winterPasspoint
HESI - Medical Surgical Nursing test-Exam TEST BANK FOR MEDICAL SURGICAL
NURSING 11TH EDITION IGNATAVICIUS 100% Guaranteed Pass Questions &
Answers Graded A+
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
C, 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?
1
, winterPasspoint
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
B
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
C. 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?
2
, winterPasspoint
a. field
b. biological
c. cognitive
d. sociologic
C. 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
D
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?
3
, winterPasspoint
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
C
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
D
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.
4
HESI - Medical Surgical Nursing test-Exam TEST BANK FOR MEDICAL SURGICAL
NURSING 11TH EDITION IGNATAVICIUS 100% Guaranteed Pass Questions &
Answers Graded A+
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
C, 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?
1
, winterPasspoint
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
B
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
C. 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?
2
, winterPasspoint
a. field
b. biological
c. cognitive
d. sociologic
C. 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
D
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?
3
, winterPasspoint
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
C
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
D
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.
4
