HESI RN Medical Surgical Nursing

HESI RN Medical Surgical Nursing Related

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History and Physical
Nurses' Notes
Orders
Imaging Studies
The client is a young male who appears to be 25 to 30 years old. He was found unconscious on a sidewalk by a jogger who was passing by. The jogger called an ambulance, and the emergency medical technicians (EMTS) transported the client to the hospital. The client is arousable but unable to say what his name is or what happened to him. A STAT head computed tomography (CT) scan in the emergency department showed no abnormalities, so the client will be admitted to the medical floor for observation and further tests.

The nurse identifies that the client is having a tonic clonic seizure. The oxygen saturation is 40% and the respiratory rate is 4 breaths/minute. The nurse calls for help and 2 other nurses enter the room. Which 3 interventions should be performed first?

  • A. Place pillows around the bed rails to provide padding.
  • B. Watch the seizure activity and document the time and client movement.
  • C. Manually ventilate the client with a bag-valve mask (BVM).
  • D. Stop the IV fluids.
  • E. Increase the supplemental oxygen to 10 L/minute via nasal cannula.
  • F. Begin chest compressions.
Correct Answer: B,C,E

Rationale: Ventilation, oxygen increase, and seizure monitoring address hypoxia and safety during a tonic-clonic seizure.

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A client who is obese reports severe pain and is unable to bear weight in the right ankle after making dietary changes 3 weeks ago for weight loss. The client's medical history indudes hypertension, gouty arthritis, and cholecystitis. Which instruction should the nurse include in the discharge teaching?

  • A. Decrease consumption of red meat and most seafood.
  • B. Replace dietary table salt with salt substitutes.
  • C. Limit use of mobility equipment to avoid muscle atrophy.
  • D. Wrap joints with elastic bandage when swollen.
Correct Answer: A

Rationale: Reducing purine-rich foods like red meat and seafood lowers uric acid levels, helping manage gouty arthritis, which likely causes the ankle pain.

A young adult client involved in a minor motor vehicle collision three weeks ago reports having a headache, blurred vision, vertigo, and nausea. The client's vital signs are within normal limits, and a nutrition history reveals that the client is eating very little because of being concerned about paying for car repairs. Priority nursing care should be based on which nursing problem?

  • A. High risk for injury related to increased intracranial pressure.
  • B. Alteration in comfort related to motor vehicle collision.
  • C. Alteration in nutrition related to poor dietary intake.
  • D. Anxiety related to unknown outcome of automobile repairs.
Correct Answer: A

Rationale: Symptoms suggest increased intracranial pressure, a serious post-collision complication, prioritizing over comfort or nutrition.

A client with an acute exacerbation of rheumatoid arthritis (RA) has localized pain and inflammation of the fingers and feet, swelling, redness, restricted joint motion, and reports feeling fatigued. Which nursing problem has the highest priority for this client?

  • A. Fatigue related to disease exacerbation.
  • B. Pain related to joint inflammation
  • C. Impaired physical mobility related to joint pain.
  • D. Self-care deficit related to disease progression.
Correct Answer: B

Rationale: Pain is the primary symptom of RA exacerbation, impacting quality of life and requiring immediate management.

The nurse is developing a teaching handout for female clients who return to the clinic for recurring urinary tract infections (UTI). Which client has the greatest risk for developing a UTI?

  • A. An adolescent who drinks a minimum of four diet drinks daily.
  • B. A client who is too busy at work to void when the urge occurs.
  • C. A multipara who had pyelonephritis during her last pregnancy.
  • D. An older adult who is usually incontinent of urine during the night
Correct Answer: C

Rationale: A history of pyelonephritis increases UTI risk due to prior severe urinary infection, unlike dietary habits or incontinence.

The healthcare provider prescribes cefazolin 800 mg IM every six hours. The available vial is labeled, 'Cefazolin 1 gram,' and the instructions for reconstitution state, For IM use add 2.5 mL sterile water for Injection to provide a total volume of 3.0 mL. After reconstitution, the solution contains how many mg/mL? Enter numeric value only. If rounding is required, round to the nearest whole number.)

Correct Answer: 333

Rationale: One gram (1000 mg) reconstituted in 3.0 mL yields a concentration of 1000 mg / 3 mL = 333.33 mg/mL, rounded to 333 mg/mL.

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