HESI - Medical Surgical Nursing test
Which intervention in a client with dehydration induced confusion is most likely to relieve the
confusion?
a. increasing the IV flow rate to 250 mL/hr
b. applying oxygen by mask or nasal cannula
c. placing the client in a high Fowler's position
d. Measuring intake and output every four hours - ANSWER-A
Dehydration most frequently leads to poor cerebra perfusion and cerebral hypoxia, causing
confusion. Applying oxygen can reduce confusion, even if perfusion is still less than optimum.
Increasing the IV flow rate would increase perfusion. However, depending on the degree of
dehydration, rehydrating the person too rapidly with IV fluids can lead to cerebral edema.
Which client is at greatest risk for dehydration?
a. younger adult client on bedrest
b. older adult client receiving hypotonic IV fluid
c. older adult client with cognitive impairment
d. younger adult client receiving hypertonic IV fluid - ANSWER-C
Older adults, because they have less total body water than younger adults, are at greater risk
for development of dehydration. Anyone who is cognitively impaired and cannot obtain fluids
independently or cannot make his or her need for fluids known is at high risk for dehydration
A nurse is caring for several clients. Which client does the nurse assess most carefully for
hyperkalemia?
a. client with type 2 diabetes taking an oral anti-diabetic agent
b. client with heart failure using a salt substitute
c. client taking a thiazide diuretic for hypertension
,d. client taking non-steroidal anti-inflammatory drugs daily - ANSWER-B
Many salt substitutes are composed of potassium chloride. Heavy use cna contribute to the
development of hyperkalemia. The client should be taught to read labels and to choose a salt
substitute that does not contain potassium. NSAIDs promote the retention of sodium but not
potassium.
An older adult client presents with signs and symptoms related to dig toxicity. Which age
related change may have contributed to this problem?
a. decreased renal blood flow
b. increased gastrointestinal motility
c. decreased ratio of adipose tissue to lean body mass
d. increased total body water - ANSWER-A
Decreased renal blood flow and reduced glomerular filtration can result in slower medication
excretion time, potentially leading to toxic drug accumulation. Aging results in decreased total
body water and gastrointestinal motility and an increase in the ratio of adipose tissue to lean
body mass, but is not related to dig toxicity.
A client is being treated for dehydration. Which statement made by the client indicates
understanding of this condition?
a. I will use a salt substitute when making and eating my meals.
b. I must drink a quart of water or other liquid each day.
c. I will not drink liquids after 6 PM so I won't have to get up at night.
d. I will weigh myself each morning before I eat or drink. - ANSWER-D
Because 1 L of water weighs 1 kg, change in body weight is a good measure of excess fluid loss
or fluid retention. Weight loss greater than 0.5 lb daily is indicative of excessive fluid loss. The
other statements are not indicative of practices that will prevent dehydration.
,The nurse notes that the handgrip of the client with hypokalemia has diminished since the
previous assessment one hour ago. Which intervention by the nurse is the priority?
a. assess the client's respiratory rate, rhythm, and depth
b. document findings and monitor the client
c. measure the client's pulse and blood pressure
d. call the health care provider - ANSWER-A
In a client with hypokkalemia, progressive skeletal muscle weakness is associated with
increasing severity of hypokalemia. The most life-threatening complication of hypokalemia is
respiratory insufficiency. It is imperative for the nurse to perform a respiratory assessment
first to make sure that the client is not in immediate jeopardy. Next, the nurse would call the
health care provider to obtain orders for potassium replacement.
The physician orders Lasix (furosemide) 60 mg po every day for your patient. On hand you
have Lasix 40 mg. How many tablets will you give the patient?
a. 3
b. 1
c. 1 1/2
d. 2 1/5 - ANSWER-C
60/40 (desired/have)
A client has been taught to restrict dietary sodium. Which food selection by the client
indicates to the nurse that teaching has been effective?
a. a grilled cheese sandwich with tomato soup
b. Chinese take-out, including steamed rice
c. a chicken leg, one slice of bread with butter, and steamed carrots
, d. slices of ham and cheese on whole grain crackers - ANSWER-C
Clients on restricted sodium diets generally should avoid processed, smoked, and pickled
foods and those with sauces and other condiments. Foods lowest in sodium include fish,
poultry, and fresh produce. The chinese food likely would have soy sauce, the tomato soup is
processed, and the crackers are a snack food - a category of foods often high in sodium.
When a client is assessed, which behavior best indicates that he or she is experiencing
changes associated with acute pain?
a. inability to concentrate
b. expressed hopelessness
c. psychosocial withdrawal
d. anger and hostility - ANSWER-A
The characteristics most common to chronic pain are psychosocial withdrawal, anger and
hostility, depression, and hopelessness. The inability to concentrate is associated much more
with acute pain, before any physiologic or behavioral adaptation has occurred.
A nurse is caring for several clients at risk for overhydration. The nurse assesses the older
client with which finding first?
