MED SURG II HESI (Elsevier)
Study online at https://quizlet.com/_8enxto
1. 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: Elevate
the head of the bed and obtain vital signs
2. 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: 4. "I have trouble breathing when I walk rapidly
3. 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.
1/5
, MED SURG II HESI (Elsevier)
Study online at https://quizlet.com/_8enxto
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.: 1. Focus on the client's feelings by exploring the reason why the question was asked.
4. 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: 3. Neck vein distention
5. 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.": 4. Leakage of red blood cells
through the vascular wall."
6. A client with arterial insufficiency of both lower extremities is visited by the
home health care nurse. An essential nursing intervention is to teach the client
to:
1. Maintain elevation of both legs
2. Massage the legs when painful
2/5
Study online at https://quizlet.com/_8enxto
1. 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: Elevate
the head of the bed and obtain vital signs
2. 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: 4. "I have trouble breathing when I walk rapidly
3. 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.
1/5
, MED SURG II HESI (Elsevier)
Study online at https://quizlet.com/_8enxto
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.: 1. Focus on the client's feelings by exploring the reason why the question was asked.
4. 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: 3. Neck vein distention
5. 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.": 4. Leakage of red blood cells
through the vascular wall."
6. A client with arterial insufficiency of both lower extremities is visited by the
home health care nurse. An essential nursing intervention is to teach the client
to:
1. Maintain elevation of both legs
2. Massage the legs when painful
2/5
