HESI RN
HESI RN Med Surg 3 Questions
Extract:
History and Physical
The client is a 29-year-old female with a history of type 1 diabetes mellitus from the age of 6. She controls her blood glucose with an insulin pump and uses a continuous glucose monitor. The client was out of town, and her insulin pump was damaged. She had forgotten her backup long-acting insulin at home, so she took the 6-hour drive home. By the time she arrived at home, she was having nausea and vomiting. Her blood glucose meter read over 500 mg/dL (27.8 mmol/L). She took a dose of insulin glargine and took herself to the emergency department (ED).
Question 1 of 5
Which are three goals of therapy for this client?
Correct Answer: B,C,D
Rationale: Reversing dehydration with IV fluids, replacing insulin to suppress ketogenesis, and correcting electrolyte imbalances are primary goals in DKA management.
Extract:
Laboratory Results
0600
Laboratory Test
Results
Reference Range
pH
7.23
7.35 to 7.45
Partial pressure of oxygen (PaO2)
89 mm Hg
80 to 100 mm Hg
Partial
37 mm
35 to 45
Question 2 of 5
Based on the ABG values, the nurse knows that the client has [condition] related to [cause].
Correct Answer: D,G
Rationale: Uncompensated metabolic acidosis is characterized by a low pH (7.23) and normal PaCOâ‚‚ (37 mmHg), indicating a primary metabolic problem without respiratory compensation. The lack of insulin in type 1 diabetes leads to ketone formation and metabolic acidosis.
Extract:
Question 3 of 5
A client diagnosed with pancreatitis reports severe epigastric pain. After administering a narcotic analgesic, the client insists on sitting up and leaning forward. Which action should the nurse implement?
Correct Answer: A
Rationale: Clients with acute pancreatitis often experience severe epigastric pain that radiates to the back. Leaning forward helps reduce pressure on the inflamed pancreas and relieves pain by minimizing peritoneal irritation. Providing a bedside table allows the client to rest in a comfortable, supported position, improving pain management without additional interventions.
Question 4 of 5
The nurse assesses the telemetry monitor of a client who is 24 hours postoperative from having a permanent pacemaker insertion. The nurse observes that a pacemaker spike is present before each QRS complex in lead II of the electrocardiogram (ECG). Which intervention should the nurse implement?
Correct Answer: A
Rationale: A pacemaker spike before each QRS complex indicates that the pacemaker is functioning properly and triggering ventricular depolarization as intended. Since the client is 24 hours postoperative from a pacemaker insertion, this is an expected finding and should be documented accordingly.
Question 5 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.