MED SURG HESI V2 EXAM
MED SURG HESI V1 -V7 PREDICTOR
EXAM 1 REAL EXAM COMPLETE
VERIFIED QUESTIONS AND CORRECT
DETAILED ANSWERS (VERIFIED
RATIONALES) |ALREADY GRADED A+
The client is a survivor of non-Hodgkin's lymphoma. Which of the following statements indicates
the client needs additional information?
1. "Regular screening is very important for me."
2. "The survivor rate is directly proportional to the incidence of second
malignancy."
3. "The survivor rate is indirectly proportional to the incidence of second
malignancy."
4. "It is important for survivors to know the stage of the disease and their current
A+ TEST BANK 1
, MED SURG HESI V2 EXAM
treatment plan." - Correct Answer :2
It is incorrect that the survivor rate is directly proportional to the incidence
of second malignancy. The survivor rate is indirectly proportional to the incidence of
second malignancy, and regular screening is very important to detect a second
malignancy, especially acute myeloid leukemia or myelodysplastic syndrome. Survivors
should know the stage of the disease and their current treatment plan so that they can
remain active participants in their health care.
Which of the following is the most important goal of nursing care for a client who is in shock?
1. Manage fluid overload.
2. Manage increased cardiac output.
3. Manage inadequate tissue perfusion.
4. Manage vasoconstriction of vascular beds - Correct Answer :3
Nursing interventions and collaborative management are focused on
correcting and maintaining adequate tissue perfusion. Inadequate tissue perfusion may
be caused by hemorrhage, as in hypovolemic shock; by decreased cardiac output, as in
cardiogenic shock; or by massive vasodilation of the vascular bed, as in neurogenic,
anaphylactic, and septic shock. Fluid deficit, not fluid overload, occurs in shock
Which of the following indicates hypovolemic shock in a client who has had a 15% blood loss?
1. Pulse rate less than 60 bpm.
2. Respiratory rate of 4 breaths/min.
A+ TEST BANK 2
, MED SURG HESI V2 EXAM
3. Pupils unequally dilated.
4. Systolic blood pressure less than 90 mm Hg. - Correct Answer :4
Typical signs and symptoms of hypovolemic shock include systolic blood
pressure less than 90 mm Hg, narrowing pulse pressure, tachycardia, tachypnea, cool
and clammy skin, decreased urine output, and mental status changes, such as irritability
or anxiety. Unequal dilation of the pupils is related to central nervous system injury or
possibly to a previous history of eye injury.
Which of the following findings is the best indication that fluid replacement for the client in
hypovolemic shock is adequate?
1. Urine output greater than 30 mL/h.
2. Systolic blood pressure greater than 110 mm Hg.
3. Diastolic blood pressure greater than 90 mm Hg.
4. Respiratory rate of 20 breaths/min. - Correct Answer :1
Urine output provides the most sensitive indication of the client's response to
therapy for hypovolemic shock. Urine output should be consistently greater than 35
mL/h. Blood pressure is a more accurate reflection of the adequacy of vasoconstriction
than of tissue perfusion. Respiratory rate is not a sensitive indicator of fluid balance in
the client recovering from hypovolemic shock.
Which of the following is a risk factor for hypovolemic shock?
1. Hemorrhage.
A+ TEST BANK 3
, MED SURG HESI V2 EXAM
2. Antigen-antibody reaction.
3. Gram-negative bacteria.
4. Vasodilation. - Correct Answer :1
Causes of hypovolemic shock include external fluid loss, such as
hemorrhage; internal fluid shifting, such as ascites and severe edema; and dehydration.
Massive vasodilation is the initial phase of vasogenic or distributive shock, which can
be further subdivided into three types of shock: septic, neurogenic, and anaphylactic. A
severe antigen-antibody reaction occurs in anaphylactic shock. Gram-negative bacterial
infection is the most common cause of septic shock. Loss of sympathetic tone
(vasodilation) occurs in neurogenic shock.
Which is a priority assessment for the client in shock who is receiving an IV infusion of packed
red blood cells and normal saline solution?
1. Fluid balance.
2. Anaphylactic reaction.
3. Pain.
4. Altered level of consciousness. - Correct Answer :2
The client who is receiving a blood product requires astute assessment for
signs and symptoms of allergic reaction and anaphylaxis, including pruritus (itching),
urticaria (hives), facial or glottal edema, and shortness of breath. If such a reaction
occurs, the nurse should stop the transfusion immediately, but leave the IV line intact,
and notify the physician. Usually, an antihistamine such as diphenhydramine
hydrochloride (Benadryl) is administered. Epinephrine and corticosteroids may be
administered in severe reactions. Fluid balance is not an immediate concern during the
A+ TEST BANK 4
MED SURG HESI V1 -V7 PREDICTOR
EXAM 1 REAL EXAM COMPLETE
VERIFIED QUESTIONS AND CORRECT
DETAILED ANSWERS (VERIFIED
RATIONALES) |ALREADY GRADED A+
The client is a survivor of non-Hodgkin's lymphoma. Which of the following statements indicates
the client needs additional information?
