HESI - Medical Surgical Nursing EXAM
WITH CORRECT ANSWERS
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 ANSWERS 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 - CORRECT ANSWERS 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 - CORRECT ANSWERS 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?
,HESI - Medical Surgical Nursing EXAM
WITH CORRECT ANSWERS
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
ANSWERS 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 - CORRECT ANSWERS 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 - CORRECT ANSWERS 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?
,HESI - Medical Surgical Nursing EXAM
WITH CORRECT ANSWERS
a. costs of creating a living will
b. stock market fluctuations
c. increased provider benefits
d. social security as the basis of income - CORRECT ANSWERS 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 - CORRECT ANSWERS 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 - CORRECT ANSWERS 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?
, HESI - Medical Surgical Nursing EXAM
WITH CORRECT ANSWERS
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 - CORRECT ANSWERS 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 - CORRECT ANSWERS
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 - CORRECT ANSWERS 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.
WITH CORRECT ANSWERS
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 ANSWERS 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 - CORRECT ANSWERS 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 - CORRECT ANSWERS 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?
,HESI - Medical Surgical Nursing EXAM
WITH CORRECT ANSWERS
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
ANSWERS 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 - CORRECT ANSWERS 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 - CORRECT ANSWERS 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?
,HESI - Medical Surgical Nursing EXAM
WITH CORRECT ANSWERS
a. costs of creating a living will
b. stock market fluctuations
c. increased provider benefits
d. social security as the basis of income - CORRECT ANSWERS 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 - CORRECT ANSWERS 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 - CORRECT ANSWERS 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?
, HESI - Medical Surgical Nursing EXAM
WITH CORRECT ANSWERS
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 - CORRECT ANSWERS 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 - CORRECT ANSWERS
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 - CORRECT ANSWERS 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.
