HESI - Medical Surgical Nursing Correct and Verified Answers Graded A.

• | P a g e

HESI - Medical Surgical Nursing Correct and Verified Answers Graded A.

• Which client is at greatest risk for dehydration? a. younger adult client on bedrest b.

older adult client receiving hypotonic IV fluid c. older adult client with cognitive impairment

d. younger adult client receiving hypertonic IV fluid Correct Answer: C

• Which intervention in a client with dehydration induced confusion is most likely to relieve

the confusion? a. increasing the IV flow rate to 250 mL/hr b. applying oxygen by mask or nasal cannula c. placing the client in a high Fowler's position d. Measuring intake and

output every four hours Correct Answer: A

• Controlling pain is important to promoting wellness. Unrelieved pain has been

associated with: a. prolonged stress response and a cascade of harmful effects system wide. b. decreased tumor growth and longevity c. large tidal volumes and decreased lung capacity d. decreased carbohydrate, protein, and fat destruction Correct Answer: A

• A nurse is caring for an older adult client who lives alone. Which economic situation

presents the most serious problem for this client? a. costs of creating a living will b. stock market fluctuations c. increased provider benefits d. social security as the basis of income

Correct Answer: D

• The client is receiving an IV of 60 mEq of potassium chloride in a 1000 mL solution of

dextrose 5% in 0.45% saline. The client states that the area around the IV site burns. What intervention does the nurse perform first? a. assess for a blood return b. notify the

physician c. document the finding d. stop the IV infusion Correct Answer: D

• The nurse is working at a first aid booth for a spring training game on a hot day. A

spectator comes in, reporting that he is not feeling well. Vital signs are temp 104.1 F, pulse 132 BPM, respirs 26 breaths/min, and blood pressure 106/66 mm Hg. He trips over his feet as the nurse leads him to a cot. What is the priory action of the nurse? a. admin tylenol 650 mg orally b. encourage rest, and reassess in 15 minutes c. sponge the victim with cool water and remove his shirt d. encourage drinking of cool water or sports drink Correct

Answer: C

• | P a g e

• Which statement made by a nurse represents the need for further education regarding

pain management in older adult clients? a. older adults tend to report pain less often than younger adults b. older clients usually have more experience with pain than younger clients

• older adults are at greatest risk for under treated pain d. older clients have a different

pain mechanism and do not feel it as much Correct Answer: D

• The nurse is assessing a group of clients. Which clients are at greater risk for

hypothermia or frostbite? (select all that apply) a. an older woman with hypertension b. a young man with a body mass index of 42 c. a young man who has just consumed six martinis d. an older man who smokes a pack of cigarettes a day e. a young woman who is

anorexic f. a young woman who is diabetic Correct Answer: C, D, E, F

• A patient expresses a strong interest in returning to their work, family, and hobbies after

having a stroke. Which theory type would the nurse use to develop a plan of care for the best results of this patient's motivation style? a. field b. biological c. cognitive d. sociologic

Correct Answer: C

• When describing patient education approaches, the nurse educator would explain that

informal teaching is an approach that: a. follows formalized plans b. has standardized

content c. often occurs one-to-one d. addresses group needs Correct Answer: C

• A nurse is caring for several clients. Which client does the nurse assess most carefully

for hyperkalemia? a. client with type 2 diabetes taking an oral anti-diabetic agent b. client with heart failure using a salt substitute c. client taking a thiazide diuretic for hypertension

d. client taking non-steroidal anti-inflammatory drugs daily Correct Answer: B

• An older adult client presents with signs and symptoms related to dig toxicity. Which

age related change may have contributed to this problem? a. decreased renal blood flow b.increased gastrointestinal motility c. decreased ratio of adipose tissue to lean body mass

d. increased total body water Correct Answer: A

• A client is being treated for dehydration. Which statement made by the client indicates

understanding of this condition? a. I will use a salt substitute when making and eating my meals. b. I must drink a quart of water or other liquid each day. c. I will not drink liquids after 6 PM so I won't have to get up at night. d. I will weigh myself each morning before I eat

or drink.Correct Answer: D

• The nurse notes that the handgrip of the client with hypokalemia has diminished since

the previous assessment one hour ago. Which intervention by the nurse is the priority? a.assess the client's respiratory rate, rhythm, and depth b. document findings and monitor the client c. measure the client's pulse and blood pressure d. call the health care provider

Correct Answer: A

• | P a g e

• The physician orders Lasix (furosemide) 60 mg po every day for your patient. On hand

you have Lasix 40 mg. How many tablets will you give the patient? a. 3 b. 1 c. 1 1/2 d. 2 1/5

