HESI MED SURG / MED SURG 55
QUESTIONS RN V1 (MOST
ANSWER(S))
A 55-year-old patient is preparing to start an exercise program. The health care
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provider wants 60% of maximum target heart rate. Calculate the heart rate that the
nurse will add to the care plan as the target heart rate. Record answer as a whole
number.
maximum
heart rate ANS:
99
Teach patients to calculate their maximum heart rate by subtracting their current
age in years from 220 and then obtaining their target heart rate by taking 60% to
90% of the maximum, depending on their health care provider’s
recommendation. 220 − 55 = 165 × 0.6 = 99.
1. A nurse is teaching a patient about medications. Which statement from
the patient indicates teaching is effective?
a. “My parenteral medication must be taken with food.”
b. “I will rotate the sites in my left leg when I give my insulin.”
c. “Once I start feeling better, I will stop taking my antibiotic.”
“If I am 30 minutes late taking my medication, I should skip that
d. dose.”
ANS: B
For daily insulin, rotate site within anatomical area. Rotating injections within
the same body part (instrasite rotation) provides greater consistency in
absorption of medication. Parenteral medication absorption is not affected by the
timing of meals. Taking a medication 30 minutes late is within the 60-minute
window of the time medications should be taken. Medications are usually
154stopped based on the provider’s orders except in extenuating circumstances.
With some medications, such as antibiotics, it is crucial that the full course of
medication is taken to avoid relapse of infection.
2. A nurse is preparing to administer an injection to a patient. Which
statement made by the patient is an indication for the nurse to use the Z-track
method?
a. “I am allergic to many medications.”
b. “I’m really afraid that a big needle will hurt.”
c. “The last shot like that turned my skin colors.”
d. “My legs are too obese for the needle to go through.”
ANS: C
The Z-track is indicated when the medication being administered has the potential
to irritate sensitive tissues. It is recommended that, when administering IM
injections, the Z-track method be used to minimize local skin irritation by sealing
the medication in muscle tissue. The Z-track method is not meant to reduce
discomfort from the procedure. If a patient is allergic to a medication, it should not
be administered. If a patient has additional subcutaneous tissue to go through, a
needle of a different size may be selected.
3. A 2-year-old child is ordered to have eardrops daily. Which action will the
nurse take?
a. Pull the auricle down and back to straighten the ear canal.
b. Pull the auricle upward and outward to straighten the ear canal.
c. Sit the child up for 2 to 3 minutes after instilling drops in ear canal.
d. Sit the child up to insert the cotton ball into the innermost ear canal.
ANS: A
Children up to 3 years of age should have the auricle pulled down and back,
children 3 years of age to adults should have the auricle pulled upward and
outward. Solution should be instilled 1 cm (1/2 in) above the opening of the ear
canal. The patient should remain in the side-lying position 2 to 3 minutes. If a
154cotton ball is needed, place it into the outermost part of the ear canal.
4. A patient has an order to receive 0.3 mL of U-500 insulin. Which syringe
will the nurse obtain to administer the medication?
a. 3-mL syringe
b. U-100 syringe
c. Needleless syringe
d. Tuberculin syringe
ANS: D
Because there is no syringe currently designed to prepare U-500 insulin, many
medication errors result with this kind of insulin. To prevent errors, ensure that the
order for U-500 specifies units and volume (e.g., 150 units, 0.3 mL of U-500
insulin), and use tuberculin syringes to draw up the doses. A 3 mL and U-100 can
result in inaccurate dosing. A needleless syringe will not be acceptable in this
situation.
5. A patient has an order to receive 12.5 mg of hydrochlorothiazide. The
nurse has on hand a 25 mg tablet of hydrochlorothiazide. How many tablet(s)
will the nurse administer?
a. 1/2 tablet
b. 1 tablet
c. 1 1/2 tablets
d. 2 tablets
ANS: A
1/2 tablet will be given. The nurse is careful to perform nursing calculations to
ensure proper medication administration. The dose ordered is 12.5. The dose on
hand is 25. 12.5/25 = 1/2 tablet.
6. The patient is to receive phenytoin (Dilantin) at 0900. When will be the
ideal time for the nurse to schedule a trough level?
a. 0800
154b. 0830
c. 0900
d. 0930
ANS: B
154Trough levels are generally drawn 30 minutes before the drug is
administered. If the medication is administered at 0900, the trough should be
drawn at 0830.
7. A patient is receiving vancomycin. Which function is the priority for the
nurses to assess?
a. Vision
b. Hearing
c. Heart tones
d. Bowel sounds
ANS: B
A side effect of vancomycin is ototoxicity—hearing. It does not affect vision,
heart tones, or bowel sounds.
8. A health care provider orders lorazepam (Ativan) 1 mg orally 2 times a
day. The dose available is 0.5 mg per tablet. How many tablet(s) will the nurs [Show Less]