HESI RN
HESI RN Medical Surgical Nursing Questions
Extract:
History and Physical
Nurses' Notes
Orders
Imaging Studies
The client is a young male who appears to be 25 to 30 years old. He was found unconscious on a sidewalk by a jogger who was passing by. The jogger called an ambulance, and the emergency medical technicians (EMTS) transported the client to the hospital. The client is arousable but unable to say what his name is or what happened to him. A STAT head computed tomography (CT) scan in the emergency department showed no abnormalities, so the client will be admitted to the medical floor for observation and further tests.
Exhibits
The nurse provides education about seizures to the client and asks the client to explain what he understands about his condition.
Question 1 of 5
The nurse provides education about seizures to the client and asks the client to explain what he understands about his condition. For each statement click to specify if the client demonstrates an understanding or no understanding.
Correct Answer: E
Rationale: Only the statement about unknown seizure causes shows understanding; others reflect misconceptions about medication, safety, and lifestyle.
Extract:
History and Physical
Nurses' Notes
Orders
Imaging Studies
The client is a young male who appears to be 25 to 30 years old. He was found unconscious on a sidewalk by a jogger who was passing by. The jogger called an ambulance, and the emergency medical technicians (EMTS) transported the client to the hospital. The client is arousable but unable to say what his name is or what happened to him. A STAT head computed tomography (CT) scan in the emergency department showed no abnormalities, so the client will be admitted to the medical floor for observation and further tests.
Question 2 of 5
The nurse identifies that the client is having a tonic clonic seizure. The oxygen saturation is 40% and the respiratory rate is 4 breaths/minute. The nurse calls for help and 2 other nurses enter the room. Which 3 interventions should be performed first?
Correct Answer: B,C,E
Rationale: Ventilation, oxygen increase, and seizure monitoring address hypoxia and safety during a tonic-clonic seizure.
Extract:
Question 3 of 5
The drainage in the chest tube of a client with emphysema has changed from viscous green to clear watery fluid. Which action is best for the nurse to take?
Correct Answer: C
Rationale: A culture of the changed drainage assesses for infection or other causes, prioritizing over imaging, antibiotics, or tube manipulation.
Extract:
Nurses' Notes
0900
The 54-year-old female client returned to room from postanesthesia care unit (PACU). Situation- background-assessment-recommendation (SBAR) communication reveals client has had no urine output during the anesthesia recovery period. Last void was 8 hours ago. Client positioned in bed. Warm blanket applied for comfort. IV fluids infusing.
1045
Client requesting pain medication and says has the urge to void. Wishes to use bedpan. Voided 75 mL.
1130
Client informs she continues to have the urge to void and feels, "Wet." Placed on bedpan. Voided 50 mL. Bladder palpated and feels full. Bladder scanner applied and revealed 600 mL residual urine.
Question 4 of 5
The nurse is planning care for the client. Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
| Actions to Take Choices A. Request prescription for external catheter device B. Request prescription for straight catheter C. Insert indwelling urinary catheter D. Assist client to bathroom for voiding E. Increase the IV fluid rate |
| Potential Condition Choices A. Urinary Retention B. Urinary tract obstruction C. Overflow Urinary Incontinence D. IV fluid intake E. Frequency of voiding |
| Parameters to monitor Choices A. Amount of urine output B. Residual urine C. Pain medication effects D. IV fluid intake E. Frequency of voiding |
Correct Answer: A
Rationale: Urinary retention, indicated by high residual urine, requires straight and indwelling catheters, with monitoring of urine output and residual urine.
Extract:
Question 5 of 5
The client's laboratory results indicate that the serum potassium level is 2.5 mEq/L (2.5 mmol/L). Which action should the nurse take?
Correct Answer: B
Rationale: Severe hypokalemia requires immediate potassium replacement, necessitating healthcare provider notification, rather than dietary changes or monitoring alone.