HESI MEDICAL-SURGICAL RN NURSING V2
Rationale 1: The body’s vasoconstrictive
Question 1 compensatory reactions are responsible for
the symptoms. The body naturally attempts
When caring for an elderly patient who is
to conserve fluid internally specifically for the
intermittently confused, what is the nurse’s
brain and heart.
primary concern regarding fluid and
electrolytes? Rationale 2: A diuretic would cause
further fluid loss and is contraindicated.
1. Risk of dehydration
Rationale 3: Rapidly infused intravenous
2. Risk of kidney damage
fluids would not cause a decrease in
3. Risk of stroke urine output.
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
, Correct Answer:
Rationale 4: The manifestations reported
are not indicative of cardiac failure in this 1
patient. Rationale 1: A urine output of less than 30
milliliters per hour must be reported to the
primary health care provider. This indicates
Question 3 inadequate renal
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
,perfusion, which places the patient at 2. Hypokalemia
increased risk for acute renal failure and
inadequate tissue perfusion. A minimum of 3. Hypercalcemia
720 milliliters over a 24- hour period is
desired (30 milliliters multiplied by 24 hours
equals 720 milliliters per 24 hours).
Rationale 2: 750 mL is above the minimum
desired level of 30 mL per hour.
Rationale 3: 1,000 mL is above the minimum
desired level of 30 mL per hour.
Rationale 4: 1,200 mL is above the minimum
desired level of 30 mL per hour.
Question 5
A patient is diagnosed with severe
hyponatremia. The nurse realizes this
patient will mostly likely need which
precautions implemented?
1. Seizure precautions
2. Infection precautions
3. Neutropenic precautions
4. High-risk fall
precautions Correct
Answer: 1
Rationale 1: Severe hyponatremia can lead
to seizures. Seizure precautions would
include a quiet environment, raised side
rails, and having an oral airway at the
bedside.
Rationale 2: Infection precautions
are not specifically indicated for a
patient with hyponatremia.
Rationale 3: Neutropenic precautions
are not specifically indicated for a
patient with hyponatremia.
Rationale 4: High-risk fall precautions
are not specifically indicated for a
patient with hyponatremia.
Question 6
A patient prescribed spironolactone is
demonstrating ECG changes and
complaining of muscle weakness. The nurse
realizes this patient is exhibiting signs of
which imbalance?
1. Hyperkalemia
, 4. Hypocalcemi Question 8
a Correct When caring for a patient diagnosed
with hypocalcemia, the nurse would also
Answer: 1 assess for which other finding?
Rationale 1: Hyperkalemia is defined as
serum potassium level greater than 5.0
mEq/L. Decreased potassium excretion is
seen with potassium-sparing diuretics such
as spironolactone. Common manifestations
of hyperkalemia are muscle weakness and
ECG changes.
Rationale 2: Hypokalemia is seen in
nonpotassium sparing diuretics such as
furosemide.
Rationale 3: Hypercalcemia has been
associated with thiazide diuretics.
Rationale 4: Hypocalcemia is seen in
patients who have received many units of
citrated blood and is not associated with
diuretic use.
Question 7
The nurse is planning care for a patient
with fluid volume overload and
hyponatremia. Which intervention should
be included in this patient’s plan of care?
1. Restrict fluids.
2. Administer intravenous fluids.
3. Provide Kayexalate.
4. Administer intravenous normal
saline with furosemide.
Correct Answer: 1
Rationale 1: The nursing care for a patient
with hyponatremia depends on the cause.
Restriction of fluids to 1,000 mL/day is
usually implemented to assist sodium
increase and to prevent the sodium level
from dropping further due to dilution.
Rationale 2: The administration of
intravenous fluids would be indicated in fluid
volume deficit and hypernatremia.
Rationale 3: Kayexalate is used in
patients with hyperkalemia.
Rationale 4: Normal saline with
furosemide is administered to
increase calcium secretion.
Rationale 1: The body’s vasoconstrictive
Question 1 compensatory reactions are responsible for
the symptoms. The body naturally attempts
When caring for an elderly patient who is
to conserve fluid internally specifically for the
intermittently confused, what is the nurse’s
brain and heart.
primary concern regarding fluid and
electrolytes? Rationale 2: A diuretic would cause
further fluid loss and is contraindicated.
1. Risk of dehydration
Rationale 3: Rapidly infused intravenous
2. Risk of kidney damage
fluids would not cause a decrease in
3. Risk of stroke urine output.
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
, Correct Answer:
Rationale 4: The manifestations reported
are not indicative of cardiac failure in this 1
patient. Rationale 1: A urine output of less than 30
milliliters per hour must be reported to the
primary health care provider. This indicates
Question 3 inadequate renal
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
,perfusion, which places the patient at 2. Hypokalemia
increased risk for acute renal failure and
inadequate tissue perfusion. A minimum of 3. Hypercalcemia
720 milliliters over a 24- hour period is
desired (30 milliliters multiplied by 24 hours
equals 720 milliliters per 24 hours).
Rationale 2: 750 mL is above the minimum
desired level of 30 mL per hour.
Rationale 3: 1,000 mL is above the minimum
desired level of 30 mL per hour.
Rationale 4: 1,200 mL is above the minimum
desired level of 30 mL per hour.
Question 5
A patient is diagnosed with severe
hyponatremia. The nurse realizes this
patient will mostly likely need which
precautions implemented?
1. Seizure precautions
2. Infection precautions
3. Neutropenic precautions
4. High-risk fall
precautions Correct
Answer: 1
Rationale 1: Severe hyponatremia can lead
to seizures. Seizure precautions would
include a quiet environment, raised side
rails, and having an oral airway at the
bedside.
Rationale 2: Infection precautions
are not specifically indicated for a
patient with hyponatremia.
Rationale 3: Neutropenic precautions
are not specifically indicated for a
patient with hyponatremia.
Rationale 4: High-risk fall precautions
are not specifically indicated for a
patient with hyponatremia.
Question 6
A patient prescribed spironolactone is
demonstrating ECG changes and
complaining of muscle weakness. The nurse
realizes this patient is exhibiting signs of
which imbalance?
1. Hyperkalemia
, 4. Hypocalcemi Question 8
a Correct When caring for a patient diagnosed
with hypocalcemia, the nurse would also
Answer: 1 assess for which other finding?
Rationale 1: Hyperkalemia is defined as
serum potassium level greater than 5.0
mEq/L. Decreased potassium excretion is
seen with potassium-sparing diuretics such
as spironolactone. Common manifestations
of hyperkalemia are muscle weakness and
ECG changes.
Rationale 2: Hypokalemia is seen in
nonpotassium sparing diuretics such as
furosemide.
Rationale 3: Hypercalcemia has been
associated with thiazide diuretics.
Rationale 4: Hypocalcemia is seen in
patients who have received many units of
citrated blood and is not associated with
diuretic use.
Question 7
The nurse is planning care for a patient
with fluid volume overload and
hyponatremia. Which intervention should
be included in this patient’s plan of care?
1. Restrict fluids.
2. Administer intravenous fluids.
3. Provide Kayexalate.
4. Administer intravenous normal
saline with furosemide.
Correct Answer: 1
Rationale 1: The nursing care for a patient
with hyponatremia depends on the cause.
Restriction of fluids to 1,000 mL/day is
usually implemented to assist sodium
increase and to prevent the sodium level
from dropping further due to dilution.
Rationale 2: The administration of
intravenous fluids would be indicated in fluid
volume deficit and hypernatremia.
Rationale 3: Kayexalate is used in
patients with hyperkalemia.
Rationale 4: Normal saline with
furosemide is administered to
increase calcium secretion.
