MED SURG II HESI Exam with Questions and Answers

MED SURG II HESI Exam with Questions and Answers 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 ANSWER Elevate the head of the bed and obtain vital signs 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 ANSWER 4. "I have trouble breathing when I walk rapidly