MED SURG II
HESI (Elsevier)
, 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 - CORRECT
ANSWERS-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 - CORRECT ANSWERS-4. "I have
trouble breathing when I walk rapidly
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 psychiatric 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 and the
dietitian. - CORRECT ANSWERS-1. Focus on the client's feelings by exploring the
reason why the question was asked.
The nurse is assessing a client for signs of right ventricular failure. What should the
nurse expect if this occurs?
1. Slowed pulse rate
2. Pleural friction rub
HESI (Elsevier)
, 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 - CORRECT
ANSWERS-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 - CORRECT ANSWERS-4. "I have
trouble breathing when I walk rapidly
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 psychiatric 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 and the
dietitian. - CORRECT ANSWERS-1. Focus on the client's feelings by exploring the
reason why the question was asked.
The nurse is assessing a client for signs of right ventricular failure. What should the
nurse expect if this occurs?
1. Slowed pulse rate
2. Pleural friction rub
