HESI - Medical Surgical Nursing test-Exam TEST BANK FOR
MEDICAL SURGICAL NURSING 11TH EDITION IGNATAVICIUS
ACTUAL COMPLETE REAL EXAM QUESTIONS AND CORRECT
DETAILEDD ANSWERS WITH RATIONALES /ALREADY
GRADEDA+.
The nurse admitting a patient to the emergency department on a
very hot summer
day would suspect hyperthermia when the patient
demonstrates:
A) slow capillary
refill.
B) red, sweaty
skin.
C) low pulse
rate.
D) decreased respirations. -
ANSWER –B
With hyperthermia, vasodilatation occurs causing the skin to
appear flushed and warm or hot to touch. There is an increased
respiration rate with hyperthermia. The heart rate increases with
hyperthermia. With hypothermia there is slow capillary refill.
,The health care provider has prescribed a client sodium warfarin
(Coumadin) while
he is still receiving intravenous heparin. Which is the
nurse's best action?
A) Turn off the heparin before administering the warfarin.
B) Clarify the warfarin order with the nursing supervisor.
C) Administer both heparin and warfarin as prescribed.
D) Hold the warfarin dose until the heparin is discontinued. -
ANSWER -C
Although both heparin and warfarin are anticoagulants, they have
different mechanisms of action and onsets of action. Because
warfarin has such a slow onset, it must be started while the client
is still receiving heparin. Once the warfarin is therapeutic, as
evidenced by the international normalized ratio (INR), the client's
heparin can be safely discontinued. Effects of heparin will be
cleared from the client's bloodstream within a few hours.
Individuals of low socioeconomic status are at an increased
risk for infection
because of which of the following? (Select all
that apply.)
,A) High cost of
medications
B) Inadequate
nutrition
C) Easy access to health
screenings
D) Uninsured or underinsured status -
ANSWER -A, B, D
Individuals of low socioeconomic status tend to be part of the
underinsured or uninsured population. Lack of insurance
decreases accessibility to health care in general and health
screening services specifically. High costs of medication and
nutritious food also make this population at higher risk for
infection.
The nurse is working on a plan of care with her patient which
includes turning and
positioning and adequate nutrition to help the patient maintain
intact skin integrity.
The nurse helps the patient to realize that this breaks the chain
of infection by
eliminating
a:
, A) portal of
entry.
B)
host.
C) mode of
transmission.
D) reservoir. -
ANSWER -A
Broken or impaired skin creates a portal of entry for pathogens.
By maintaining intact tissue, the patient and the nurse have
broken the chain of infection by eliminating a portal of entry. Host
is incorrect because you are not eliminating the person or
organism. Intact tissue does not eliminate the mode of
transmission.
Skin can still be used to transfer pathogens regardless of it being
intact or broken. Intact skin does not eliminate the location for
pathogens to live and grow.
The nurse is preparing to administer a prescribed IV antibiotic to
a client admitted
with a serious infection. Which action by the nurse is
most important?
A) Double check the "five rights."
MEDICAL SURGICAL NURSING 11TH EDITION IGNATAVICIUS
ACTUAL COMPLETE REAL EXAM QUESTIONS AND CORRECT
DETAILEDD ANSWERS WITH RATIONALES /ALREADY
GRADEDA+.
The nurse admitting a patient to the emergency department on a
very hot summer
day would suspect hyperthermia when the patient
demonstrates:
A) slow capillary
refill.
B) red, sweaty
skin.
C) low pulse
rate.
D) decreased respirations. -
ANSWER –B
With hyperthermia, vasodilatation occurs causing the skin to
appear flushed and warm or hot to touch. There is an increased
respiration rate with hyperthermia. The heart rate increases with
hyperthermia. With hypothermia there is slow capillary refill.
,The health care provider has prescribed a client sodium warfarin
(Coumadin) while
he is still receiving intravenous heparin. Which is the
nurse's best action?
A) Turn off the heparin before administering the warfarin.
B) Clarify the warfarin order with the nursing supervisor.
C) Administer both heparin and warfarin as prescribed.
D) Hold the warfarin dose until the heparin is discontinued. -
ANSWER -C
Although both heparin and warfarin are anticoagulants, they have
different mechanisms of action and onsets of action. Because
warfarin has such a slow onset, it must be started while the client
is still receiving heparin. Once the warfarin is therapeutic, as
evidenced by the international normalized ratio (INR), the client's
heparin can be safely discontinued. Effects of heparin will be
cleared from the client's bloodstream within a few hours.
Individuals of low socioeconomic status are at an increased
risk for infection
because of which of the following? (Select all
that apply.)
,A) High cost of
medications
B) Inadequate
nutrition
C) Easy access to health
screenings
D) Uninsured or underinsured status -
ANSWER -A, B, D
Individuals of low socioeconomic status tend to be part of the
underinsured or uninsured population. Lack of insurance
decreases accessibility to health care in general and health
screening services specifically. High costs of medication and
nutritious food also make this population at higher risk for
infection.
The nurse is working on a plan of care with her patient which
includes turning and
positioning and adequate nutrition to help the patient maintain
intact skin integrity.
The nurse helps the patient to realize that this breaks the chain
of infection by
eliminating
a:
, A) portal of
entry.
B)
host.
C) mode of
transmission.
D) reservoir. -
ANSWER -A
Broken or impaired skin creates a portal of entry for pathogens.
By maintaining intact tissue, the patient and the nurse have
broken the chain of infection by eliminating a portal of entry. Host
is incorrect because you are not eliminating the person or
organism. Intact tissue does not eliminate the mode of
transmission.
Skin can still be used to transfer pathogens regardless of it being
intact or broken. Intact skin does not eliminate the location for
pathogens to live and grow.
The nurse is preparing to administer a prescribed IV antibiotic to
a client admitted
with a serious infection. Which action by the nurse is
most important?
A) Double check the "five rights."
