HESI - Medical Surgical Nursing test
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1. When describing patient education approaches, the nurse educator would
explain that informal teaching is an approach that
a. follows formalized plans
b. has standardized content
c. often occurs one-to-one
d. addresses group needs: C. Informal teaching is individualized one on one teaching which represents the
majority of patient education done by nurses that occurs when an intervention is explained or a question is answered.
Group needs are often the focus of formal patient education courses or classes. Informal teaching does not necessarily
follow a specific formalized plan. It may be planned with specific content, but it is individualized responses to patient
needs. Formal teaching involves the use of a curriculum/course plan with standardized content.
2. A patient expresses a strong interest in returning to their work, family, and
hobbies after having a stroke. Which theory type would the nurse use to
develop a plan of care for the best results of this patient's motivation style?
a. field
b. biological
c. cognitive
d. sociologic: C. Cognitive theorists believe that attention, relevance, confidence, and satisfaction (ARCS) are the
conditions that, when integrated, motivate someone to learn. Field theorists place significance on how achievement,
power, the need for affiliation, and avoidance motives influence individual behavior. Sociologic theories are not involved
in motivation.
3. The nurse is assessing a group of clients. Which clients are at greater risk for
hypothermia or frostbite? (select all that apply)
a. an older woman with hypertension
b. a young man with a body mass index of 42
c. a young many who has just consumed six martinis
d. an older man who smokes a pack of cigarettes a day
e. a young woman who is anorexic
f. a young woman who is diabetic: C, D, E, F
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clients with poor nutrition, fatigue, and multiple chronic illnesses are at greater risk for hypothermia. Clients who smoke,
consume alcohol, or have impaired peripheral circulation have a higher incidence of frostbite.
4. Which statement made by a nurse represents the need for further education
regarding pain management in older adult clients?
a. older adults tend to report pain less often than younger adults
b. older clients usually have more experience with pain than younger clients
c. older adults are at greatest risk for under treated pain
d. older clients have a different pain mechanism and do not feel it as much: D
There is no evidence to support the idea that older adult clients perceive pain any differently than younger clients. The
other statements are accurate regarding older clients and pain.
5. The nurse is working at a first aid booth for a spring training game on a
hot day. A spectator comes in, reporting that he is not feeling well. Vital signs
are temp 104.1 F, pulse 132 BPM, respirs 26 breaths/min, and blood pressure
106/66 mm Hg. He trips over his feet as the nurse leads him to a cot. What is
the priory action of the nurse?
a. admin tylenol 650 mg orally
b. encourage rest, and reassess in 15 minutes
c. sponge the victim with cool water and remove his shirt
d. encourage drinking of cool water or sports drink: C
The spectator shows signs of heat stroke, which is a medical emergency. The spectator should be transported to the
ED ASAP. The nurs should take actions to lower his body temp in teh meantime by removing his shirt and sponging
his body with cool water. Lowering body temp by drinking cool fluids or taking acetaminophen is not as effective in an
emergency situation. The client needs to be cooled quickly and is a priority for treatment
6. The client is receiving an IV of 60 mEq of potassium chloride ina 1000 mL
solution of dextrose 5% in 0.45% saline. The client states that the area around
the IV site burns. What intervention does the nurse perform first?
a. assess for a blood return
b. notify the physician
, HESI - Medical Surgical Nursing test
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c. document the finding
d. stop the IV infusion: D
Potassium is a severe tissue irritant. The safest action is to discontinue the solution that contains the potassium and
discontinue the IV altogether, in which case the client would need another site started. Assessing for a blood return
may or may not be successful. The solution could be diluted (less potassium) and the rate could be slowed once it is
determined that the needle is in the vein.
7. A nurse is caring for an older adult client who lives alone. Which economic
situation presents the most serious problem for this client?
a. costs of creating a living will
b. stock market fluctuations
c. increased provider benefits
d. social security as the basis of income: D
Older adults on fixed incomes are unable to adjust their income to meet rising costs associated with meeting basic
needs
8. Controlling pain is important to promoting wellness. Unrelieved pain has
been associated with
a. prolonged stress response and a cascade of harmful effects system wide.
