HESI RN
HESI RN Med Surg Exam 2 Questions
Extract:
Question 1 of 5
Which nursing problem should be selected for a client who is receiving thrombolytic infusions for treatment of an acute myocardial infarction (AMI)?
Correct Answer: C
Rationale: The correct answer is C because thrombolytics increase bleeding risk, making injury prevention critical.
Choice A is less common.
Choice B is secondary to immediate risks.
Choice D is relevant but not the priority.
Question 2 of 5
The nurse assesses an adult client 24 hours after a bowel exploration and formation of a sigmoid colostomy. Which assessment finding should be reported to the surgeon immediately?
Correct Answer: B
Rationale: The correct answer is B because a purple stoma indicates compromised blood flow, risking necrosis and requiring urgent intervention.
Choice A is expected post-surgery.
Choice C is normal shortly after surgery.
Choice D is a normal finding.
Question 3 of 5
A client with an external fixation device for a fractured left femur is troubled with left foot pain. Which intervention should the nurse implement first?
Correct Answer: A
Rationale: The correct answer is A because swelling may indicate compartment syndrome, a serious complication requiring immediate assessment.
Choice B is unrelated to the pain or fixation device.
Question 4 of 5
A nurse is caring for a client with diabetes insipidus (DI). Which data warrants the most immediate intervention by the nurse?
Correct Answer: A
Rationale: The correct answer is A because severe hypernatremia (185 mEq/L) can cause neurological damage and requires urgent correction.
Choice B is a symptom of DI but less urgent.
Choice C indicates dehydration but is secondary.
Choice D is elevated but not as critical.
Question 5 of 5
A client reports to the nurse of recently visiting someone who has a shingles infection. The client believes that having had chickenpox as a child will be protective against shingles. How should the nurse respond? Select all that apply.
Correct Answer: B,E
Rationale: The correct answers are B and E for the same reasons as Question 1: affirming the link between chickenpox and shingles (
B) and distinguishing herpes varicella from herpes zoster (E) address the client's misconception.
Choice A does not clarify the client's risk.
Choice C is unrelated to the question about protection.
Choice D is incorrect as the risk of shingles increases with age.