Medical-Surgical Nursing Test Bank (11th Edition |
Ignatavicius) – Complete NCLEX & HESI Review with
correct Answers, Clinical Rationales & Interprofessional
Care Focus
The nurse is assessing a group of clients. Which clients are at greater risk for hypothermia or
frostbite? (select all that apply)
a. an older woman with hypertension
b. a young man with a body mass index of 42
c. a young many who has just consumed six martinis
d. an older man who smokes a pack of cigarettes a day
e. a young woman who is anorexic
f. a young woman who is diabetic - correct answersC, D, E, F
clients with poor nutrition, fatigue, and multiple chronic illnesses are at greater risk for
hypothermia. Clients who smoke, consume alcohol, or have impaired peripheral circulation have
a higher incidence of frostbite.
The nurse is caring for four clients. Which client assessment is the most indicative of having
pain?
A) Client stating that he is "anxious"
B) Heart rate of 105 beats/min and restlessness
C) Blood pressure 150/70 mm Hg and sleeping
D) Postoperative client with a neck incision - correct answersB
,At times clients are unable to verbalize that they are in pain but there are indicators that the
client may have acute pain such as increased heart rate, increased blood pressure, increased
respirations, sweating, restlessness, and overall distress. All the other distractors could indicate
clients who have the potential for being in pain, but restlessness with tachycardia is the most
indicative.
When describing patient education approaches, the nurse educator would explain that informal
teaching is an approach that
a. follows formalized plans
b. has standardized content
c. often occurs one-to-one
d. addresses group needs - correct answersC. Informal teaching is individualized one on one
teaching which represents the majority of patient education done by nurses that occurs when
an intervention is explained or a question is answered. Group needs are often the focus of
formal patient education courses or classes. Informal teaching does not necessarily follow a
specific formalized plan. It may be planned with specific content, but it is individualized
responses to patient needs. Formal teaching involves the use of a curriculum/course plan with
standardized content.
A patient expresses a strong interest in returning to their work, family, and hobbies after having
a stroke. Which theory type would the nurse use to develop a plan of care for the best results of
this patient's motivation style?
a. field
b. biological
c. cognitive
d. sociologic - correct answersC. Cognitive theorists believe that attention, relevance,
confidence, and satisfaction (ARCS) are the conditions that, when integrated, motivate someone
to learn. Field theorists place significance on how achievement, power, the need for affiliation,
,and avoidance motives influence individual behavior. Sociologic theories are not involved in
motivation.
Which statement made by a nurse represents the need for further education regarding pain
management in older adult clients?
a. older adults tend to report pain less often than younger adults
b. older clients usually have more experience with pain than younger clients
c. older adults are at greatest risk for under treated pain
d. older clients have a different pain mechanism and do not feel it as much - correct answersD
There is no evidence to support the idea that older adult clients perceive pain any differently
than younger clients. The other statements are accurate regarding older clients and pain.
The nurse is working at a first aid booth for a spring training game on a hot day. A spectator
comes in, reporting that he is not feeling well. Vital signs are temp 104.1 F, pulse 132 BPM,
respirs 26 breaths/min, and blood pressure 106/66 mm Hg. He trips over his feet as the nurse
leads him to a cot. What is the priory action of the nurse?
a. admin tylenol 650 mg orally
b. encourage rest, and reassess in 15 minutes
c. sponge the victim with cool water and remove his shirt
d. encourage drinking of cool water or sports drink - correct answersC
The spectator shows signs of heat stroke, which is a medical emergency. The spectator should
be transported to the ED ASAP. The nurs should take actions to lower his body temp in teh
meantime by removing his shirt and sponging his body with cool water. Lowering body temp by
drinking cool fluids or taking acetaminophen is not as effective in an emergency situation. The
client needs to be cooled quickly and is a priority for treatment
, The client is receiving an IV of 60 mEq of potassium chloride ina 1000 mL solution of dextrose
5% in 0.45% saline. The client states that the area around the IV site burns. What intervention
does the nurse perform first?
a. assess for a blood return
b. notify the physician
c. document the finding
d. stop the IV infusion - correct answersD
Potassium is a severe tissue irritant. The safest action is to discontinue the solution that
contains the potassium and discontinue the IV altogether, in which case the client would need
another site started. Assessing for a blood return may or may not be successful. The solution
could be diluted (less potassium) and the rate could be slowed once it is determined that the
needle is in the vein.
