HESI RN
HESI RN Medical Surgical Exam I Questions
Extract:
History and Physical
Nurse's Notes
A 34-year-old male client presents to the emergency department (ED) for an asthma attack that began after jogging through a local park. The client is able to answer questions every few words to catch his breath. He reports using his rescue inhaler three times, but he couldn't catch his breath. He reports that his symptoms are worse when outdoors and when exercising, and episodes like this make him extremely nervous. He says that it has been a couple of months since his last asthma attack, and he came to the ED today because he noticed his inhaler was expired and was worried the medication was not working.
Question 1 of 5
The nurse performs an initial focused assessment of the client. Based on the client's history and assessment data, the nurse's hypothesis is that the client's vital signs are most likely the result of a disease process, medication use, or neither.
Correct Answer: A,B,C,D,E
Rationale: Temperature and blood pressure are normal (neither), while heart rate, respirations, and oxygen saturation reflect asthma (disease process).
Extract:
Question 2 of 5
A client who had a C5 spinal cord injury 2 years ago is admitted to the emergency department (ED) with the diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding should the nurse expect this client to exhibit?
Correct Answer: D
Rationale: Profuse diaphoresis and severe headache are classic symptoms of autonomic dysreflexia due to sympathetic overactivity.
Question 3 of 5
The nurse assesses an adult client 24 hours after a bowel exploration and formation of a sigmoid colostomy. Which assessment finding should be reported to the surgeon immediately?
Correct Answer: D
Rationale: Purple stoma mucosa indicates possible ischemia, requiring immediate reporting to prevent tissue necrosis.
Question 4 of 5
A client receives a prescription for 2 liters of lactated Ringer's IV to be infused over 12 hours. The IV administration set delivers 20 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)
Correct Answer: A
Rationale: Calculation: 2 liters = 2000 mL, 2000 mL × 20 gtt/mL = 40,000 gtt, 12 hours = 720 minutes, 40,000 ÷ 720 = 55.56, rounded to 56 gtt/min.
Question 5 of 5
A nurse is caring for a client with acute kidney injury (AKI). Which assessment finding warrants immediate intervention?
Correct Answer: C
Rationale: Dyspnea and sinus tachycardia indicate possible fluid overload or pulmonary edema, requiring immediate intervention.