(A+ solutions) HESI - Medical Surgical Nursing Exam Test 1, with rationale. 2022

(A+ solutions) HESI - Medical Surgical Nursing Exam Test 1, with rationale. 2022 HESI - Medical Surgical Nursing test 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? 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. 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. 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? 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. 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 (- D 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 a. prolonged stress response and a cascade of harmful effects system wide. b. decreased tumor growth and longevity c. large tidal volumes and decreased lung capacity d. decreased carbohydrate, protein, and fat destruction (- A Pain triggers a number of physiologic stress responses in the human body. Unrelieved pain can prolong the stress response and produce a cascade of harmful effects in all body systems. The stress response causes the endocrine system to release excessive amounts of hormones, such as cortisol, catecholamines, and glucagon. Insulin and testosterone levels decrease. Increased endocrine activity in turn initiates a number of metabolic processes, in particular, accelerated carbohydrate, protein, and fat destruction, whcih can result in weight loss, tachycardia, increased respiratory rate, shock, and even death. The immune system is also affected by pain as demonstrated by research showing a link between unrelieved pain and a higher incidence of nosocomial infections and increased tumor growth. Large tidal volumes are not associated with pain while decreased lung capacity is associated with unrelieved pain. Decreased tumor growth and longevity are not associated with unrelieved pain. Decreased carbs, protein, and fat are not associated with pain or stress response. Which intervention in a client with dehydration induced confusion is most likely to relieve the confusion? a. increasing the IV flow rate to 250 mL/hr b. applying oxygen by mask or nasal cannula c. placing the client in a high Fowler's position d. Measuring intake and output every four hours (- A Dehydration most frequently leads to poor cerebra perfusion and cerebral hypoxia, causing confusion. Applying oxygen can reduce confusion, even if perfusion is still less than optimum. Increasing the IV flow rate would increase perfusion. However, depending on the degree of dehydration, rehydrating the person too rapidly with IV fluids can lead to cerebral edema. Which client is at greatest risk for dehydration? a. younger adult client on bedrest b. older adult client receiving hypotonic IV fluid c. older adult client with cognitive impairment d. younger adult client receiving hypertonic IV fluid (- C Older adults, because they have less total body water than younger adults, are at greater risk for development of dehydration. Anyone who is cognitively impaired and cannot obtain fluids independently or cannot make his or her need for fluids known is at high risk for dehydration A nurse is caring for several clients. Which client does the nurse assess most carefully for hyperkalemia? a. client with type 2 diabetes taking an oral anti-diabetic agent b. client with heart failure using a salt substitute c. client taking a thiazide diuretic for hypertension d. client taking non-steroidal anti-inflammatory drugs daily (- B Many salt substitutes are composed of potassium chloride. Heavy use cna contribute to the development of hyperkalemia. The client should be taught to read labels and to choose a salt substitute that does not contain potassium. NSAIDs promote the retention of sodium but not potassium. An older adult client presents with signs and symptoms related to dig toxicity. Which age related change may have contributed to this problem? a. decreased renal blood flow b. increased gastrointestinal motility c. decreased ratio of adipose tissue to lean body mass d. increased total body water (- A Decreased renal blood flow and reduced glomerular filtration can result in slower medication excretion time, potentially leading to toxic drug accumulation. Aging results in decreased total body water and gastrointestinal motility and an increase in the ratio of adipose tissue to lean body mass, but is not related to dig toxicity. A client is being treated for dehydration. Which statement made by the client indicates understanding of this condition? a. I will use a salt substitute when making and eating my meals. b. I must drink a quart of water or other liquid each day. c. I will not drink liquids after 6 PM so I won't have to get up at night. d. I will weigh myself each morning before I eat or drink. (- D Because 1 L of water weighs 1 kg, change in body weight is a good measure of excess fluid loss or fluid retention. Weight loss greater than 0.5 lb daily is indicative of excessive fluid loss. The other statements are not indicative of practices that will prevent dehydration. The nurse notes that the handgrip of the client with hypokalemia has diminished since the previous assessment one hour ago. Which intervention by the nurse is the priority? a. assess the client's respiratory rate, rhythm, and depth b. document findings and monitor the client c. measure the client's pulse and blood pressure d. call the health care provider (- A In a client with hypokkalemia, progressive skeletal muscle weakness is associated with increasing severity of hypokalemia. The