Correct Answer: C

• A client has been taught to restrict dietary sodium. Which food selection by the client

indicates to the nurse that teaching has been effective? a. a grilled cheese sandwich with tomato soup b. Chinese take-out, including steamed rice c. a chicken leg, one slice of bread with butter, and steamed carrots d. slices of ham and cheese on whole grain

crackers Correct Answer: C

• When a client is assessed, which behavior best indicates that he or she is experiencing

changes associated with acute pain? a. inability to concentrate b. expressed hopelessness

c. psychosocial withdrawal d. anger and hostility Correct Answer: A

• A nurse is caring for several clients at risk for overhydration. The nurse assesses the

older client with which finding first? A) Has had diabetes mellitus for 12 years B) Had abdominal surgery and has a nasogastric tube C) Just received 3 units of packed red blood

cells D) Uses sodium-containing antacids frequently Correct Answer: C

• The client with a stroke was admitted to a medical-surgical unit. Which tasks does the

nurse delegate to the unlicensed assistive personnel? A) Assess level of consciousness. B) Evaluate the pulse oximetry reading. C) Assist the client with meals. D) Complete the

nursing care plan.Correct Answer: C

• Interrelated concepts to the professional nursing role a nurse manager would consider

when addressing concerns about the quality of patient education include: A) adherence. B)

developmental level. C) motivation. D) technology.Correct Answer: D

• During orientation to an emergency department, the nurse educator would be

concerned if the new nurse listed which of the following as a risk factor for impaired thermoregulation? A) Temperature extremes B) Occupational exposure C) Impaired

cognition D) Physical agility Correct Answer: D

• An older adult client is in physical restraints. Which intervention by the nurse is the

priority? A) Assess the client hourly while keeping the restraints in place. B) Assess the client once each shift, releasing the restraints for feeding. C) Assess the client twice each shift while keeping the restraints in place. D) Assess the client every 30 to 60 minutes,

releasing restraints every 2 hours.Correct Answer: D

• The nurse is assessing a client with a long-term history of arthritic pain. Assessment

reveals a heart rate of 115 beats/min and blood pressure of 170/80 mm Hg. Which intervention will the nurse carry out first? A) Administer blood pressure medication. B)

• | P a g e

Administer a drug to lower the heart rate. C) Continue to assess for possible causes of elevated vital signs. D) Assess whether the client needs anti-arthritis medication.Correct

Answer: C

• The nurse is assigned to care for the following four clients who have the potential for

having pain. Which client is most likely not to be treated adequately for this problem? A) Middle-aged woman with a fractured arm B) Client with expressive aphasia C) Younger adult with metastatic cancer D) Client who has undergone an appendectomy Correct

Answer: B

• Before surgery, the nurse observes the client listening to music on the radio. Based on

this observation, the nurse may try which nonpharmacologic intervention for pain relief in the postoperative setting? A) Cutaneous skin stimulation B) Imagery C) Radiofrequency

ablation D) Hypnosis Correct Answer: B

• What interrelated constructs facilitate a nurse to become culturally competent? A)

Cultural desire, self-awareness, cultural knowledge, and cultural skill B) Cultural desire, self-awareness, cultural knowledge, and cultural diversity C) Cultural desire, self- awareness, cultural knowledge, and cultural identity D) Cultural diversity, self-awareness,

cultural skill, and cultural knowledge Correct Answer: A

• The emphasis on understanding cultural influence on health care is important because

of: A) disability entitlements. B) HIPAA requirements. C) litigious society. D) increasing

global diversity.Correct Answer: D

• The patient's laboratory report today indicates severe hypokalemia, and the nurse has

notified the physician. Nursing assessment indicates that heart rhythm is regular. What is the most important nursing intervention for this patient now? A) Examine sacral area and patient's heels for skin breakdown due to potential edema. B) Establish seizure precautions due to potential muscle twitching, cramps, and seizures. C) Institute fall precautions due to potential postural hypotension and weak leg muscles. D) Raise bed side rails due to potential decreased level of consciousness and confusion.Correct

Answer: C

• A nurse is assessing clients for fluid and electrolyte imbalances. Which client is at

greatest risk for developing hyponatremia? A) Client taking digoxin (Lanoxin) B) Client who is NPO receiving intravenous D5W C) Client taking ibuprofen (Motrin) D) Client taking a

sulfonamide antibiotic Correct Answer: B

• The nurse accidentally administers 10 mg of morphine intravenously to a client who

had been given another dose of morphine, 5 mg IV, about 30 minutes earlier. What action