pg. 1 HESI - Medical Surgical Nursing Newest Exam 2024
TEST BANK FOR MEDICAL SURGICAL NURSING 11TH
EDITION IGNATAVICIUS
Questions with Correct Detailed Answers (Verified Answers) Graded A+
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
Rationale; 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?
- decreased renal blood flow
- increased gastrointestinal motility
- decreased ratio of adipose tissue to lean body mass
- increased total body water - Correct Answer - A
- / 4
pg. 2 Rationale; 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.
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
Rationale; Because 1 L of water weighs 1 kg, change in body weight is a good measure of excess fluid loss or fluid retention. Weight loss greater than 0.5 lb daily is indicative of excessive fluid loss. The other statements are not indicative of practices that will prevent dehydration.
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
- measure the client's pulse and blood pressure
- call the health care provider - Correct Answer - A
Rationale; In a client with hypokkalemia, progressive skeletal muscle weakness is associated with increasing severity of hypokalemia. The most life-threatening complication of hypokalemia is respiratory insufficiency. It is imperative for the nurse to perform a respiratory assessment first to make sure that the client is not in immediate jeopardy.Next, the nurse would call the health care provider to obtain orders for potassium replacement. 2 / 4
pg. 3 The physician orders Lanoxin(digoxin)0.375 mg po every day. On hand you have 0.25mg/5 mL. How many mL would you give your patient?
- 8 mL
- 7.5 mL
- 7 mL
- 5.5 mL - Correct Answer - B
The nurse is admitting an older adult with decompensated congestive heart failure. The nursing assessment reveals adventitious lung sounds, dyspnea, and orthopnea. The nurse should question which doctor's order?
- KCl 20 mEq PO two times per day
- Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr
- Oxygen via face mask at 8 L/min
- Furosemide (Lasix) 20 mg PO now - Correct Answer - B
Rationale; A patient with decompensated heart failure has extracellular fluid volume (ECV) excess.The IV of 0.9% NaCl is normal saline, which should be questioned because it would expand ECV and place an additional load on the failing heart. Diuretics such as furosemide are appropriate to decrease the ECV during heart failure. Increasing the potassium intake with KCl is appropriate, because furosemide increases potassium excretion. Oxygen administration is appropriate in this situation of near pulmonary edema from ECV excess.
The priority nursing intervention for a patient suspected to be hypothermic would be to:
- hydrate with intravenous (IV) fluids.
- remove wet clothes.
- assess vital signs.
- provide a warm blanket. - Correct Answer - B 3 / 4
pg. 4 Rationale; The first thing to do with a patient suspected to be hypothermic is to remove wet clothes, because heat loss is five times greater when clothing is wet. Assessing vital signs is important, but the wet clothes should be removed first. Hydration is very important with hyperthermia and the associated danger of dehydration, but there is not a similar risk with hypothermia. A warm blanket over wet clothes would not be an effective warming strategy.
The nurse admitting a patient to the emergency department on a very hot summer day
would suspect hyperthermia when the patient demonstrates:
- slow capillary refill.
- red, sweaty skin.
- low pulse rate.
- decreased respirations. - Correct Answer - B
Rationale; With hyperthermia, vasodilatation occurs causing the skin to appear flushed and warm or hot to touch. There is an increased respiration rate with hyperthermia. The heart rate increases with hyperthermia. With hypothermia there is slow capillary refill.
Why does the nurse always ask the client his or her pain level after taking routine vital signs?
- To follow McCaffery's guidelines on pain management
- To ensure that pain assessment occurs on a regular basis
- To determine the need for more frequent vital sign measurement
- To determine whether pain is influencing blood pressure and heart rate - Correct
- / 4
Answer - B Rationale; Making pain the fifth vital sign allows more frequent and accurate assessment, which can contribute to better pain management.