HESI RN
HESI RN Med Surg Exam 3 Questions
Extract:
Question 1 of 5
The nurse is obtaining vital sign measurements every 15 minutes for a client who had an emergency appendectomy and currently has a temperature of 101.4°F (38.6°C). Which vital sign measurements should the nurse report to the healthcare provider?
Correct Answer: Heart rate 110 beats/minute and blood pressure 88/56 mmHg indicate tachycardia and hypotension, suggesting potential complications like sepsis or hypovolemia, requiring immediate reporting.
Rationale:
Question 2 of 5
A client with heart failure (HF) is waiting in the preoperative area for a scheduled procedure and tells the nurse, 'My heart feels like it is beating too fast and I feel faint.' After initiating a call for an electrocardiogram (ECG), which assessment data is most important for the nurse to obtain?
Correct Answer: The rhythm of the apical pulse is critical to identify possible arrhythmias causing palpitations and faintness.
Rationale:
Question 3 of 5
The nurse is assessing a client who has left ventricular heart failure. Which assessment finding is this client most likely to exhibit?
Correct Answer: Bilateral basilar crackles are a hallmark sign of left ventricular heart failure due to pulmonary congestion.
Rationale:
Question 4 of 5
Which technique should the nurse use when assessing for early signs of rheumatoid arthritis?
Correct Answer: Observing the client's fingers is crucial because early signs of rheumatoid arthritis often present in the small joints of the hands and fingers.
Rationale:
Question 5 of 5
Which statement by a client with systemic lupus erythematosus (SLE) indicates the best understanding of proper skin care?
Correct Answer: Using strong sunblock is crucial to protect skin and prevent flares in SLE.
Rationale: