- | P a g e
HESI - Medical Surgical Nursing test Questions And Correct Detailed Answers (Verified Answers) Already 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
Rationale: Older adults, because they have less total body water than younger adults, are at greater risk for development of dehydration. Anyone who is cognitively impaired and cannot obtain fluids independently or cannot make his or her need for fluids known is at high risk for dehydration.
- Which intervention in a client with dehydration induced confusion is most likely to
- 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
relieve the confusion?
Correct Answer: A
Rationale: Dehydration most frequently leads to poor cerebra perfusion and cerebral hypoxia, causing confusion. Applying oxygen can reduce confusion, even if perfusion is still less than optimum. Increasing the IV flow rate would increase perfusion. However,
- | P a g e
depending on the degree of dehydration, rehydrating the person too rapidly with IV fluids can lead to cerebral edema.
- 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
Rationale: Pain triggers a number of physiologic stress responses in the human body.Unrelieved pain can prolong the stress response and produce a cascade of harmful effects in all body systems.
- A nurse is caring for an older adult client who lives alone. Which economic situation
- costs of creating a living will
- stock market fluctuations
- increased provider benefits
- social security as the basis of income
presents the most serious problem for this client?
Correct Answer: D
Rationale: Older adults on fixed incomes are unable to adjust their income to meet rising costs associated with meeting basic needs.
- The client is receiving an IV of 60 mEq of potassium chloride in a 1000 mL solution of
- assess for a blood return
- notify the physician
- document the finding
- stop the IV infusion
dextrose 5% in 0.45% saline. The client states that the area around the IV site burns.What intervention does the nurse perform first?
- | P a g e
Correct Answer: D
Rationale: Potassium is a severe tissue irritant. The safest action is to discontinue the solution that contains the potassium and discontinue the IV altogether.
- The nurse is working at a first aid booth for a spring training game on a hot day. A
- 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
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 priority action of the nurse?
Correct Answer: C
Rationale: The spectator shows signs of heat stroke, which is a medical emergency. The nurse should take actions to lower his body temp in the meantime by removing his shirt and sponging his body with cool water.
- Which statement made by a nurse represents the need for further education
- older adults tend to report pain less often than younger adults
- 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
regarding pain management in older adult clients?
Correct Answer: D
Rationale: There is no evidence to support the idea that older adult clients perceive pain any differently than younger clients.
- The nurse is assessing a group of clients. Which clients are at greater risk for
- an older woman with hypertension
- a young man with a body mass index of 42
- a young man who has just consumed six martinis
hypothermia or frostbite? (select all that apply)
- | P a g e
- 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
Rationale: Clients with poor nutrition, fatigue, and multiple chronic illnesses are at greater risk for hypothermia. Clients who smoke, consume alcohol, or have impaired peripheral circulation have a higher incidence of frostbite.
- A patient expresses a strong interest in returning to their work, family, and hobbies
- field
- biological
- cognitive
- sociologic
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?
Correct Answer: C
Rationale: Cognitive theorists believe that attention, relevance, confidence, and satisfaction (ARCS) are the conditions that, when integrated, motivate someone to learn.
- 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
Correct Answer: C
Rationale: Informal teaching is individualized one on one teaching which represents the majority of patient education done by nurses that occurs when an intervention is explained or a question is answered.
- A nurse is caring for several clients. Which client does the nurse assess most
carefully for hyperkalemia?
