MED SURG EXAM TEST BANK
MED SURG EXAM TEST BANK with 263 Questions
and Correct Answers with Detailed Rationales /
MED SURG Hesi, RN Med Surg Proctored, Evolve
HESI Med Surg Comprehensive Practice Exam
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Which statement reflects the highest priority nursing diagnosis for an older client
recently admitted to the hospital for a new-onset cardiac dysrhythmia?
A.
Diarrhea related to medication side effects
B.
Anxiety related to fear of recurrent anginal episodes
C.
Altered nutrition related to high serum lipid levels
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D.
Risk for injury related to syncope and confusion –
Correct Answer :D
Rationale:
The loss of cardiac function in aging decreases cardiac output, so dysrhythmias,
particularly tachycardias, are poorly tolerated. With onset of a tachycardic or
bradycardic dysrhythmia, cardiac output is compromised further, placing the
client at risk of syncope and falling, as well as confusion. Option A is of high
priority but less so than maintaining client safety. Clients may experience option
B as a result of a newly diagnosed cardiac condition, but this nursing diagnosis
does not have the priority of option D. Option C also does not have the priority
of option D.
The client returns to the unit after abdominal surgery with a 5″ × 9″ absorbent
dressing in place to the mid abdomen. The nurse notes a spot of red staining
centrally on the dressing. What is the nurse's next action?
A.
Note the size of the stain in the chart.
B.
Circle the stain with an ink pen.
C.
Remove the dressing to assess the source of the bleeding.
D.
Place a pressure dressing on the existing dressing. –
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Correct Answer :B
Rationale:
By circling the existing stain upon admission to the unit, the nurse can then
assess any increase, though subtle, in the amount of drainage over time. The
size of the stain will need to be noted in the chart, but it is not the first action.
The nurse removes the dressing under the prescription of the health care
provider or in an emergency. Neither of those conditions exist in the question.
The dressing in place is an absorbent dressing. There is no need for a further
dressing until the existing dressing becomes saturated.
For the client undergoing hemodialysis, the nurse suspects the client has an air
embolism. What symptoms lead the nurse to this conclusion? (Select all that
apply.)
A.
Dyspnea
B.
B/P 168/92 mm Hg
C.
Chest pain
D.
Anxiety
E.
O2 saturation of 98%
F.
Blue nail beds –
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Correct Answer :A, C, D, F
Rationale:
For the client experiencing an air embolism, the nurse will see hypotension and
not hypertension. The O2 saturation will also fall with an air embolism. The
remaining are signs of an air embolism.
The nurse is preparing teaching for nursing students who are participating in a
flu vaccine clinic at a local school. Who should receive the vaccine? (Select all
that apply.)
A.
Health care personnel
B.
Those who are allergic to eggs
C.
Individuals who are over 50 years old
D.
Individuals with chronic health conditions
E.
Those who live in nursing homes
F.
Infants under 6 months of age –
Correct Answer :A, C, D, E
Rationale: