2020 Hesi Medical-Surgical Rn Nursing

2020 HESI MEDICAL-SURGICAL RN NURSING V2 Question 1 When caring for an elderly patient who is intermittently confused, what is the nurse’s primary concern regarding fluid and electrolytes? 1. Risk of dehydration 2. Risk of kidney damage 3. Risk of stroke 4. Risk of bleeding Correct Answer: 1 Rationale 1: As an adult ages, the perception of thirst declines. In an older patient with an altered level of consciousness, there is an increased risk of dehydration and high serum osmolality. Rationale 2: The risk of kidney damage is not specifically related to aging or fluid and electrolyte issues. Rationale 3: The risk of stroke is not specifically related to aging or fluid and electrolyte issues. Rationale 4: The risk of bleeding is not specifically related to aging or fluid and electrolyte issues. Question 2 A patient experiencing multisystem fluid volume deficit has tachycardia and decreased urine output. The nurse realizes these findings are most likely a direct result of which factor? 1. The body’s natural compensatory mechanisms 2. Pharmacologic effects of a diuretic 3. Effects of rapidly infused intravenous fluids 4. Cardiac failure Correct Answer: 1 Rationale 1: The body’s vasoconstrictive compensatory reactions are responsible for the symptoms. The body naturally attempts to conserve fluid internally specifically for the brain and heart. Rationale 2: A diuretic would cause further fluid loss and is contraindicated. Rationale 3: Rapidly infused intravenous fluids would not cause a decrease in urine output. Rationale 4: The manifestations reported are not indicative of cardiac failure in this patient. Question 3 A pregnant patient is admitted with excessive thirst, increased urination, and a medical diagnosis of diabetes insipidus. The nurse chooses which nursing diagnosis as most appropriate? 1. Risk for Imbalanced Fluid Volume 2. Excess Fluid Volume 3. Imbalanced Nutrition 4. Ineffective Tissue Perfusion Correct Answer: 1 Rationale 1: The patient with excessive thirst, increased urination, and a medical diagnosis of diabetes insipidus is at risk for Imbalanced Fluid Volume due to excess volume loss that can increase the serum levels of sodium. Rationale 2: Excess Fluid Volume is not an issue for patients with diabetes insipidus, especially during the early stages of treatment. Rationale 3: Imbalanced Nutrition is not supported by the assessment data provided. Rationale 4: Ineffective Tissue Perfusion is not supported by the assessment data provided. Question 4 An adult patient recovering from surgery has an indwelling urinary catheter. The nurse would contact the patient’s primary health care provider with which 24-hour urine output volume? 1. 600 milliliters 2. 750 milliliters 3. 1,000 milliliters 4. 1,200 milliliters Correct Answer: 1 Rationale 1: A urine output of less than 30 milliliters per hour must be reported to the primary health care provider. This indicates inadequate renal perfusion, which places the patient at increased risk for acute renal failure and inadequate tissue perfusion. A minimum of 720 milliliters over a 24- hour period is desired (30 milliliters multiplied by 24 hours equals 720 milliliters per 24 hours). Rationale 2: 750 mL is above the minimum desired level of 30 mL per hour. Rationale 3: 1,000 mL is above the minimum desired level of 30 mL per hour. Rationale 4: 1,200 mL is above the minimum desired level of 30 mL per hour. Question 5 A patient is diagnosed with severe hyponatremia. The nurse realizes this patient will mostly likely need which precautions implemented? 1. Seizure precautions 2. Infection precautions 3. Neutropenic precautions 4. High-risk fall precautions Correct Answer: 1 Rationale 1: Severe hyponatremia can lead to seizures. Seizure precautions would include a quiet environment, raised side rails, and having an oral airway at the bedside. Rationale 2: Infection precautions are not specifically indicated for a patient with hyponatremia. Rationale 3: Neutropenic precautions are not specifically indicated for a patient with hyponatremia. Rationale 4: High-risk fall precautions are not specifically indicated for a patient with hyponatremia. Question 6 A patient prescribed spironolactone is demonstrating ECG changes and complaining of muscle weakness. The nurse realizes this patient is exhibiting signs of which imbalance? 1. Hyperkalemia 2. Hypokalemia 3. Hypercalcemia 4. Hypocalcemia Correct Answer: 1 Rationale 1: Hyperkalemia is defined as serum potassium level greater than 5.0 mEq/L. Decreased potassium excretion is seen with potassium-sparing diuretics such as spironolactone. Common manifestations of hyperkalemia are muscle weakness and ECG changes. Rationale 2: Hypokalemia is seen in nonpotassium sparing diuretics such as furosemide. Rationale 3: Hypercalcemia has been associated with thiazide diuretics. Rationale 4: Hypocalcemia is seen in patients who have received many units of citrated blood and is not associated with diuretic use. Question 7 The nurse is planning care for a patient with fluid volume overload and hyponatremia. Which intervention should be included in this patient’s plan of care? 1. Restrict fluids. 