HESI - Medical Surgical Nursing Correct and Verified Answers Graded A

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HESI - Medical Surgical Nursing Correct and Verified Answers Graded A

• Which client is at greatest risk for dehydration?
• younger adult client on bedrest
• older adult client receiving hypotonic IV fluid
• older adult client with cognitive impairment
• 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?

• increasing the IV flow rate to 250 mL/hr
• applying oxygen by mask or nasal cannula
• placing the client in a high Fowler's position
• Measuring intake and output every four hours

Correct Answer: A

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

associated with:

• prolonged stress response and a cascade of harmful effects system wide.
• decreased tumor growth and longevity
• large tidal volumes and decreased lung capacity
• decreased carbohydrate, protein, and fat destruction

Correct Answer: A

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

presents the most serious problem for this client?

• costs of creating a living will
• stock market fluctuations
• increased provider benefits
• 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?

• assess for a blood return
• notify the physician
• document the finding
• 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, respirations 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 priority action of the nurse?

• admin tylenol 650 mg orally
• encourage rest, and reassess in 15 minutes
• sponge the victim with cool water and remove his shirt
• encourage drinking of cool water or sports drink

Correct Answer: C

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

regarding pain management in older adult clients?

• older adults tend to report pain less often than younger adults

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• older clients usually have more experience with pain than younger clients
• older adults are at greatest risk for under treated pain
• 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)

• an older woman with hypertension
• a young man with a body mass index of 42
• a young many who has just consumed six martinis
• an older man who smokes a pack of cigarettes a day
• a young woman who is anorexic
• 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?

• field
• biological
• cognitive
• sociologic

Correct Answer: C

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

that informal teaching is an approach that:

• follows formalized plans
• has standardized content
• often occurs one-to-one
• addresses group needs

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Correct Answer: C

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

carefully for hyperkalemia?

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

• decreased renal blood flow
• increased gastrointestinal motility
• decreased ratio of adipose tissue to lean body mass
• 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?

• I will use a salt substitute when making and eating my meals.
• I must drink a quart of water or other liquid each day.
• I will not drink liquids after 6 PM so I won't have to get up at night.
• 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?

• assess the client's respiratory rate, rhythm, and depth
• document findings and monitor the client