(A+ solutions) HESI - Medical Surgical Nursing Exam Test 1, with rationale. 2022
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HESI - Medical Surgical Nursing
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HESI - Medical Surgical Nursing
(A+ solutions) HESI - Medical Surgical Nursing Exam Test 1, with rationale. 2022
HESI - Medical Surgical Nursing test
When describing patient education approaches, the nurse educator would explain that informal teaching is an approach that
a. follows formalized plans
b. has standardized con...
HESI - Medical Surgical Nursing test
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 (✅- C. 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. Group needs are often the focus of formal patient education
courses or classes. Informal teaching does not necessarily follow a specific formalized plan. It
may be planned with specific content, but it is individualized responses to patient needs. Formal
teaching involves the use of a curriculum/course plan with standardized content.
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 (✅- C. Cognitive theorists believe that attention, relevance, confidence, and
satisfaction (ARCS) are the conditions that, when integrated, motivate someone to learn. Field
theorists place significance on how achievement, power, the need for affiliation, and avoidance
motives influence individual behavior. Sociologic theories are not involved in motivation.
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 many 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 (✅- C, D, E, F
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.
,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
c. 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 (✅- D
There is no evidence to support the idea that older adult clients perceive pain any differently than
younger clients. The other statements are accurate regarding older clients and pain.
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 (✅- C
The spectator shows signs of heat stroke, which is a medical emergency. The spectator should be
transported to the ED ASAP. The nurs should take actions to lower his body temp in teh
meantime by removing his shirt and sponging his body with cool water. Lowering body temp by
drinking cool fluids or taking acetaminophen is not as effective in an emergency situation. The
client needs to be cooled quickly and is a priority for treatment
The client is receiving an IV of 60 mEq of potassium chloride ina 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 (✅- D
Potassium is a severe tissue irritant. The safest action is to discontinue the solution that contains
the potassium and discontinue the IV altogether, in which case the client would need another site
started. Assessing for a blood return may or may not be successful. The solution could be diluted
(less potassium) and the rate could be slowed once it is determined that the needle is in the vein.
,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 (✅- D
Older adults on fixed incomes are unable to adjust their income to meet rising costs associated
with meeting basic needs
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 (✅- A
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. The
stress response causes the endocrine system to release excessive amounts of hormones, such as
cortisol, catecholamines, and glucagon. Insulin and testosterone levels decrease. Increased
endocrine activity in turn initiates a number of metabolic processes, in particular, accelerated
carbohydrate, protein, and fat destruction, whcih can result in weight loss, tachycardia, increased
respiratory rate, shock, and even death. The immune system is also affected by pain as
demonstrated by research showing a link between unrelieved pain and a higher incidence of
nosocomial infections and increased tumor growth. Large tidal volumes are not associated with
pain while decreased lung capacity is associated with unrelieved pain. Decreased tumor growth
and longevity are not associated with unrelieved pain. Decreased carbs, protein, and fat are not
associated with pain or stress response.
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 (✅- A
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, depending on the degree of
dehydration, rehydrating the person too rapidly with IV fluids can lead to cerebral edema.
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 (✅- C
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
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 (✅- B
Many salt substitutes are composed of potassium chloride. Heavy use cna contribute to the
development of hyperkalemia. The client should be taught to read labels and to choose a salt
substitute that does not contain potassium. NSAIDs promote the retention of sodium but not
potassium.
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 (✅- A
Decreased renal blood flow and reduced glomerular filtration can result in slower medication
excretion time, potentially leading to toxic drug accumulation. Aging results in decreased total
body water and gastrointestinal motility and an increase in the ratio of adipose tissue to lean
body mass, but is not related to dig toxicity.
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