MED SURG II HESI (Elsevier)
Study online at https://quizlet.com/_8enxto
1. A client is admitted for dehydration, and an intra- Elevate the head of the
venous (IV) infusion of normal saline at 125 mL/hr bed and obtain vital signs
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 intermit-
tent infusion device
2. A nurse is assessing a client with a diagnosis of early 4. "I have trouble breath-
left ventricular heart failure. Specific to this type of ing when I walk rapidly
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
3. A client who had a myocardial infarction asks the 1. Focus on the client's
nurse, "What's the chance of my having another heart feelings by exploring the
attack if I carefully watch my diet and stress levels?" reason why the question
What is the nurse's most appropriate initial response? was asked.
1/5
, MED SURG II HESI (Elsevier)
Study online at https://quizlet.com/_8enxto
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.
4. The nurse is assessing a client for signs of right ven- 3. Neck vein distention
tricular failure. What should the nurse expect if this
occurs?
1. Slowed pulse rate
2. Pleural friction rub
3. Neck vein distention
4. Increasing hypotension
5. A client with bilateral varicose veins of the lower ex- 4. Leakage of red blood
tremities questions the nurse about the brownish dis- cells through the vascular
coloration of the lower legs. The best response by the wall."
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."
2/5
Study online at https://quizlet.com/_8enxto
1. A client is admitted for dehydration, and an intra- Elevate the head of the
venous (IV) infusion of normal saline at 125 mL/hr bed and obtain vital signs
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 intermit-
tent infusion device
2. A nurse is assessing a client with a diagnosis of early 4. "I have trouble breath-
left ventricular heart failure. Specific to this type of ing when I walk rapidly
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
3. A client who had a myocardial infarction asks the 1. Focus on the client's
nurse, "What's the chance of my having another heart feelings by exploring the
attack if I carefully watch my diet and stress levels?" reason why the question
What is the nurse's most appropriate initial response? was asked.
1/5
, MED SURG II HESI (Elsevier)
Study online at https://quizlet.com/_8enxto
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.
4. The nurse is assessing a client for signs of right ven- 3. Neck vein distention
tricular failure. What should the nurse expect if this
occurs?
1. Slowed pulse rate
2. Pleural friction rub
3. Neck vein distention
4. Increasing hypotension
5. A client with bilateral varicose veins of the lower ex- 4. Leakage of red blood
tremities questions the nurse about the brownish dis- cells through the vascular
coloration of the lower legs. The best response by the wall."
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."
2/5
