HESI RN
HESI RN Med Surg Questions
Extract:
History and Physical
Nurses’ Notes
Flow sheet
Orders
Imaging Studies
A 19-year-old female client presents to the emergency department reporting tightness in her chest and difficulty breathing. The client's friend, who accompanied the client to the emergency department, reports she was at a park playing soccer with a group of college friends when the symptoms started. The park is close to a residential area where a fire was burning and there was a moderate breeze in the air. The client reported itching eyes and coughing. Approximately 15 minutes into the game, the client stopped running and held her hand on her chest, saying it felt tight. The client had difficulty catching her breath.
Home Medications
Albuterol/ipratropium every 4 hours by inhaler PRN for shortness of breath, last dose 2 days ago
Fluticasone/vilanterol 100/25 mcg inhaled daily, last dose 3 days ago
Ibuprofen 600 mg PO PRN for pain, last dose this morning for headache
Question 1 of 5
What finding(s) are cues for a respiratory problem? Select all that apply.
Correct Answer: A,B,D,E,F,G
Rationale: Sitting upright, chest tightness, tachypnea, restlessness, dyspnea, and low pulse oxygenation (85%) are direct indicators of respiratory distress, unlike medication compliance which is not a symptom.
Extract:
Question 2 of 5
Click to mark whether the client statement indicates understanding or no understanding of the education given.
| Options | Understanding | No understanding |
|---|---|---|
| Making these changes will also help me avoid other chronic health conditions. (Understanding) | ||
| If I have symptoms like increased thirst and urination, I should come in and get my blood sugar checked. (Understanding) | ||
| If my fasting blood sugar is less than 100 mg/dL (5.6 mmol/L) next time, I can go back to my usual eating habits. (No understanding) | ||
| I can never eat sugar again. (No understanding) | ||
| If I make the changes we talked about, I will not get type 2 diabetes. (No understanding) | ||
| Understanding: A,B; No understanding: C,D,E |
Correct Answer:
Rationale: Understanding statements reflect benefits of lifestyle changes and symptom monitoring. Misunderstandings include assuming normal glucose allows poor habits, banning all sugar, or believing changes eliminate diabetes risk entirely.
Question 3 of 5
A client with a right ulnar fracture and cast placement reports an increase in arm pain. Which action should the nurse take next?
Correct Answer: B
Rationale: Increased pain post-cast placement may indicate compartment syndrome, a serious condition. Assessing radial pulse volume evaluates circulation distal to the fracture, critical for detecting compromised perfusion.
Question 4 of 5
When providing care for a child who is in balanced suspension skeletal traction using a Thomas splint and Pearson attachment to the right femur, which intervention is most important for the nurse to implement?
Correct Answer: D
Rationale: Monitoring pulses and sensation prevents complications like compartment syndrome or nerve damage, which are critical in traction. Other interventions are secondary.
Question 5 of 5
A school-age child with nephrotic syndrome is receiving salt-poor human albumin IV. Which findings indicate to the nurse that the child is manifesting a therapeutic response?
Correct Answer: C
Rationale: Decreased periorbital edema indicates restored blood protein levels and reduced fluid leakage, a therapeutic response. Other findings suggest complications.