HESI RN
HESI RN Medical Surgical Nursing Questions
Extract:
Question 1 of 5
The nurse reviews discharge instructions with a client who has gastroesophageal reflux disease (GERD). Which instruction is most important for the nurse to emphasize?
Correct Answer: B
Rationale: Remaining upright after meals prevents acid reflux by facilitating digestion, making it the most critical instruction for GERD management.
Question 2 of 5
A client with pancreatitis is receiving 0.9% normal saline, and the prescribed IV infusion rate was increased from 100 mL/hour to 150 mL/hour. Which assessment finding indicates to the nurse that the prescription has a therapeutic outcome?
Correct Answer: C
Rationale: A decrease in BUN indicates improved renal perfusion, a therapeutic outcome of increased IV fluids. Increased hematocrit suggests fluid volume deficit, increased blood glucose is undesirable, and amylase decrease is not directly related to fluid increase.
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 3 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 4 of 5
A client is receiving a secondary infusion of vancomycin 1,500 mg in 250 ml to be infused over two hours. The IV administration set delivers 15 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: 31
Rationale: Using the formula (250 mL x 15 gtt/mL) / 120 min = 31.25 gtt/min, rounded to 31 gtt/min.
Question 5 of 5
A young adult client involved in a minor motor vehicle collision three weeks ago reports having a headache, blurred vision, vertigo, and nausea. The client's vital signs are within normal limits, and a nutrition history reveals that the client is eating very little because of being concerned about paying for car repairs. Priority nursing care should be based on which nursing problem?
Correct Answer: A
Rationale: Symptoms suggest increased intracranial pressure, a serious post-collision complication, prioritizing over comfort or nutrition.