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MED-SURG II HESI EXAM TEST BANK ACTUAL EXAM
350 QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES ||VERIFIED EXAM!!
(VERIFIED ANSWERS) |AGRADE||NEWEST EXAM!!!
Mild hypothermia is manifested by shivering, slurred
speech, poor muscular coordination, and impaired
cognitive abilities. Mild hypothermia may be treated with
dry clothing and warm blankets. Rewarming should occur
slowly by removing wet clothing and providing dry warm
blankets first. Other treatments are secondary and should
be used to treat moderate to severe hypothermia. -
ANSWER-A client presents to the emergency department
after prolonged exposure to the cold. The client is
shivering, has slurred speech, and is slow to respond to
questions. Which intervention will the nurse prepare for
this client FIRST?
A) Continuous arteriovenous rewarming
B) Dry clothing and warm blankets
C) Peritoneal lavage with warmed normal saline
D) Administration of warmed IV fluids
B
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It is important for the nurse to assess respirations of the
client when administering opioids because of the
possibility of respiratory depression. The other
interventions may or may not be necessary in the care of
the client and do not focus on safety. - ANSWER-The
Joint Commission focuses on safety in health care. Which
action by the nurse reflects The Joint Commission's main
objective?
A) Performing range-of-motion exercises on the client
three times each day
B) Assessing the client's respirations when administering
opioids
C) Delegating to the nursing assistant to give the client a
complete bath daily
D) Ensuring that the client is eating 100% of the meals
served to him or her
D
Advanced age and multiple illnesses, particularly those
that result in alterations in sensation, such as diabetes,
predispose this client to falls. The nurse should provide
assistance to the client with transfer and ambulation to
prevent falls. The client should not be restrained or
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maintained on bedrest without adequate indication.
Although family members are encouraged to visit, their
presence around the clock is not necessary at this point. -
ANSWER-What is a priority nursing intervention to prevent
falls for an older adult client with multiple chronic
diseases?
A) Requesting that a family member remain with the client
to assist in ambulation
B) Keeping all four siderails up while the client is in bed
C) Placing the client in restraints to prevent movement
without assistance
D) Providing assistance to the client in getting out of the
bed or chair
B
At times clients are unable to verbalize that they are in
pain but there are indicators that the client may have acute
pain such as increased heart rate, increased blood
pressure, increased respirations, sweating, restlessness,
and overall distress. All the other distractors could indicate
clients who have the potential for being in pain, but
restlessness with tachycardia is the most indicative. -
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ANSWER-The nurse is caring for four clients. Which client
assessment is the most indicative of having pain?
A) Client stating that he is "anxious"
B) Heart rate of 105 beats/min and restlessness
C) Blood pressure 150/70 mm Hg and sleeping
D) Postoperative client with a neck incision
C
The only intervention identified within the scope of nursing
practice is to use sterile technique. Central line insertion,
intubation, and prescription are functions of the physician.
- ANSWER-The Institute for Healthcare Improvement (IHI)
identified interventions to save client lives. Which actions
are within the scope of nursing practice to improve quality
of care?
A) Prescribe aspirin for a client who presents with an
acute myocardial infarction
B) Insert a central line to give intravenous fluid to a
dehydrated client.
C) Use sterile technique when changing dressings on a
new surgical site.
MED-SURG II HESI EXAM TEST BANK ACTUAL EXAM
350 QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES ||VERIFIED EXAM!!
(VERIFIED ANSWERS) |AGRADE||NEWEST EXAM!!!
Mild hypothermia is manifested by shivering, slurred
speech, poor muscular coordination, and impaired
cognitive abilities. Mild hypothermia may be treated with
dry clothing and warm blankets. Rewarming should occur
slowly by removing wet clothing and providing dry warm
blankets first. Other treatments are secondary and should
be used to treat moderate to severe hypothermia. -
ANSWER-A client presents to the emergency department
after prolonged exposure to the cold. The client is
shivering, has slurred speech, and is slow to respond to
questions. Which intervention will the nurse prepare for
this client FIRST?
A) Continuous arteriovenous rewarming
B) Dry clothing and warm blankets
C) Peritoneal lavage with warmed normal saline
D) Administration of warmed IV fluids
B
,2|Page
It is important for the nurse to assess respirations of the
client when administering opioids because of the
possibility of respiratory depression. The other
interventions may or may not be necessary in the care of
the client and do not focus on safety. - ANSWER-The
Joint Commission focuses on safety in health care. Which
action by the nurse reflects The Joint Commission's main
objective?
A) Performing range-of-motion exercises on the client
three times each day
B) Assessing the client's respirations when administering
opioids
C) Delegating to the nursing assistant to give the client a
complete bath daily
D) Ensuring that the client is eating 100% of the meals
served to him or her
D
Advanced age and multiple illnesses, particularly those
that result in alterations in sensation, such as diabetes,
predispose this client to falls. The nurse should provide
assistance to the client with transfer and ambulation to
prevent falls. The client should not be restrained or
,3|Page
maintained on bedrest without adequate indication.
Although family members are encouraged to visit, their
presence around the clock is not necessary at this point. -
ANSWER-What is a priority nursing intervention to prevent
falls for an older adult client with multiple chronic
diseases?
A) Requesting that a family member remain with the client
to assist in ambulation
B) Keeping all four siderails up while the client is in bed
C) Placing the client in restraints to prevent movement
without assistance
D) Providing assistance to the client in getting out of the
bed or chair
B
At times clients are unable to verbalize that they are in
pain but there are indicators that the client may have acute
pain such as increased heart rate, increased blood
pressure, increased respirations, sweating, restlessness,
and overall distress. All the other distractors could indicate
clients who have the potential for being in pain, but
restlessness with tachycardia is the most indicative. -
, 4|Page
ANSWER-The nurse is caring for four clients. Which client
assessment is the most indicative of having pain?
A) Client stating that he is "anxious"
B) Heart rate of 105 beats/min and restlessness
C) Blood pressure 150/70 mm Hg and sleeping
D) Postoperative client with a neck incision
C
The only intervention identified within the scope of nursing
practice is to use sterile technique. Central line insertion,
intubation, and prescription are functions of the physician.
- ANSWER-The Institute for Healthcare Improvement (IHI)
identified interventions to save client lives. Which actions
are within the scope of nursing practice to improve quality
of care?
A) Prescribe aspirin for a client who presents with an
acute myocardial infarction
B) Insert a central line to give intravenous fluid to a
dehydrated client.
C) Use sterile technique when changing dressings on a
new surgical site.