1. "Regular screening is very important for me."
2. "The survivor rate is directly proportional to the incidence of second
malignancy."
3. "The survivor rate is indirectly proportional to the incidence of second
malignancy."
4. "It is important for survivors to know the stage of the disease and their current
A+ TEST BANK 1
, MED SURG HESI V2 EXAM
treatment plan." - Correct Answer :2
It is incorrect that the survivor rate is directly proportional to the incidence
of second malignancy. The survivor rate is indirectly proportional to the incidence of
second malignancy, and regular screening is very important to detect a second
malignancy, especially acute myeloid leukemia or myelodysplastic syndrome. Survivors
should know the stage of the disease and their current treatment plan so that they can
remain active participants in their health care.
Which of the following is the most important goal of nursing care for a client who is in shock?
1. Manage fluid overload.
2. Manage increased cardiac output.
3. Manage inadequate tissue perfusion.
4. Manage vasoconstriction of vascular beds - Correct Answer :3
Nursing interventions and collaborative management are focused on
correcting and maintaining adequate tissue perfusion. Inadequate tissue perfusion may
be caused by hemorrhage, as in hypovolemic shock; by decreased cardiac output, as in
cardiogenic shock; or by massive vasodilation of the vascular bed, as in neurogenic,
anaphylactic, and septic shock. Fluid deficit, not fluid overload, occurs in shock
Which of the following indicates hypovolemic shock in a client who has had a 15% blood loss?
1. Pulse rate less than 60 bpm.
2. Respiratory rate of 4 breaths/min.
A+ TEST BANK 2
, MED SURG HESI V2 EXAM
3. Pupils unequally dilated.
4. Systolic blood pressure less than 90 mm Hg. - Correct Answer :4
Typical signs and symptoms of hypovolemic shock include systolic blood
pressure less than 90 mm Hg, narrowing pulse pressure, tachycardia, tachypnea, cool
and clammy skin, decreased urine output, and mental status changes, such as irritability
or anxiety. Unequal dilation of the pupils is related to central nervous system injury or
possibly to a previous history of eye injury.
Which of the following findings is the best indication that fluid replacement for the client in
hypovolemic shock is adequate?
1. Urine output greater than 30 mL/h.
2. Systolic blood pressure greater than 110 mm Hg.
3. Diastolic blood pressure greater than 90 mm Hg.
4. Respiratory rate of 20 breaths/min. - Correct Answer :1
Urine output provides the most sensitive indication of the client's response to
therapy for hypovolemic shock. Urine output should be consistently greater than 35
mL/h. Blood pressure is a more accurate reflection of the adequacy of vasoconstriction
than of tissue perfusion. Respiratory rate is not a sensitive indicator of fluid balance in
the client recovering from hypovolemic shock.
Which of the following is a risk factor for hypovolemic shock?
1. Hemorrhage.
A+ TEST BANK 3
, MED SURG HESI V2 EXAM
2. Antigen-antibody reaction.
3. Gram-negative bacteria.
4. Vasodilation. - Correct Answer :1
Causes of hypovolemic shock include external fluid loss, such as
hemorrhage; internal fluid shifting, such as ascites and severe edema; and dehydration.
Massive vasodilation is the initial phase of vasogenic or distributive shock, which can
be further subdivided into three types of shock: septic, neurogenic, and anaphylactic. A
severe antigen-antibody reaction occurs in anaphylactic shock. Gram-negative bacterial
infection is the most common cause of septic shock. Loss of sympathetic tone
(vasodilation) occurs in neurogenic shock.
Which is a priority assessment for the client in shock who is receiving an IV infusion of packed
red blood cells and normal saline solution?
1. Fluid balance.
2. Anaphylactic reaction.
3. Pain.
4. Altered level of consciousness. - Correct Answer :2
The client who is receiving a blood product requires astute assessment for
signs and symptoms of allergic reaction and anaphylaxis, including pruritus (itching),
urticaria (hives), facial or glottal edema, and shortness of breath. If such a reaction
occurs, the nurse should stop the transfusion immediately, but leave the IV line intact,
and notify the physician. Usually, an antihistamine such as diphenhydramine
hydrochloride (Benadryl) is administered. Epinephrine and corticosteroids may be
administered in severe reactions. Fluid balance is not an immediate concern during the
A+ TEST BANK 4
