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 - correct
answerElevate the head of the bed and obtain vital signs
A client is hospitalized for the treatment of thrombophlebitis. What should the nurse
include in the client's teaching plan related to how to prevent thrombophlebitis?
1. Perform leg exercises
2. Sit with the knees flexed
3. Apply warm soaks to the legs daily
4. Put on elastic stockings before arising - correct answer4. Put on elastic stockings
before arising
A client on a telemetry unit demonstrates a regular sinus rhythm (RSR) with an
occasional premature atrial contraction (PAC). What action should the nurse take?
1. Continue to monitor the client.
2. Notify the health care provider.
3. Ensure that a defibrillator is close by.
4. Administer lidocaine intravenously as per protocol. - correct answer1. Continue to
monitor the client.
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.
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 - correct
answerElevate the head of the bed and obtain vital signs
A client is hospitalized for the treatment of thrombophlebitis. What should the nurse
include in the client's teaching plan related to how to prevent thrombophlebitis?
1. Perform leg exercises
2. Sit with the knees flexed
3. Apply warm soaks to the legs daily
4. Put on elastic stockings before arising - correct answer4. Put on elastic stockings
before arising
A client on a telemetry unit demonstrates a regular sinus rhythm (RSR) with an
occasional premature atrial contraction (PAC). What action should the nurse take?
1. Continue to monitor the client.
2. Notify the health care provider.
3. Ensure that a defibrillator is close by.
4. Administer lidocaine intravenously as per protocol. - correct answer1. Continue to
monitor the client.
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.
