2020 HESI Medical-Surgical RN Nursing V2
Question 1
When caring for an elderly patient who is
intermittently confused, what is the nurse’s
... [Show More] 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 milliliter [Show Less]