HESI RN
HESI RN Med Surg 3 Questions
Extract:
Question 1 of 5
Twelve hours following orthopedic surgery on the right leg, the client begins to have acute chest pain and difficulty breathing. Which action should the nurse take first?
Correct Answer: B
Rationale: Acute chest pain and difficulty breathing suggest a pulmonary embolism. Providing oxygen and increasing IV flow rate support vital functions immediately.
Question 2 of 5
A client who is admitted to the intensive care unit (ICU) with acute decompensated heart failure is receiving a continuous infusion of milrinone via a subclavian venous catheter. Which action should the nurse take when preparing to administer the first dose of IV furosemide?
Correct Answer: D
Rationale: Milrinone and furosemide are incompatible due to pH differences, which can cause precipitation. Administering furosemide through a separate IV line ensures safe delivery.
Question 3 of 5
A client is admitted to the intensive care unit (ICU) with sepsis and acute respiratory distress syndrome (ARDS). The client is orally intubated and mechanically ventilated. Which intervention is most important for the nurse to include in the client's plan of care (POC)?
Correct Answer: B
Rationale: Using antiseptic solution for oral care reduces bacterial colonization, decreasing the risk of ventilator-associated pneumonia (VAP), a critical intervention in ARDS.
Question 4 of 5
After intubating a client, correct placement of the endotracheal tube (ETT) is confirmed with a chest x-ray. Which intervention should the nurse implement to ensure that the ETT placement is maintained?
Correct Answer: C
Rationale: After proper ETT placement is confirmed with a chest x-ray, securing the tube with adhesive tape or a commercial ETT holder prevents displacement. Unintentional extubation or tube migration can lead to hypoxia, respiratory distress, or esophageal intubation, making proper tube fixation a priority intervention.
Question 5 of 5
After 15 minutes of cardiopulmonary resuscitation (CPR) and multiple defibrillations, a client has return of spontaneous circulation (ROSC) with a heart rate of 130 beats/minute and ST elevation in leads I,II, III, aVF, aVL, V5, V6. Which serum laboratory values are most important for the nurse to monitor?
Correct Answer: D
Rationale: Troponin is the most specific and sensitive biomarker for myocardial infarction, indicated by ST elevation in multiple leads.