2020 HESI MEDICAL-SURGICAL RN NURSING V2

2020 HESI MEDICAL-SURGICAL RN NURSING V2 Question 1 When caring for an elderly patient who is intermittently confused, what is the nurse’s primary concern regarding fluid and electrolytes? 1. Risk of dehydration 2. Risk of kidney damage 3. Risk of stroke 4. Risk of bleeding Correct Answer: 1 Rationale 1: As an adult ages, the perception of thirst declines. In an older patient with an altered level of consciousness, there is an increased risk of dehydration and high serum osmolality. Rationale 2: The risk of kidney damage is not specifically related to aging or fluid and electrolyte issues. Rationale 3: The risk of stroke is not specifically related to aging or fluid and electrolyte issues. Rationale 4: The risk of bleeding is not specifically related to aging or fluid and electrolyte issues. Question 2 A patient experiencing multisystem fluid volume deficit has tachycardia and decreased urine output. The nurse realizes these findings are most likely a direct result of which factor? 1. The body’s natural compensatory mechanisms 2. Pharmacologic effects of a diuretic 3. Effects of rapidly infused intravenous fluids 4. Cardiac failure Correct Answer: 1 Rationale 1: The body’s vasoconstrictive compensatory reactions are responsible for the symptoms. The body naturally attempts to conserve fluid internally specifically for the brain and heart. Rationale 2: A diuretic would cause further fluid loss and is contraindicated. Rationale 3: Rapidly infused intravenous fluids would not cause a decrease in urine output. Rationale 4: The manifestations reported are not indicative of cardiac failure in this patient. Question 3 A pregnant patient is admitted with excessive thirst, increased urination, and a medical diagnosis of diabetes insipidus. The nurse chooses which nursing diagnosis as most appropriate? 1. Risk for Imbalanced Fluid Volume 2. Excess Fluid Volume 3. Imbalanced Nutrition 4. Ineffective Tissue Perfusion Correct Answer: 1 Rationale 1: The patient with excessive thirst, increased urination, and a medical diagnosis of diabetes insipidus is at risk for Imbalanced Fluid Volume due to excess volume loss that can increase the serum levels of sodium. Rationale 2: Excess Fluid Volume is not an issue for patients with diabetes insipidus, especially during the early stages of treatment. Rationale 3: Imbalanced Nutrition is not supported by the assessment data provided. Rationale 4: Ineffective Tissue Perfusion is not supported by the assessment data provided. Question 4 An adult patient recovering from surgery has an indwelling urinary catheter. The nurse would contact the patient’s primary health care provider with which 24-hour urine output volume? 1. 600 milliliters 2. 750 milliliters 3. 1,000 milliliters 4. 1,200 milliliters Correct Answer: 1 Rationale 1: A urine output of less than 30 milliliters per hour must be reported to the primary health care provider. This indicates inadequate renal