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
While assisting a client to the toilet, the client begins to have a seizure and the nurse eases the client to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first?
Correct Answer: A
Rationale: Prolonged apnea during a seizure can lead to hypoxia or cardiac arrest, making it the priority to monitor to ensure respiratory status and client safety post-seizure.
Question 3 of 5
The nurse is conducting an admission assessment of an infant with heart failure who is scheduled for repair of restenosis of coarctation of the aorta that was repaired 4 days after birth. Findings include blood pressure higher in the arms than the lower extremities, pounding brachial pulses, and slightly palpable femoral pulses. Which pathophysiologic mechanism supports these findings?
Correct Answer: A
Rationale: Coarctation of the aorta narrows the aortic lumen, reducing blood flow to the lower extremities, causing higher blood pressure in the arms and weaker pulses in the legs.
Question 4 of 5
The nurse is teaching the parents about important dietary changes for their child who is newly diagnosed with celiac disease. Which foods should the nurse include in the list of allowed foods for this child?
Correct Answer: A
Rationale: Rice is gluten-free and safe for celiac disease. Other grains contain gluten, which triggers intestinal damage.
Question 5 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.