A nurse is caring for an older adult client who lives alone. Which economic situation presents
the most serious problem for this client?
a. costs of creating a living will
b. stock market fluctuations
c. increased provider benefits
d. social security as the basis of income - correct answersD
Older adults on fixed incomes are unable to adjust their income to meet rising costs associated
with meeting basic needs
Controlling pain is important to promoting wellness. Unrelieved pain has been associated with
Ignatavicius) – Complete NCLEX & HESI Review with
correct Answers, Clinical Rationales & Interprofessional
Care Focus
The nurse is assessing a group of clients. Which clients are at greater risk for hypothermia or
frostbite? (select all that apply)
a. an older woman with hypertension
b. a young man with a body mass index of 42
c. a young many who has just consumed six martinis
d. an older man who smokes a pack of cigarettes a day
e. a young woman who is anorexic
f. a young woman who is diabetic - correct answersC, D, E, F
clients with poor nutrition, fatigue, and multiple chronic illnesses are at greater risk for
hypothermia. Clients who smoke, consume alcohol, or have impaired peripheral circulation have
a higher incidence of frostbite.
The nurse is caring for four clients. Which client assessment is the most indicative of having
pain?
A) Client stating that he is "anxious"
B) Heart rate of 105 beats/min and restlessness
C) Blood pressure 150/70 mm Hg and sleeping
D) Postoperative client with a neck incision - correct answersB
,At times clients are unable to verbalize that they are in pain but there are indicators that the
client may have acute pain such as increased heart rate, increased blood pressure, increased
respirations, sweating, restlessness, and overall distress. All the other distractors could indicate
clients who have the potential for being in pain, but restlessness with tachycardia is the most
indicative.
When describing patient education approaches, the nurse educator would explain that informal
teaching is an approach that
a. follows formalized plans
b. has standardized content
c. often occurs one-to-one
d. addresses group needs - correct answersC. Informal teaching is individualized one on one
teaching which represents the majority of patient education done by nurses that occurs when
an intervention is explained or a question is answered. Group needs are often the focus of
formal patient education courses or classes. Informal teaching does not necessarily follow a
specific formalized plan. It may be planned with specific content, but it is individualized
responses to patient needs. Formal teaching involves the use of a curriculum/course plan with
standardized content.
A patient expresses a strong interest in returning to their work, family, and hobbies after having
a stroke. Which theory type would the nurse use to develop a plan of care for the best results of
this patient's motivation style?
a. field
b. biological
c. cognitive
d. sociologic - correct answersC. Cognitive theorists believe that attention, relevance,
confidence, and satisfaction (ARCS) are the conditions that, when integrated, motivate someone
to learn. Field theorists place significance on how achievement, power, the need for affiliation,
,and avoidance motives influence individual behavior. Sociologic theories are not involved in
motivation.
Which statement made by a nurse represents the need for further education regarding pain
management in older adult clients?
a. older adults tend to report pain less often than younger adults
b. older clients usually have more experience with pain than younger clients
c. older adults are at greatest risk for under treated pain
d. older clients have a different pain mechanism and do not feel it as much - correct answersD
There is no evidence to support the idea that older adult clients perceive pain any differently
than younger clients. The other statements are accurate regarding older clients and pain.
The nurse is working at a first aid booth for a spring training game on a hot day. A spectator
comes in, reporting that he is not feeling well. Vital signs are temp 104.1 F, pulse 132 BPM,
respirs 26 breaths/min, and blood pressure 106/66 mm Hg. He trips over his feet as the nurse
leads him to a cot. What is the priory action of the nurse?
a. admin tylenol 650 mg orally
b. encourage rest, and reassess in 15 minutes
c. sponge the victim with cool water and remove his shirt
d. encourage drinking of cool water or sports drink - correct answersC
The spectator shows signs of heat stroke, which is a medical emergency. The spectator should
be transported to the ED ASAP. The nurs should take actions to lower his body temp in teh
meantime by removing his shirt and sponging his body with cool water. Lowering body temp by
drinking cool fluids or taking acetaminophen is not as effective in an emergency situation. The
client needs to be cooled quickly and is a priority for treatment
, The client is receiving an IV of 60 mEq of potassium chloride ina 1000 mL solution of dextrose
5% in 0.45% saline. The client states that the area around the IV site burns. What intervention
does the nurse perform first?
a. assess for a blood return
b. notify the physician
c. document the finding
d. stop the IV infusion - correct answersD
Potassium is a severe tissue irritant. The safest action is to discontinue the solution that
contains the potassium and discontinue the IV altogether, in which case the client would need
another site started. Assessing for a blood return may or may not be successful. The solution
could be diluted (less potassium) and the rate could be slowed once it is determined that the
needle is in the vein.
A nurse is caring for an older adult client who lives alone. Which economic situation presents
the most serious problem for this client?
a. costs of creating a living will
b. stock market fluctuations
c. increased provider benefits
d. social security as the basis of income - correct answersD
Older adults on fixed incomes are unable to adjust their income to meet rising costs associated
with meeting basic needs
Controlling pain is important to promoting wellness. Unrelieved pain has been associated with