b. decreased tumor growth and longevity
c. large tidal volumes and decreased lung capacity
d. decreased carbohydrate, protein, and fat destruction: A
Pain triggers a number of physiologic stress responses in the human body. Unrelieved pain can prolong the stress
response and produce a cascade of harmful effects in all body systems. The stress response causes the endocrine
system to release excessive amounts of hormones, such as cortisol, catecholamines, and glucagon. Insulin and
testosterone levels decrease. Increased endocrine activity in turn initiates a number of metabolic processes, in particular,
accelerated carbohydrate, protein, and fat destruction, whcih can result in weight loss, tachycardia, increased respiratory
rate, shock, and even death. The immune system is also affected by pain as demonstrated by research showing a link
between unrelieved pain and a higher incidence of nosocomial infections and increased tumor growth. Large tidal
volumes are not associated with pain while decreased lung capacity is associated with unrelieved pain. Decreased tumor
, HESI - Medical Surgical Nursing test
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growth and longevity are not associated with unrelieved pain. Decreased carbs, protein, and fat are not associated with
pain or stress response.
9. Which intervention in a client with dehydration induced confusion is most
likely to relieve the confusion?
a. increasing the IV flow rate to 250 mL/hr
b. applying oxygen by mask or nasal cannula
c. placing the client in a high Fowler's position
d. Measuring intake and output every four hours: A
Dehydration most frequently leads to poor cerebra perfusion and cerebral hypoxia, causing confusion. Applying oxygen
can reduce confusion, even if perfusion is still less than optimum. Increasing the IV flow rate would increase perfusion.
However, depending on the degree of dehydration, rehydrating the person too rapidly with IV fluids can lead to cerebra
edema.
10. Which client is at greatest risk for dehydration?
a. younger adult client on bedrest
b. older adult client receiving hypotonic IV fluid
c. older adult client with cognitive impairment
d. younger adult client receiving hypertonic IV fluid: C
Older adults, because they have less total body water than younger adults, are at greater risk for development of
dehydration. Anyone who is cognitively impaired and cannot obtain fluids independently or cannot make his or her
need for fluids known is at high risk for dehydration
11. A nurse is caring for several clients. Which client does the nurse assess most
carefully for hyperkalemia?
a. client with type 2 diabetes taking an oral anti-diabetic agent
b. client with heart failure using a salt substitute
c. client taking a thiazide diuretic for hypertension
d. client taking non-steroidal anti-inflammatory drugs daily: B
Many salt substitutes are composed of potassium chloride. Heavy use cna contribute to the development of hyper-
Study online at https://quizlet.com/_3m27bu
1. When describing patient education approaches, the nurse educator would
explain that informal teaching is an approach that
a. follows formalized plans
b. has standardized content
c. often occurs one-to-one
d. addresses group needs: C. Informal teaching is individualized one on one teaching which represents the
majority of patient education done by nurses that occurs when an intervention is explained or a question is answered.
Group needs are often the focus of formal patient education courses or classes. Informal teaching does not necessarily
follow a specific formalized plan. It may be planned with specific content, but it is individualized responses to patient
needs. Formal teaching involves the use of a curriculum/course plan with standardized content.
2. A patient expresses a strong interest in returning to their work, family, and
hobbies after having a stroke. Which theory type would the nurse use to
develop a plan of care for the best results of this patient's motivation style?
a. field
b. biological
c. cognitive
d. sociologic: C. Cognitive theorists believe that attention, relevance, confidence, and satisfaction (ARCS) are the
conditions that, when integrated, motivate someone to learn. Field theorists place significance on how achievement,
power, the need for affiliation, and avoidance motives influence individual behavior. Sociologic theories are not involved
in motivation.
3. The nurse is assessing a group of clients. Which clients are at greater risk for
hypothermia or frostbite? (select all that apply)
a. an older woman with hypertension
b. a young man with a body mass index of 42
c. a young many who has just consumed six martinis
d. an older man who smokes a pack of cigarettes a day
e. a young woman who is anorexic
f. a young woman who is diabetic: C, D, E, F
, HESI - Medical Surgical Nursing test
Study online at https://quizlet.com/_3m27bu
clients with poor nutrition, fatigue, and multiple chronic illnesses are at greater risk for hypothermia. Clients who smoke,
consume alcohol, or have impaired peripheral circulation have a higher incidence of frostbite.
4. Which statement made by a nurse represents the need for further education
regarding pain management in older adult clients?
a. older adults tend to report pain less often than younger adults
b. older clients usually have more experience with pain than younger clients
c. older adults are at greatest risk for under treated pain
d. older clients have a different pain mechanism and do not feel it as much: D
There is no evidence to support the idea that older adult clients perceive pain any differently than younger clients. The
other statements are accurate regarding older clients and pain.
