HESI RN
HESI RN Med Surg Exam 3 Questions
Extract:
Question 1 of 5
When assessing a client on the first postoperative day following abdominal surgery, the nurse does not hear any bowel sounds. In response to this finding, which action should the nurse implement?
Correct Answer: Documenting the assessment finding is the most appropriate initial action. This ensures that the lack of bowel sounds is recorded in the client's medical record, which is crucial for ongoing monitoring and communication with the healthcare team.
Rationale:
Question 2 of 5
The nurse is evaluating a client's understanding of diet teaching about the DASH (Dietary Approaches to Stop Hypertension) eating plan. Which behaviour indicates that the client is adhering to the eating plan?
Correct Answer: Enjoying fat-free yogurt aligns with the DASH diet's emphasis on low-fat dairy products.
Rationale:
Question 3 of 5
Which technique should the nurse use when assessing for early signs of rheumatoid arthritis?
Correct Answer: Observing the client's fingers is crucial because early signs of rheumatoid arthritis often present in the small joints of the hands and fingers.
Rationale:
Question 4 of 5
An older client who is agitated, dyspneic, orthopneic, and using accessory muscles to breathe is admitted for further treatment. Initial assessment includes a heart rate of 128 beats/minute and irregular, respirations of 38 breaths/minute, blood pressure of 168/100 mm Hg, and oxygen saturation of 90% on room air. Wheezes and crackles are noted throughout bilateral lung fields. An hour after the administration of furosemide 60 mg IV push (IVP), which assessments should the nurse obtain to determine the client's response to treatment? Select all that apply.
Correct Answer: Lung sounds, oxygen saturation, and urinary output are direct measures of furosemide's effectiveness in reducing fluid overload and improving respiratory status.
Rationale:
Question 5 of 5
When assessing a client on the first postoperative day following abdominal surgery, the nurse does not hear any bowel sounds. In response to this finding, which action should the nurse implement?
Correct Answer: Documenting the assessment finding is the most appropriate initial action. This ensures that the lack of bowel sounds is recorded in the client's medical record, which is crucial for ongoing monitoring and communication with the healthcare team.
Rationale: