MED SURG II HESI (Elsevier) 2023
(Verified Answers)
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: -
ANS 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:
1/4
, 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: ANS 4. "I have trouble breathing
whenI 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 psychi-
atric 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
2/4
(Verified Answers)
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: -
ANS 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:
1/4
, 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: ANS 4. "I have trouble breathing
whenI 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 psychi-
atric 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
2/4