5. The nurse is working at a first aid booth for a spring training game on a
hot day. A spectator comes in, reporting that he is not feeling well. Vital signs
are temp 104.1 F, pulse 132 BPM, respirs 26 breaths/min, and blood pressure
106/66 mm Hg. He trips over his feet as the nurse leads him to a cot. What is
the priory action of the nurse?
a. admin tylenol 650 mg orally
b. encourage rest, and reassess in 15 minutes
c. sponge the victim with cool water and remove his shirt
d. encourage drinking of cool water or sports drink: C
The spectator shows signs of heat stroke, which is a medical emergency. The spectator should be transported to the
ED ASAP. The nurs should take actions to lower his body temp in teh meantime by removing his shirt and sponging
his body with cool water. Lowering body temp by drinking cool fluids or taking acetaminophen is not as effective in an
emergency situation. The client needs to be cooled quickly and is a priority for treatment
6. The client is receiving an IV of 60 mEq of potassium chloride ina 1000 mL
solution of dextrose 5% in 0.45% saline. The client states that the area around
the IV site burns. What intervention does the nurse perform first?
a. assess for a blood return
b. notify the physician
, HESI - Medical Surgical Nursing test
Study online at https://quizlet.com/_3m27bu
c. document the finding
d. stop the IV infusion: D
Potassium is a severe tissue irritant. The safest action is to discontinue the solution that contains the potassium and
discontinue the IV altogether, in which case the client would need another site started. Assessing for a blood return
may or may not be successful. The solution could be diluted (less potassium) and the rate could be slowed once it is
determined that the needle is in the vein.
7. A nurse is caring for an older adult client who lives alone. Which economic
situation presents the most serious problem for this client?
a. costs of creating a living will
b. stock market fluctuations
c. increased provider benefits
d. social security as the basis of income: D
Older adults on fixed incomes are unable to adjust their income to meet rising costs associated with meeting basic
needs
8. Controlling pain is important to promoting wellness. Unrelieved pain has
been associated with
a. prolonged stress response and a cascade of harmful effects system wide.
b. decreased tumor growth and longevity
c. large tidal volumes and decreased lung capacity
d. decreased carbohydrate, protein, and fat destruction: A
Pain triggers a number of physiologic stress responses in the human body. Unrelieved pain can prolong the stress
response and produce a cascade of harmful effects in all body systems. The stress response causes the endocrine
system to release excessive amounts of hormones, such as cortisol, catecholamines, and glucagon. Insulin and
testosterone levels decrease. Increased endocrine activity in turn initiates a number of metabolic processes, in particular,
accelerated carbohydrate, protein, and fat destruction, whcih can result in weight loss, tachycardia, increased respiratory
rate, shock, and even death. The immune system is also affected by pain as demonstrated by research showing a link
between unrelieved pain and a higher incidence of nosocomial infections and increased tumor growth. Large tidal
volumes are not associated with pain while decreased lung capacity is associated with unrelieved pain. Decreased tumor
, HESI - Medical Surgical Nursing test
Study online at https://quizlet.com/_3m27bu
growth and longevity are not associated with unrelieved pain. Decreased carbs, protein, and fat are not associated with
pain or stress response.
9. Which intervention in a client with dehydration induced confusion is most
likely to relieve the confusion?
a. increasing the IV flow rate to 250 mL/hr
b. applying oxygen by mask or nasal cannula
c. placing the client in a high Fowler's position
d. Measuring intake and output every four hours: A
Dehydration most frequently leads to poor cerebra perfusion and cerebral hypoxia, causing confusion. Applying oxygen
can reduce confusion, even if perfusion is still less than optimum. Increasing the IV flow rate would increase perfusion.
However, depending on the degree of dehydration, rehydrating the person too rapidly with IV fluids can lead to cerebra
edema.
10. Which client is at greatest risk for dehydration?
a. younger adult client on bedrest
b. older adult client receiving hypotonic IV fluid
c. older adult client with cognitive impairment
d. younger adult client receiving hypertonic IV fluid: C
Older adults, because they have less total body water than younger adults, are at greater risk for development of
dehydration. Anyone who is cognitively impaired and cannot obtain fluids independently or cannot make his or her
need for fluids known is at high risk for dehydration
11. A nurse is caring for several clients. Which client does the nurse assess most
carefully for hyperkalemia?
a. client with type 2 diabetes taking an oral anti-diabetic agent
b. client with heart failure using a salt substitute
c. client taking a thiazide diuretic for hypertension
d. client taking non-steroidal anti-inflammatory drugs daily: B
Many salt substitutes are composed of potassium chloride. Heavy use cna contribute to the development of hyper-
