HESI RN Medical Surgical

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History and Physical
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.

Click to highlight the two pieces of key subjective data which indicate the client is in need of health interventions.

  • A. The client reports using a rescue inhaler three times, but he just couldn't catch his breath.
  • B. Symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous.
Correct Answer: A,B

Rationale: The client's report of using a rescue inhaler multiple times without relief and the exacerbation of symptoms when outdoors and during exercise suggest that the client's asthma is not well-controlled, warranting immediate medical attention.

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The nurse reviews discharge instructions with a client who has gastroesophageal reflux disease (GERD). Which instruction is most important for the nurse to emphasize?

  • A. Avoid wearing tight fitting clothes.
  • B. Minimize intake of spicy foods.
  • C. Begin a smoking cessation program.
  • D. Remain upright following meals.
Correct Answer: D

Rationale: Remaining upright following meals is essential to prevent gastric reflux by reducing pressure on the lower esophageal sphincter, minimizing reflux episodes.

The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. Which action should the nurse take?

  • A. Collect the blood sample.
  • B. Select another finger.
  • C. Apply pressure to the site.
  • D. Assess radial pulse volume.
Correct Answer: B

Rationale: Selecting another finger ensures an accurate blood sample and minimizes discomfort, as a reddened and engorged fingertip may lead to inaccurate readings.

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

Complete the following sentences by choosing from the lists of corresponding options. Based on history and assessment data, the nurse should prioritize [condition] as the priority problem for this client, as evidenced by the client's statement, [statement].

  • A. chronic bronchitis
  • B. anxiety disorder
  • C. exercise-induced bronchospasm
  • D. impaired gas exchange
  • E. cardiovascular disease
  • F. respiratory infection
Correct Answer: D

Rationale: The client's difficulty breathing, need to pause to catch breath, ineffective rescue inhaler, and oxygen saturation of 88% indicate impaired gas exchange, requiring immediate intervention to improve respiratory function.

The nurse is caring for a client who tests positive for the sexually transmitted infection (STI) gonorrhea. The client reports having sex with someone who has many partners. Which response should the nurse provide?

  • A. Teach importance of medication regimen and follow-up protocol.
  • B. Discuss that partners without similar symptoms may not be infected.
  • C. Emphasize that using safe sex practices removes the risk of STIs.
  • D. Clarify that all STIs are transmitted through sexual intercourse.
Correct Answer: A

Rationale: Teaching the importance of medication regimen and follow-up protocol is crucial for treating gonorrhea and preventing its spread.

While caring for a client with amyotrophic lateral sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse?

  • A. Increasing anxiety.
  • B. Inappropriate laughter.
  • C. Asymmetrical weakness.
  • D. Weakened cough effort.
Correct Answer: D

Rationale: Weakened cough effort is a critical finding in a client with ALS, as it can lead to ineffective airway clearance and increase the risk of aspiration pneumonia. Immediate intervention, such as suctioning or respiratory support, may be necessary to maintain airway patency and prevent complications.

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