HESI RN
HESI RN Med Surg 3 Questions
Extract:
History and Physical Orders
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 other labs would be helpful for the treatment of diabetic ketoacidosis (DKA)? Select all that apply.
Correct Answer: C,E,F
Rationale: Serum electrolytes are crucial for guiding fluid and electrolyte replacement. The anion gap assesses the severity of acidosis, and urine ketones confirm ketoacidosis and monitor treatment response.
Extract:
Client is a 61-year-old male with COVID pneumonia. He was on high-flow oxygen for 3 days and was transferred to the intensive care unit (ICU) after being intubated and placed on a mechanical ventilator. Has sedation and a neuromuscular blockade infusing due to the high inspiratory pressures required to ventilate the client.
Question 2 of 5
Click to mark whether the actions are indicated, contraindicated, or nonessential for this client.
| Options | Indicated | Contraindicated | Nonessential |
|---|---|---|---|
| Increase the fraction of inspired oxygen (FiOâ‚‚). | |||
| Collect equipment for a needle aspiration. | |||
| Replace the ventilator. | |||
| Measure the nasogastric tube output. | |||
| Place the client in Trendelenburg. |
Correct Answer: A,D
Rationale: Increasing FiOâ‚‚ is indicated if oxygenation is inadequate. Measuring NG output is essential to assess for gastrointestinal issues. Other actions lack clinical justification.
Extract:
Question 3 of 5
A client has a chest tube connected to a closed water-seal drainage system with suction. Which equipment should the nurse always have available at the client's bedside?
Correct Answer: C
Rationale: If the chest tube accidentally dislodges, an occlusive dressing (such as sterile gauze with petroleum jelly) should be applied immediately to prevent air from re-entering the pleural space, which could lead to a tension pneumothorax. Keeping sterile gauze at the bedside ensures rapid intervention in case of accidental chest tube removal.
Question 4 of 5
A client who is admitted to the emergency department (ED) following a motorcycle collision is having difficulty breathing. While assessing the client's chest and lungs, the nurse notes that there are no breath sounds over the left lung fields. Which action(s) should the nurse implement? Select all that apply.
Correct Answer: A,B
Rationale: High-flow oxygen improves oxygenation in suspected pneumothorax or hemothorax. Obtaining a chest tube insertion kit prepares for definitive treatment.
Question 5 of 5
Twelve hours following orthopedic surgery on the right leg, the client begins to have acute chest pain and difficulty breathing. Which action should the nurse take first?
Correct Answer: B
Rationale: Acute chest pain and difficulty breathing suggest a pulmonary embolism. Providing oxygen and increasing IV flow rate support vital functions immediately.