HESI RN Medical Surgical

HESI RN Medical Surgical Related

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Initial Assessment
Orders
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.

After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen. Which action(s) should the nurse take next? Select all that apply.

  • A. Increase oxygen flow.
  • B. Administer additional nebulizer treatment as ordered.
  • C. Raise the head of the bed.
  • D. Apply a nonrebreather oxygen mask.
  • E. Provide client incentive spirometer and instruct on use.
  • F. Take and monitor vital signs.
Correct Answer: A,B,C,D,F

Rationale: Increasing oxygen flow, administering additional nebulizer treatment, raising the head of the bed, applying a nonrebreather mask, and monitoring vital signs address persistent respiratory distress and low oxygen saturation.

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The nurse is providing teaching to a client about self-management of type 2 diabetes mellitus. Which information provided by the client indicates understanding?

  • A. Using salt, herbs, and spices will improve the flavor of foods.
  • B. Restrict alcoholic beverages to no more than 1-2 per week.
  • C. Eat a protein snack 30 minutes before any exercise workout.
  • D. Get an influenza vaccine every year as soon as available.
Correct Answer: D

Rationale: Getting an influenza vaccine every year is a crucial aspect of diabetes self-management, as people with diabetes are at increased risk of complications from influenza.

A client is admitted to the medical unit during an exacerbation of systemic lupus erythematosus (SLE). It is most important for the nurse to report which assessment finding to the healthcare provider?

  • A. Muscle atrophy.
  • B. Low grade fever.
  • C. Joint pain.
  • D. Hematuria.
Correct Answer: D

Rationale: Hematuria can indicate lupus nephritis, a serious complication of SLE. Prompt reporting to the healthcare provider is crucial for appropriate management and prevention of further kidney damage.

History and Physical
Nurses' Notes
Flow Sheet
Laboratory Results
The nurse is caring for a client who was admitted to the hospital with reports of shortness of breath, fever, fatigue, and oral thrush three days ago. The health care provider reviews the laboratory and diagnostic tests with the client and informs of the diagnosis of Pneumocystis pneumonia. The client reports that they recently tested HIV positive. The nurse reviews the client's medical record.
HIV diagnosed 4 months ago with no medications prescribed.
Note added to H&P reporting client wishes to be confidential since family and friends are unaware of the HIV diagnosis.

What order(s) should the nurse anticipate being prescribed after an update is reported to the healthcare providers? Select all that apply.

  • A. Increase IV fluids to 150 mL/hr
  • B. Monitor for adverse reaction to antibiotics
  • C. Repeat CD4+ T-cell count STAT
  • D. Initiate airborne isolation
  • E. Administer antiemetic
Correct Answer: A,B,E

Rationale: Increasing IV fluids, monitoring for antibiotic reactions, and administering an antiemetic address the client's fever, potential infection, and nausea associated with Pneumocystis pneumonia.

History and Physical Nurses' Notes
Flow Sheet
A 59-year-old male client presents to the clinic reporting pain in the right great toe. The client says that the pain feels like it is another attack of gout, which he has had on 2 other occasions in the last 4 months.
The client tells the nurses that the pain started about 9 days ago in the evening and that it got very painful and swollen shortly thereafter. In the past, the gout attacks have resolved without treatment after about 5 days, but the client reports that his condition has not

Which finding(s) in the client's health record should the nurse recognize places the client at a greater risk of developing gout? Select all that apply.

  • A. Obesity
  • B. Hypertension
  • C. Drinks beer nightly
  • D. Daily aspirin
  • E. Type 2 diabetes mellitus
  • F. Sleep apnea
  • G. Ibuprofen for pain
Correct Answer: A,B,C,D,E,F

Rationale: Obesity, hypertension, alcohol consumption (especially beer), low-dose aspirin, type 2 diabetes mellitus, and sleep apnea are all associated with increased uric acid levels or decreased excretion, contributing to gout risk. Ibuprofen, smoking status, and osteoarthritis do not directly increase gout risk.

A client presents to the emergency department reporting chest pain that is radiating to the left arm, shortness of breath, and diaphoresis. Which medication should the nurse anticipate being prescribed by the healthcare provider?

  • A. Fentanyl.
  • B. Hydromorphone.
  • C. Morphine.
  • D. Oxycodone.
Correct Answer: C

Rationale: Morphine is the medication of choice for managing acute chest pain associated with myocardial infarction. It helps alleviate pain, reduce myocardial oxygen demand, and relieve anxiety.

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