2020 HESI MEDICAL-SURGICAL RN NURSING

2020 HESI MEDICAL-SURGICAL RN NURSING V2 Question 1 When caring for an elderly patient who is intermittently confused, what is the nurse’s primary concern regarding fluid and electrolytes? 1. Risk of dehydration 2. Risk of kidney damage 3. Risk of stroke 4. Risk of bleeding Correct Answer: 1 Rationale 1: As an adult ages, the perception of thirst declines. In an older patient with an altered level of consciousness, there is an increased risk of dehydration and high serum osmolality. Rationale 2: The risk of kidney damage is not specifically related to aging or fluid and electrolyte issues. Rationale 3: The risk of stroke is not specifically related to aging or fluid and electrolyte issues. Rationale 4: The risk of bleeding is not specifically related to aging or fluid and electrolyte issues. Question 2 A patient experiencing multisystem fluid volume deficit has tachycardia and decreased urine output. The nurse realizes these findings are most likely a direct result of which factor? 1. The body’s natural compensatory mechanisms 2. Pharmacologic effects of a diuretic 3. Effects of rapidly infused intravenous fluids 4. Cardiac failure Correct Answer: 1 Rationale 1: The body’s vasoconstrictive compensatory reactions are responsible for the symptoms. The body naturally attempts to conserve fluid internally specifically for the brain and heart. Rationale 2: A diuretic would cause further fluid loss and is contraindicated. Rationale 3: Rapidly infused intravenous fluids would not cause a decrease in urine output. Rationale 4: The manifestations reported are not indicative of cardiac failure in this patient. Question 3 A pregnant patient is admitted with excessive thirst, increased urination, and a medical diagnosis of diabetes insipidus. The nurse chooses which nursing diagnosis as most appropriate? 1. Risk for Imbalanced Fluid Volume 2. Excess Fluid Volume 3. Imbalanced Nutrition 4. Ineffective Tissue Perfusion Correct Answer: 1 Rationale 1: The patient with excessive thirst, increased urination, and a medical diagnosis of diabetes insipidus is at risk for Imbalanced Fluid Volume due to excess volume loss that can increase the serum levels of sodium. Rationale 2: Excess Fluid Volume is not an issue for patients with diabetes insipidus, especially during the early stages of treatment. Rationale 3: Imbalanced Nutrition is not supported by the assessment data provided. Rationale 4: Ineffective Tissue Perfusion is not supported by the assessment data provided. Question 4 An adult patient recovering from surgery has an indwelling urinary catheter. The nurse would contact the patient’s primary health care provider with which 24-hour urine output volume? 1. 600 milliliters 2. 750 milliliters 3. 1,000 milliliters 4. 1,200 milliliters Correct Answer: 1 Rationale 1: A urine output of less than 30 milliliters per hour must be reported to the primary health care provider. This indicates inadequate renal perfusion, which places the patient at increased risk for acute renal failure and inadequate tissue perfusion. A minimum of 720 milliliters over a 24- hour period is desired (30 milliliters multiplied by 24 hours equals 720 milliliters per 24 hours). Rationale 2: 750 mL is above the minimum desired level of 30 mL per hour. Rationale 3: 1,000 mL is above the minimum desired level of 30 mL per hour. Rationale 4: 1,200 mL is above the minimum desired level of 30 mL per hour. Question 5 A patient is diagnosed with severe hyponatremia. The nurse realizes this patient will mostly likely need which precautions implemented? 1. Seizure precautions 2. Infection precautions 3. Neutropenic precautions 4. High-risk fall precautions Correct Answer: 1 Rationale 1: Severe hyponatremia can lead to seizures. Seizure precautions would include a quiet environment, raised side rails, and having an oral airway at the bedside. Rationale 2: Infection precautions are not specifically indicated for a patient with hyponatremia. Rationale 3: Neutropenic precautions are not specifically indicated for a patient with hyponatremia. Rationale 4: High-risk fall precautions are not specifically indicated for a patient with hyponatremia. Question 6 A patient prescribed spironolactone is demonstrating ECG changes and complaining of muscle weakness. The nurse realizes this patient is exhibiting signs of which imbalance? 