HESI RN
HESI RN Med Surg Questions
Extract:
Question 1 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 2 of 5
A client with draining skin lesions of the lower extremity is admitted with possible methicillin resistant Staphylococcus aureus (MRSA). What nursing intervention(s) should the nurse include in the plan of care? Select all that apply.
Correct Answer: A,C,E
Rationale: Standard precautions with a mask, culturing wound drainage for MRSA confirmation, and contact precautions prevent transmission and guide treatment, critical for managing potential MRSA infections.
Question 3 of 5
The healthcare provider prescribes diazepam 8 mg IM every 4 hours PRN muscle spasms for a client with a fractured femur. The available vial is labeled, 'Diazepam Injection, USP 10 mg/2 mL.' How many mL should the nurse administer to the client? (Enter numerical value only. If rounding is required round to the nearest tenth.)
Correct Answer: 1.6 mL
Rationale: The vial provides 5 mg/mL (10 mg/2 mL). For an 8 mg dose, the nurse should administer 1.6 mL (8 mg ÷ 5 mg/mL), calculated to meet the prescribed dose.
Question 4 of 5
The nurse is performing a routine assessment of a 3-year-old at a community health center. Which behavior by the child should alert the nurse to request a follow-up for a possible autism spectrum disorder (ASD)?
Correct Answer: D
Rationale: Odd repetitive behaviors are specific to ASD, indicating a need for follow-up. Other behaviors are less specific or normal.
Question 5 of 5
A client with a cervical spinal injury (C7) is experiencing autonomic dysreflexia. The nurse should first assess the client for which precipitating factor?
Correct Answer: A
Rationale: Autonomic dysreflexia is often triggered by a distended bladder, which sends signals to the spinal cord that cannot pass the injury level, causing uncontrolled sympathetic activation. Assessing for this common precipitating factor is the priority to address the underlying cause.