HESI RN
HESI RN Medical Surgical Questions
Extract:
Question 1 of 5
While caring for a client with a full thickness burn covering 40% of the body, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values?
Correct Answer: A
Rationale: Reviewing the white blood cell count is important because purulent drainage suggests infection, and an elevated WBC count may indicate an inflammatory response to infection.
Question 2 of 5
A college student comes to the school's health clinic troubled by urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first?
Correct Answer: D
Rationale: Measuring temperature and pulse rate is important to identify signs of systemic infection or inflammation contributing to the client's symptoms.
Question 3 of 5
A client with a renal calculus reports severe right flank pain, nausea, and vomiting. Which nursing problem has the highest priority?
Correct Answer: D
Rationale: Risk for aspiration related to vomiting is the highest priority because it addresses the immediate potential for airway compromise, which can be life-threatening if the client aspirates vomitus.
Extract:
History and Physical Nurses' Notes
A 34-year-old male client presents to the emergency department (ED) for an acute asthma attack which began after jogging through a local park. The client is able to answer questions, pausing every few words to catch his breath. The client reports using a rescue Inhaler three times, but he just couldn't catch his breath. The client reports that symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous. The client reports that it has been a couple of months since he had an asthma attack, and he came to the ED today because he noticed that his inhaler was expired and was worried the medication was not working.
Initial Assessment
Temperature 98.9° F (37.1° C)
Heart rate 112 beats/minute
Respirations 28 breaths/minute
Blood pressure 130/86 mm Hg
Oxygen saturation 88% on room air
Lung sounds reveal expiratory wheezes
Capillary refill time 2 seconds
Orders
Administer albuterol 2.5 mg/ipratropium bromide 0.5 mg in 3 mL solution via nebulizer four times a day and PRN.
Administer prednisone 60 mg PO
Administer oxygen to keep oxygen saturation greater than 94%, titrate as needed.
Question 4 of 5
The nurse has implemented additional needed actions. Click the assessment data which indicates the interventions were successful and which assessment data provides no indication that the interventions were successful.
| Options | Indicates the Interventions Were Successful | No Indication that the Interventions Were Successful |
|---|---|---|
| Decrease in heart rate from 112 to 105 beats per minute. | ||
| Client able to speak in full sentences without pausing. | ||
| Clear lung sounds. | ||
| Reduction in respiratory rate to 16 breaths per minute. | ||
| Client reports breathing is eased. | ||
| Blood pressure within normal limits. |
Correct Answer: A,B,C,D,E,F
Rationale: The assessment data showing decreased heart rate, ability to speak in full sentences, clear lung sounds, reduced respiratory rate, eased breathing, and stable blood pressure all indicate successful interventions for the asthma attack.
Extract:
Question 5 of 5
A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing care plan?
Correct Answer: A
Rationale: Assessing pin sites for signs of infection is essential to detect early signs of complications in skeletal traction.