1. Hyperkalemia 2. Hypokalemia 3. Hypercalcemia 4. Hypocalcemia Correct Answer: 1 Rationale 1: Hyperkalemia is defined as serum potassium level greater than 5.0 mEq/L. Decreased potassium excretion is seen with potassium-sparing diuretics such as spironolactone. Common manifestations of hyperkalemia are muscle weakness and ECG changes. Rationale 2: Hypokalemia is seen in nonpotassium sparing diuretics such as furosemide. Rationale 3: Hypercalcemia has been associated with thiazide diuretics. Rationale 4: Hypocalcemia is seen in patients who have received many units of citrated blood and is not associated with diuretic use. Question 7 The nurse is planning care for a patient with fluid volume overload and hyponatremia. Which intervention should be included in this patient’s plan of care? 1. Restrict fluids. 2. Administer intravenous fluids. 3. Provide Kayexalate. 4. Administer intravenous normal saline with furosemide. Correct Answer: 1 Rationale 1: The nursing care for a patient with hyponatremia depends on the cause. Restriction of fluids to 1,000 mL/day is usually implemented to assist sodium increase and to prevent the sodium level from dropping further due to dilution. Rationale 2: The administration of intravenous fluids would be indicated in fluid volume deficit and hypernatremia. Rationale 3: Kayexalate is used in patients with hyperkalemia. Rationale 4: Normal saline with furosemide is administered to increase calcium secretion. Question 8 When caring for a patient diagnosed with hypocalcemia, the nurse would also assess for which other finding? 1. Other electrolyte disturbances 2. Hypertension 3. Visual disturbances 4. Drug toxicity Correct Answer: 1 Rationale 1: The patient diagnosed with hypocalcemia may also have high phosphorus or decreased magnesium levels. Rationale 2: The patient with hypocalcemia may exhibit hypotension, not hypertension. Rationale 3: Visual disturbances do not occur with hypocalcemia. Rationale 4: Hypercalcemia is more commonly caused by drug toxicities. Question 9 A patient with a history of stomach ulcers is diagnosed with hypophosphatemia. Which intervention should the nurse include in this patient’s plan of care? 1. Request a dietitian consult to select foods high in phosphorous. 2. Provide aluminum hydroxide antacids as prescribed. 3. Instruct the patient to avoid poultry, peanuts, and seeds. 4. Instruct the patient to avoid the intake of sodium phosphate. Correct Answer: 1 Rationale 1: Treatment of hypophosphatemia includes treating the underlying cause and promoting a high-phosphate diet, especially milk if it is tolerated. Other foods high in phosphate are dried beans and peas, eggs, fish, organ meats, Brazil nuts and peanuts, poultry, seeds, and whole grains. Rationale 2: Phosphate-binding antacids, such as aluminum hydroxide, should be avoided. Rationale 3: Poultry, peanuts, and seeds are part of a high-phosphate diet. Rationale 4: Mild hypophosphatemia may be corrected with oral supplements, such as sodium phosphate. Question 10 When analyzing an arterial blood gas report of a patient with COPD and respiratory acidosis, the nurse anticipates that compensation will develop through which mechanism? 1. The kidneys retain bicarbonate. 2. The kidneys excrete bicarbonate. 3. The lungs will retain carbon dioxide. 4. The lungs will excrete carbon dioxide. Correct Answer: 1 Rationale 1: The kidneys will compensate for a respiratory disorder by retaining bicarbonate. Rationale 2: Excreting bicarbonate causes acidosis to develop. Rationale 3: Retaining carbon dioxide causes respiratory acidosis. Rationale 4: Excreting carbon dioxide causes respiratory alkalosis. Question 11 The nurse is caring for a patient diagnosed with renal failure. Which compensation does the nurse expect for the acid-base disturbance found in patients with renal failure? 1. The patient breathes rapidly to eliminate carbon dioxide. 2. The patient will retain bicarbonate in excess of normal. 3. The pH will decrease from the present value. 4. The patient’s oxygen saturation level will improve. Correct Answer: 1 Rationale 1: In metabolic acidosis, compensation is accomplished through increased ventilation or “blowing off” CO2. This raises the pH by eliminating the volatile respiratory acid and compensates for the acidosis. Rationale 2: Because compensation must be performed by the system other than the affected system, the patient cannot retain bicarbonate; the manifestation of metabolic acidosis of renal failure is a lower than normal bicarbonate value.