does the nurse expect in the blood gas? Select all that apply.
Correct Answer: C,D
Rationale: Diabetic ketoacidosis (DK
A) causes metabolic acidosis due to ketone accumulation, leading to a pH below 7.35. Bicarbonate is depleted while neutralizing excess acids, resulting in levels below 18 mEq/L.
Extract:
Question 5 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.