HESI RN
HESI RN Medical Surgical Questions
Extract:
Question 1 of 5
The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. Which action should the nurse take?
Correct Answer: B
Rationale: Selecting another finger ensures an accurate blood sample and minimizes discomfort, as a reddened and engorged fingertip may lead to inaccurate readings.
Extract:
History and Physical Nurses' Notes
A 34-year-old male client presents to the emergency department (ED) for an acute asthma attack which began after jogging through a local park. The client is able to answer questions, pausing every few words to catch his breath. The client reports using a rescue Inhaler three times, but he just couldn't catch his breath. The client reports that symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous. The client reports that it has been a couple of months since he had an asthma attack, and he came to the ED today because he noticed that his inhaler was expired and was worried the medication was not working.
Initial Assessment
Temperature 98.9° F (37.1° C)
Heart rate 112 beats/minute
Respirations 28 breaths/minute
Blood pressure 130/86 mm Hg
Oxygen saturation 88% on room air
Lung sounds reveal expiratory wheezes
Capillary refill time 2 seconds
Orders
Administer albuterol 2.5 mg/ipratropium bromide 0.5 mg in 3 mL solution via nebulizer four times a day and PRN.
Administer prednisone 60 mg PO
Administer oxygen to keep oxygen saturation greater than 94%, titrate as needed.
Question 2 of 5
The nurse has implemented additional needed actions. Click the assessment data which indicates the interventions were successful and which assessment data provides no indication that the interventions were successful.
| Options | Indicates the Interventions Were Successful | No Indication that the Interventions Were Successful |
|---|---|---|
| Decrease in heart rate from 112 to 105 beats per minute. | ||
| Client able to speak in full sentences without pausing. | ||
| Clear lung sounds. | ||
| Reduction in respiratory rate to 16 breaths per minute. | ||
| Client reports breathing is eased. | ||
| Blood pressure within normal limits. |
Correct Answer: A,B,C,D,E,F
Rationale: The assessment data showing decreased heart rate, ability to speak in full sentences, clear lung sounds, reduced respiratory rate, eased breathing, and stable blood pressure all indicate successful interventions for the asthma attack.
Extract:
Question 3 of 5
The nurse is caring for a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?
Correct Answer: A
Rationale: Eating patterns and dietary intake are crucial in managing chronic pancreatitis as certain foods can exacerbate symptoms. Identifying dietary triggers and making appropriate dietary modifications can help alleviate abdominal pain.
Extract:
History and Physical
A 59-year-old male client presents to the clinic, reporting pain in the right great toe. The client says that the pain feels like it is another attack of gout, which he has had on 2 other occasions in the last 4 months.
The client tells the nurses that the pain started about 9 days ago in the evening and that it got very painful and swollen shortly thereafter. In the past, the gout attacks have resolved without treatment after about 5 days, but the client reports that his condition has not improved and that he is unable to walk or work
Question 4 of 5
Select the 3 dietary choices that are not part of the recommended diet for a client with gout.
| Garlic |
| Liver |
| Spinach |
| Oatmeal |
| Chicken |
| Shrimp |
| Lentil |
Correct Answer: B,F
Rationale: Liver and shrimp are high in purines, which can exacerbate gout by increasing uric acid levels. Garlic, oatmeal, chicken, quinoa, oranges, spinach, and lentils are generally safe or have minimal impact on gout.
Extract:
Question 5 of 5
The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?
Correct Answer: D
Rationale: Platelet count is crucial in assessing for thrombocytopenia, which can lead to increased bleeding and bruising, including petechiae and ecchymosis.