2. Administer intravenous fluids. 3. Provide Kayexalate. 4. Administer intravenous normal saline with furosemide. Correct Answer: 1 Rationale 1: The nursing care for a patient with hyponatremia depends on the cause. Restriction of fluids to 1,000 mL/day is usually implemented to assist sodium increase and to prevent the sodium level from dropping further due to dilution. Rationale 2: The administration of intravenous fluids would be indicated in fluid volume deficit and hypernatremia. Rationale 3: Kayexalate is used in patients with hyperkalemia. Rationale 4: Normal saline with furosemide is administered to increase calcium secretion. Question 8 When caring for a patient diagnosed with hypocalcemia, the nurse would also assess for which other finding? 1. Other electrolyte disturbances 2. Hypertension 3. Visual disturbances 4. Drug toxicity Correct Answer: 1 Rationale 1: The patient diagnosed with hypocalcemia may also have high phosphorus or decreased magnesium levels. Rationale 2: The patient with hypocalcemia may exhibit hypotension, not hypertension. Rationale 3: Visual disturbances do not occur with hypocalcemia. Rationale 4: Hypercalcemia is more commonly caused by drug toxicities. Question 9 A patient with a history of stomach ulcers is diagnosed with hypophosphatemia. Which intervention should the nurse include in this patient’s plan of care? 1. Request a dietitian consult to select foods high in phosphorous. 2. Provide aluminum hydroxide antacids as prescribed. 3. Instruct the patient to avoid poultry, peanuts, and seeds. 4. Instruct the patient to avoid the intake of sodium phosphate. Correct Answer: 1 Rationale 1: Treatment of hypophosphatemia includes treating the underlying cause and promoting a high-phosphate diet, especially milk if it is tolerated. Other foods high in phosphate are dried beans and peas, eggs, fish, organ meats, Brazil nuts and peanuts, poultry, seeds, and whole grains. Rationale 2: Phosphate-binding antacids, such as aluminum hydroxide, should be avoided. Rationale 3: Poultry, peanuts, and seeds are part of a high-phosphate diet. Rationale 4: Mild hypophosphatemia may be corrected with oral supplements, such as sodium phosphate. Question 10 When analyzing an arterial blood gas report of a patient with COPD and respiratory acidosis, the nurse anticipates that compensation will develop through which mechanism? 1. The kidneys retain bicarbonate. 2. The kidneys excrete bicarbonate. 3. The lungs will retain carbon dioxide. 4. The lungs will excrete carbon dioxide. Correct Answer: 1 Rationale 1: The kidneys will compensate for a respiratory disorder by retaining bicarbonate. Rationale 2: Excreting bicarbonate causes acidosis to develop. Rationale 3: Retaining carbon dioxide causes respiratory acidosis. Rationale 4: Excreting carbon dioxide causes respiratory alkalosis. Question 11 The nurse is caring for a patient diagnosed with renal failure. Which compensation does the nurse expect for the acid-base disturbance found in patients with renal failure? 1. The patient breathes rapidly to eliminate carbon dioxide. 2. The patient will retain bicarbonate in excess of normal. 3. The pH will decrease from the present value. 4. The patient’s oxygen saturation level will improve. Correct Answer: 1 Rationale 1: In metabolic acidosis, compensation is accomplished through increased ventilation or “blowing off” CO2. This raises the pH by eliminating the volatile respiratory acid and compensates for the acidosis. Rationale 2: Because compensation must be performed by the system other than the affected system, the patient cannot retain bicarbonate; the manifestation of metabolic acidosis of renal failure is a lower than normal bicarbonate value. Rationale 3: Metabolic acidosis of renal failure causes a low pH; this is the manifestation of the disease process, not the compensation. Rationale 4: Oxygenation disturbance is not part of the acid-base status of the patient with renal failure. Question 12 The nurse would assess specifically for metabolic alkalosis in which patient? 1. A patient admitted for treatment of bulimia 2. A patient who has been on dialysis for 2 months 3. A patient with a nonhealing venous stasis ulcer 4. A patient with newly diagnosed with COPD Correct Answer: 1 Rationale 1: Metabolic alkalosis is caused by vomiting, diuretic therapy, or nasogastric suction, among others. A patient with bulimia may engage in vomiting or the indiscriminate use of diuretics. Rationale 2: A patient receiving dialysis has kidney failure, which causes metabolic acidosis. Rationale 3: A venous stasis ulcer does not lead to an acid-base disorder. Rationale 4: The patient diagnosed with COPD typically has hypercapnea and respiratory acidosis. Question 13 The nurse is caring for a patient who is anxious and dizzy following a traumatic experience. The arterial blood gas findings include: pH 7.48, PaO2 110, PaCO2 25, and HCO3 24. The nurse would anticipate which initial intervention to correct this problem? 