A) Has had diabetes mellitus for 12 years
B) Had abdominal surgery and has a nasogastric tube
C) Just received 3 units of packed red blood cells
D) Uses sodium-containing antacids frequently - ANSWER-C
Blood replacement therapy involves intravenous fluid administration, which inherently
increases the risk for overhydration. The fact that the fluid consists of packed red blood cells
greatly increases the risk, because this fluid increases the colloidal oncotic pressure of the
Which intervention in a client with dehydration induced confusion is most likely to relieve the
confusion?
a. increasing the IV flow rate to 250 mL/hr
b. applying oxygen by mask or nasal cannula
c. placing the client in a high Fowler's position
d. Measuring intake and output every four hours - ANSWER-A
Dehydration most frequently leads to poor cerebra perfusion and cerebral hypoxia, causing
confusion. Applying oxygen can reduce confusion, even if perfusion is still less than optimum.
Increasing the IV flow rate would increase perfusion. However, depending on the degree of
dehydration, rehydrating the person too rapidly with IV fluids can lead to cerebral edema.
Which client is at greatest risk for dehydration?
a. younger adult client on bedrest
b. older adult client receiving hypotonic IV fluid
c. older adult client with cognitive impairment
d. younger adult client receiving hypertonic IV fluid - ANSWER-C
Older adults, because they have less total body water than younger adults, are at greater risk
for development of dehydration. Anyone who is cognitively impaired and cannot obtain fluids
independently or cannot make his or her need for fluids known is at high risk for dehydration
A nurse is caring for several clients. Which client does the nurse assess most carefully for
hyperkalemia?
a. client with type 2 diabetes taking an oral anti-diabetic agent
b. client with heart failure using a salt substitute
c. client taking a thiazide diuretic for hypertension
,d. client taking non-steroidal anti-inflammatory drugs daily - ANSWER-B
Many salt substitutes are composed of potassium chloride. Heavy use cna contribute to the
development of hyperkalemia. The client should be taught to read labels and to choose a salt
substitute that does not contain potassium. NSAIDs promote the retention of sodium but not
potassium.
An older adult client presents with signs and symptoms related to dig toxicity. Which age
related change may have contributed to this problem?
a. decreased renal blood flow
b. increased gastrointestinal motility
c. decreased ratio of adipose tissue to lean body mass
d. increased total body water - ANSWER-A
Decreased renal blood flow and reduced glomerular filtration can result in slower medication
excretion time, potentially leading to toxic drug accumulation. Aging results in decreased total
body water and gastrointestinal motility and an increase in the ratio of adipose tissue to lean
body mass, but is not related to dig toxicity.
A client is being treated for dehydration. Which statement made by the client indicates
understanding of this condition?
a. I will use a salt substitute when making and eating my meals.
b. I must drink a quart of water or other liquid each day.
c. I will not drink liquids after 6 PM so I won't have to get up at night.
d. I will weigh myself each morning before I eat or drink. - ANSWER-D
Because 1 L of water weighs 1 kg, change in body weight is a good measure of excess fluid loss
or fluid retention. Weight loss greater than 0.5 lb daily is indicative of excessive fluid loss. The
other statements are not indicative of practices that will prevent dehydration.
,The nurse notes that the handgrip of the client with hypokalemia has diminished since the
previous assessment one hour ago. Which intervention by the nurse is the priority?
a. assess the client's respiratory rate, rhythm, and depth
b. document findings and monitor the client
c. measure the client's pulse and blood pressure
d. call the health care provider - ANSWER-A
In a client with hypokkalemia, progressive skeletal muscle weakness is associated with
increasing severity of hypokalemia. The most life-threatening complication of hypokalemia is
respiratory insufficiency. It is imperative for the nurse to perform a respiratory assessment
first to make sure that the client is not in immediate jeopardy. Next, the nurse would call the
health care provider to obtain orders for potassium replacement.
The physician orders Lasix (furosemide) 60 mg po every day for your patient. On hand you
have Lasix 40 mg. How many tablets will you give the patient?
a. 3
b. 1
c. 1 1/2
d. 2 1/5 - ANSWER-C
60/40 (desired/have)
A client has been taught to restrict dietary sodium. Which food selection by the client
indicates to the nurse that teaching has been effective?
a. a grilled cheese sandwich with tomato soup
b. Chinese take-out, including steamed rice
c. a chicken leg, one slice of bread with butter, and steamed carrots
, d. slices of ham and cheese on whole grain crackers - ANSWER-C
Clients on restricted sodium diets generally should avoid processed, smoked, and pickled
foods and those with sauces and other condiments. Foods lowest in sodium include fish,
poultry, and fresh produce. The chinese food likely would have soy sauce, the tomato soup is
processed, and the crackers are a snack food - a category of foods often high in sodium.
When a client is assessed, which behavior best indicates that he or she is experiencing
changes associated with acute pain?
a. inability to concentrate
b. expressed hopelessness
c. psychosocial withdrawal
d. anger and hostility - ANSWER-A
The characteristics most common to chronic pain are psychosocial withdrawal, anger and
hostility, depression, and hopelessness. The inability to concentrate is associated much more
with acute pain, before any physiologic or behavioral adaptation has occurred.
A nurse is caring for several clients at risk for overhydration. The nurse assesses the older
client with which finding first?
A) Has had diabetes mellitus for 12 years
B) Had abdominal surgery and has a nasogastric tube
C) Just received 3 units of packed red blood cells
D) Uses sodium-containing antacids frequently - ANSWER-C
Blood replacement therapy involves intravenous fluid administration, which inherently
increases the risk for overhydration. The fact that the fluid consists of packed red blood cells
greatly increases the risk, because this fluid increases the colloidal oncotic pressure of the