most life-threatening complication of hypokalemia is respiratory insufficiency. It is imperative for the nurse to perform a respiratory assessment first to make sure that the client is not in immediate jeopardy. Next, the nurse would call the health care provider to obtain orders for potassium replacement. The physician orders Lasix (furosemide) 60 mg po every day for your patient. On hand you have Lasix 40 mg. How many tablets will you give the patient? a. 3 b. 1 c. 1 1/2 d. 2 1/5 (- C 60/40 (desired/have) A client has been taught to restrict dietary sodium. Which food selection by the client indicates to the nurse that teaching has been effective? a. a grilled cheese sandwich with tomato soup b. Chinese take-out, including steamed rice c. a chicken leg, one slice of bread with butter, and steamed carrots d. slices of ham and cheese on whole grain crackers (- C Clients on restricted sodium diets generally should avoid processed, smoked, and pickled foods and those with sauces and other condiments. Foods lowest in sodium include fish, poultry, and fresh produce. The chinese food likely would have soy sauce, the tomato soup is processed, and the crackers are a snack food - a category of foods often high in sodium. When a client is assessed, which behavior best indicates that he or she is experiencing changes associated with acute pain? a. inability to concentrate b. expressed hopelessness c. psychosocial withdrawal d. anger and hostility (- A The characteristics most common to chronic pain are psychosocial withdrawal, anger and hostility, depression, and hopelessness. The inability to concentrate is associated much more with acute pain, before any physiologic or behavioral adaptation has occurred. A nurse is caring for several clients at risk for overhydration. The nurse assesses the older client with which finding first? A) Has had diabetes mellitus for 12 years B) Had abdominal surgery and has a nasogastric tube C) Just received 3 units of packed red blood cells D) Uses sodium-containing antacids frequently (- C Blood replacement therapy involves intravenous fluid administration, which inherently increases the risk for overhydration. The fact that the fluid consists of packed red blood cells greatly increases the risk, because this fluid increases the colloidal oncotic pressure of the blood, causing fluid to move from interstitial and intracellular spaces into the plasma volume. An older adult may not have sufficient cardiac or renal reserve to manage this extra fluid. The client with a stroke was admitted to a medical-surgical unit. Which tasks does the nurse delegate to the unlicensed assistive personnel? A) Assess level of consciousness. B) Evaluate the pulse oximetry reading. C) Assist the client with meals. D) Complete the nursing care plan. (- C The nurse needs to know the five rights of delegation: right task, right circumstances, right person, right communication, and right supervision. Unlicensed assistive personnel can help with feeding, but only the nurse can care plan, assess the level of consciousness, and evaluate the oxygenation of the client. Interrelated concepts to the professional nursing role a nurse manager would consider when addressing concerns about the quality of patient education include: A) adherence. B) developmental level. C) motivation. D) technology. (- D The interrelated concepts to the professional role of a nurse include health promotion, leadership, technology/informatics, quality, collaboration, and communication. Adherence, culture, developmental level, family dynamics, and motivation are considered interrelated concepts to patient attributes and preference. During orientation to an emergency department, the nurse educator would be concerned if the new nurse listed which of the following as a risk factor for impaired thermoregulation? A) Temperature extremes B) Occupational exposure C) Impaired cognition D) Physical agility (- D Physical agility is not a risk factor for impaired thermoregulation. The nurse educator would use this information to plan additional teaching to include medical conditions and gait disturbance as risk factors for hypothermia, because their bodies have a reduced ability to generate heat. Impaired cognition is a risk factor. Recreational or occupational exposure is a risk factor. Temperature extremes are risk factors for impaired thermoregulation. An older adult client is in physical restraints. Which intervention by the nurse is the priority? A) Assess the client hourly while keeping the restraints in place. B) Assess the client once each shift, releasing the restraints for feeding. C) Assess the client twice each shift while keeping the restraints in place. D) Assess the client every 30 to 60 minutes, releasing restraints every 2 hours. (- D The application of restraints can have serious consequences. Thus, the nurse should check the client every 30 to 60 minutes, releasing the restraints every 2 hours for positioning and toileting. The other answers would not be appropriate because the client would not be assessed frequently enough, and circulation to the limbs could be compromised. Assessing every hour and releasing the restraints every 2 hours is in compliance with federal policy for monitoring clients in restraints. The nurse is assessing a client with a long-term history of arthritic pain. Assessment reveals a heart rate of 115 beats/min and blood pressure of 170/80 mm Hg. Which intervention will the nurse carry out