1. Encourage the patient to breathe in and out slowly into a paper bag. 2. Immediately administer oxygen via a mask and monitor oxygen saturation. 3. Start an intravenous fluid bolus using isotonic fluids. 4. Administer intravenous sodium bicarbonate. Correct Answer: 1 Rationale 1: This patient is exhibiting signs of hyperventilation, which is confirmed with the blood gas results of respiratory alkalosis. Breathing into a paper bag will help the patient retain carbon dioxide and lower oxygen levels to normal, correcting the cause of the problem. Rationale 2: The oxygen levels are high, so oxygen is not indicated and would exacerbate the problem if given. Rationale 3: Not enough information is given to determine the need for intravenous fluids. Question 14 An elderly patient does not complain of thirst. Which information would the nurse evaluate to determine if the patient is dehydrated? 1. Magnesium level 2. Chest X-ray 3. Urine osmolality 4. Brain scan Correct Answer: 3 Rationale 1: The magnesium level is not a sensitive indicator of fluid status. Rationale 2: A chest X-ray would be more useful in discovering if the patient is overhydrated. Rationale 3: The thirst mechanism declines with aging, which makes older adults more vulnerable to dehydration and hyperosmolality. Urine osmolality would help to determine the need for more detailed or invasive testing. Rationale 4: There is no data to support the need for a brain scan. Question 15 A clinic patient is short of breath and has ankle edema. Today’s weight is 8 pounds heavier that last week’s weight. The nurse determines that the patient could have retained pints of fluid. Correct Answer: 8 Rationale : Each pint of fluid weighs 1 pound. Question 16 A postoperative patient is diagnosed with fluid volume overload. Which assessment would the nurse attribute to this diagnosis? 1. The patient has poor skin turgor. 2. The patient has decreased urine output. 3. The patient reports sleeping on two pillows. 4. The patient’s laboratory testing reveals concentrated hemoglobin and hematocrit levels. Correct Answer: 3 Rationale 1: Poor skin turgor is associated with fluid volume deficit. Rationale 2: Decreased urine output is associated with fluid volume deficit. Rationale 3: Fluid volume overload can result in difficulty breathing when the patient tries to sleep. The patient may compensate for this condition by sleeping on more than one pillow. Rationale 4: Increased hemoglobin and hematocrit values are associated with fluid volume deficit. Question 17 An elderly patient reports having watery diarrhea for several days before coming to the clinic. This morning the patient is lethargic and confused. The nurse would assess this patient for which electrolyte imbalance? 1. Hypernatremia 2. Hyponatremia 3. Hypermagnesemia 4. Hyperkalemia Correct Answer: 2 Rationale 1: Hypernatremia is associated with fluid retention and overload. It is unlikely that this patient has fluid volume overload. Rationale 2: Watery diarrhea contributes to the loss of sodium. The lethargy and confusion are manifestations of a low serum sodium level. Rationale 3: Hypermagnesemia is found in patients with renal failure or adrenal insufficiency. It is also seen in obstetric settings where women receive IV magnesium to decrease symptoms of pregnancy- induced hypertension. Rationale 4: A patient with hyperkalemia is more likely to experience cardiac dysrhythmias. Question 18 A patient is diagnosed with hypokalemia. Which medication order would the nurse anticipate? 1. Potassium 40 mEq IV push 2. Potassium 40 mEq added to the next liter of IV fluids 3. Potassium 40 mEq by rectal suppository 4. Potassium 40 mEq IM Correct Answer: 2 Rationale 1: Potassium should never be given IV push. Rationale 2: The intravenous route is the recommended route for diluted potassium. Rationale 3: Potassium is irritating to tissues and is not given rectally. Rationale 4: Potassium is irritating to tissues and is not given IM. Question 19 A patient’s blood gases show a pH of 7.53 and bicarbonate level of 36 mEq/L. The nurse prepares to treat this patient for which acid-base disorder? 1. Respiratory acidosis 2. Metabolic acidosis 3. Respiratory alkalosis 4. Metabolic alkalosis Correct Answer: 4 Rationale 1: Respiratory acidosis is consistent with a pH lower than 7.35. Rationale 2: Metabolic acidosis is consistent with pH lower than 7.35. Rationale 3: Respiratory alkalosis is associated with a pH greater than 7.45 and a PaCO2 of less than 35 mmHG. It is caused by respiratory-related conditions. Rationale 4: When the patient is in metabolic alkalosis, arterial blood gases (ABGs) show a pH greater than 7.45 and bicarbonate level greater than 26 mEq/L. Question 20 An elderly postoperative patient is demonstrating lethargy, confusion, and a respiratory rate of 8 per