MED SURG II HESI (Elsevier)
A client is admitted for dehydration, and an intravenous (IV) infusion of normal saline at 125 mL/hr has
been started. One hour after the IV initiation the client begins screaming, "I can't breathe!" The nursing
priority action is:
1. Discontinue the IV site and contact the primary health care provider
2. Elevate the head of the bed and obtain vital signs
3. Contact the primary health care provider to obtain a prescription for a sedative
4. Assess for allergies and change the IV to an intermittent infusion device Ans- Elevate the head of the
bed and obtain vital signs
A nurse is assessing a client with a diagnosis of early left ventricular heart failure. Specific to this type of
heart failure, the nurse expects the client to state:
1. "My ankles are swollen."
2. "I am tired at the end of the day."
3. "When I eat a large meal, I feel bloated."
4. "I have trouble breathing when I walk rapidly Ans- 4. "I have trouble breathing when I walk rapidly
A client who had a myocardial infarction asks the nurse, "What's the chance of my having another heart
attack if I carefully watch my diet and stress levels?" What is the nurse's most appropriate initial
response?
1. Focus on the client's feelings by exploring the reason why the question was asked.
, 2. Explain that it is all right to be frightened and refer the client to the psychiatric nurse.
3. Provide information that the client is correct in being especially careful in these areas.
4. Suggest that the client discuss follow-up care with the health care provider and the dietitian. Ans- 1.
Focus on the client's feelings by exploring the reason why the question was asked.
The nurse is assessing a client for signs of right ventricular failure. What should the nurse expect if this
occurs?
1. Slowed pulse rate
2. Pleural friction rub
3. Neck vein distention
4. Increasing hypotension Ans- 3. Neck vein distention
A client with bilateral varicose veins of the lower extremities questions the nurse about the brownish
discoloration of the lower legs. The best response by the nurse is, "This is probably the result of:
1. Inadequate arterial blood supply."
2. Delayed healing of tissues after an injury."
3. Increased production of melanin in the area."
4. Leakage of red blood cells through the vascular wall." Ans- 4. Leakage of red blood cells through the
vascular wall."
A client is admitted for dehydration, and an intravenous (IV) infusion of normal saline at 125 mL/hr has
been started. One hour after the IV initiation the client begins screaming, "I can't breathe!" The nursing
priority action is:
1. Discontinue the IV site and contact the primary health care provider
2. Elevate the head of the bed and obtain vital signs
3. Contact the primary health care provider to obtain a prescription for a sedative
4. Assess for allergies and change the IV to an intermittent infusion device Ans- Elevate the head of the
bed and obtain vital signs
A nurse is assessing a client with a diagnosis of early left ventricular heart failure. Specific to this type of
heart failure, the nurse expects the client to state:
1. "My ankles are swollen."
2. "I am tired at the end of the day."
3. "When I eat a large meal, I feel bloated."
4. "I have trouble breathing when I walk rapidly Ans- 4. "I have trouble breathing when I walk rapidly
A client who had a myocardial infarction asks the nurse, "What's the chance of my having another heart
attack if I carefully watch my diet and stress levels?" What is the nurse's most appropriate initial
response?
1. Focus on the client's feelings by exploring the reason why the question was asked.
, 2. Explain that it is all right to be frightened and refer the client to the psychiatric nurse.
3. Provide information that the client is correct in being especially careful in these areas.
4. Suggest that the client discuss follow-up care with the health care provider and the dietitian. Ans- 1.
Focus on the client's feelings by exploring the reason why the question was asked.
The nurse is assessing a client for signs of right ventricular failure. What should the nurse expect if this
occurs?
1. Slowed pulse rate
2. Pleural friction rub
3. Neck vein distention
4. Increasing hypotension Ans- 3. Neck vein distention
A client with bilateral varicose veins of the lower extremities questions the nurse about the brownish
discoloration of the lower legs. The best response by the nurse is, "This is probably the result of:
1. Inadequate arterial blood supply."
2. Delayed healing of tissues after an injury."
3. Increased production of melanin in the area."
4. Leakage of red blood cells through the vascular wall." Ans- 4. Leakage of red blood cells through the
vascular wall."
