HESI MED SURG 1 FINAL EXAM TEST
BANK EXAM AND PRACTICE EXAM WITH
UPDATED QUESTIONS AND DETAILED
CORRECT ANSWERS WITH RATIONALES
(ALREADY GRADED
... [Show More] A+)
After receiving a change-of-shift report at 7:00 AM, the nurse
should assess which of these clients first?
A. A 23-year-old with a migraine headache who has severe
nausea associated with retching.
B. A 45-year-old who is scheduled for a craniotomy in 30 minutes
and needs preoperative teaching.
C. A 59-year-old with Parkinson's disease who will need a
swallowing assessment before breakfast.
D. A 63-year-old with multiple sclerosis who has an oral
temperature of 101.8^\circF and flank pain. - ANSWER-Answer:
D: A 63-year-old with MS who has an oral temperature of 101.8
and flank pain.
Rationale: Urinary tract infections are a frequent
complication in clients with multiple sclerosis because of the
effect on bladder function; therefore, that client should been
seen first by the nurse. The elevated temperature and flank
pain suggest that this patient may have pyelonephritis. The
physician should be notified immediately so that antibiotic
therapy can be started quickly. The other clients should be
assessed soon, but do not have needs as urgent as this
client. (Billings & Hensel, 2014, p. 599)
The nurse employed in an emergency department is assigned to
triage clients coming to the emergency department for treatment
on the evening shift. The nurse should assign priority to which
client?
A. A client complaining of muscle aches, a headache, and
malaise
B. A client who twisted her ankle when she fell while rollerblading
C. A client with a minor laceration on the index finger while cutting
an eggplant
D. A client with chest pain who states that he just ate pizza that
was made with a very spicy sauce - ANSWER-Answer: D. A client
with chest paint who states that he just ate pizza that was made
with a very spicy sauce.
Rationale: in an ED, triage involves brief client assessment to
classify clients according to their need for care and includes
establishing priorities of care. Clients with trauma, chest
pain, severe respiratory distress or cardiac arrest, limb
amputation, and acute neurological deficits, or who have
sustained chemical splashes to the eyes, are classified as
emergent and are the number 1 priority. Clients with
conditions such as simple fracture, asthma without
respiratory distress, fever, hypertension, abdominal pain, or
a renal stone have urgent needs and are classified as a
number 2 priority. Clients with conditions such as laceration,
sprain, or cold symptoms are classified as nonurgent are a
number 3 priority.
An older client presents to the emergency department (ED) with a
2-day history of cough, pain on inspiration, shortness of breath,
and dyspnea. The client never had a pneumococcal vaccine. The
client's chest x-ray shows density in both bases. The client has
wheezing upon auscultation of both lungs. Would a bronchodilator
be beneficial for this client?
A. A bronchodilator would not be beneficial for this client
B. A bronchodilator would help decrease the bronchospasm
C. It would clear up the density in the base of the client's lungs
D. It will decrease the client's pain on inspiration - ANSWERCorrect: A bronchodilator would help decrease bronchospasm
Rationale: A bronchodilator would help decrease
bronchospasm and would open up the airways, so it would
be beneficial for this client
Which priority problems may be considered for the client with
heart failure? Select all that apply.
A. Decreased fluid volume related to compromised regulatory
mechanism
B. Impaired Physical Mobility related to limited cardiovascular
endurance
C. Impaired Gas Exchange related to ventilation-perfusion
imbalance
D. Potential for pulmonary edema
E. Risk for Ineffective renal Perfusion related to hypervolemia -
ANSWER-Correct: B, C, D, E
B. Rationale-Owing to intra-alveolar edema and poor cardiac
output, the client is fatigues and has limited endurance.
C. Rationale-Owing to intra-alveolar edema and poor cardiac
output, the client may develop hypoxemia.
D. Rationale-Owing to limited cardiac reserve, the client is at
risk for pulmonary edema
E. Rationale-The client with heart failure has poor cardiac
output, reduced blood flow to the kidney and accumulation
of pulmonary and peripheral fluid.The nurse is caring for the
following clients. Which client should the nurse assess FIRST?
A. the client whose partial thromboplastin time (PTT) is 38
seconds.
B. The client whose hemoglobin is 14 g/dl and hematocrit is 45%.
C. The client whose platelet count is 75,000 per cubic millimeter
of blood.
D. The client whose red blood cell count is 4.8 x 10^6/mm^3. -
ANSWER-Answer: C
Rationale:
A normal range for PTT is 32 to 39 seconds.
These are normal hemoglobin/hematocrit levels for either a
male or female client.
A PLATELET COUNT OF LESS THAN 100,000 PER CUBIC
MILLIMETER OF BLOOD INDICATES THROMBOCYTOPENIA.
This is a normal red blood cell count.
Which cast care instructions should the nurse provide to a client
who just had a plaster cast applied to the right forearm? Select all
that apply.
a. Keep the cast clean and dry
b. Allow the cast 24-72 hours to dry
c. Keep the cast and extremity elevated
d. Use a hairdryer set on warm to hot setting to dry the cast
e. Use a soft padded object that will fit under the cast to scratch
the skin under the cast - ANSWER-Answer:
A: Keep the cast clean and dry.
B: Allow cast 24-72 hours to dry
C: Keep the cast and extremity elevated [Show Less]