first? A) Administer blood pressure medication. B) Administer a drug to lower the heart rate. C) Continue to assess for possible causes of elevated vital signs. D) Assess whether the client needs anti-arthritis medication. (- C Arthritis is categorized as chronic pain. With chronic pain, the body adapts by blocking the sympathetic nervous system; this normally causes tachycardia and increased blood pressure. Therefore, this client's high blood pressure and heart rate are not caused by chronic pain and may be a result of a more acute type of pain. Therefore, the best intervention is for the nurse to establish whether the client is having pain other than arthritic pain, and then to decide which intervention should be carried out. The nurse is assigned to care for the following four clients who have the potential for having pain. Which client is most likely not to be treated adequately for this problem? A) Middle-aged woman with a fractured arm B) Client with expressive aphasia C) Younger adult with metastatic cancer D) Client who has undergone an appendectomy (- B Populations at highest risk for inadequate pain treatment include older adults, minorities, and those with a history of substance abuse. Nonverbal clients are very difficult to assess for pain because self-report is not possible, and the nurse needs to rely on client behaviors or surrogate reporting. Before surgery, the nurse observes the client listening to music on the radio. Based on this observation, the nurse may try which nonpharmacologic intervention for pain relief in the postoperative setting? A) Cutaneous skin stimulation B) Imagery C) Radiofrequency ablation D) Hypnosis (- B Imagery is a form of distraction in which the client is encouraged to visualize about some pleasant or desirable feeling, sensation, or event. Behaviors that are helpful in assessing a client's capacity for imagery include being able to listen to music or other auditory stimuli. What interrelated constructs facilitate a nurse to become culturally competent? A) Cultural desire, self-awareness, cultural knowledge, and cultural skill B) Cultural desire, self-awareness, cultural knowledge, and cultural diversity C) Cultural desire, self-awareness, cultural knowledge, and cultural identity D) Cultural diversity, self-awareness, cultural skill, and cultural knowledge (- A The process of cultural competence consists of four interrelated constructs: cultural desire, self-awareness, cultural knowledge, and cultural skill. Cultural diversity in the context of health care refers to achieving the highest level of health care for all people by addressing societal inequalities and historical and contemporary injustices. Cultural identity is the norms, values, beliefs, and behaviors of a culture learned through families and group members. The emphasis on understanding cultural influence on health care is important because of: A) disability entitlements. B) HIPAA requirements. C) litigious society. D) increasing global diversity. (- D Culture is an essential aspect of health care because of increasing diversity. Disability entitlements refer to defined benefits for eligible mental or physically disabled beneficiaries in relation to housing, employment, and health care. HIPAA requirements refers to the HIPAA Privacy Rule, which protects the privacy of individually identifiable health information; the HIPAA Security Rule, which sets national standards for the security of electronic protected health information; and the confidentiality provisions of the Patient Safety Rule, which protect identifiable information being used to analyze patient safety events and improve patient safety. Litigious society refers to excessively ready to go to law or initiate a lawsuit. The patient's laboratory report today indicates severe hypokalemia, and the nurse has notified the physician. Nursing assessment indicates that heart rhythm is regular. What is the most important nursing intervention for this patient now? A) Examine sacral area and patient's heels for skin breakdown due to potential edema. B) Establish seizure precautions due to potential muscle twitching, cramps, and seizures. C) Institute fall precautions due to potential postural hypotension and weak leg muscles. D) Raise bed side rails due to potential decreased level of consciousness and confusion. (- C Hypokalemia can cause postural hypotension and bilateral muscle weakness, especially in the lower extremities. Both of these increase the risk of falls. Hypokalemia does not cause edema, decreased level of consciousness, or seizures. A nurse is assessing clients for fluid and electrolyte imbalances. Which client is at greatest risk for developing hyponatremia? A) Client taking digoxin (Lanoxin) B) Client who is NPO receiving intravenous D5W C) Client taking ibuprofen (Motrin) D) Client taking a sulfonamide antibiotic (- B D5W contains no electrolytes. Because the client is not taking any food or fluids by mouth, normal sodium excretion can lead to hyponatremia. The antibiotic, Motrin, and digoxin will not put a client at risk for hyponatremia. The nurse accidentally administers 10 mg of morphine intravenously to a client who had been given another dose of morphine, 5 mg IV, about 30 minutes earlier. What action must the nurse be prepared to take? A) Assist with intubation. B) Monitor pain level. C) Administer oxygen. D) Administer naloxone (Narcan). (- D ***************************************CONTINUED*********************