HESI Med Surg 1
Study online at https://quizlet.com/_9cxqk1
1. The nurse observes ventricular fibrilla- B.
tion on telemetry and, on entering the Start cardiopulmonary resuscitation.
client's bathroom, finds the client un-
conscious on the floor. Which interven- Rationale:
tion should the nurse implement first? Ventricular fibrillation is a life-threatening dys-
A. rhythmia, and CPR should be started immediately
Administer an antidysrhythmic med- (B). (A and C) are appropriate, but CPR is the
ication. priority action. The client is dying, and (D) does
B. not address the seriousness of this situation.
Start cardiopulmonary resuscitation.
C.
Defibrillate the client at 200 J.
D.
Assess the client's pulse oximetry.
2. The nurse assesses a client who has D.
been prescribed furosemide (Lasix) for Presence of a U wave
cardiac disease. Which electrocardio-
graphic change would be a concern for Rationale:
a client taking a diuretic? A U wave (D) is a positive deflection following the
A. T wave and is often present with hypokalemia (low
Tall, spiked T waves potassium level). (A, B, and C) are all signs of
B. hyperkalemia.
A prolonged QT interval
C.
A widening QRS complex
D.
Presence of a U wave
3. A 43-year-old homeless, malnourished B.
female client with a history of alco- Magnesium sulfate
holism is transferred to the ICU. She is
, HESI Med Surg 1
Study online at https://quizlet.com/_9cxqk1
placed on telemetry, and the rhythm Rationale:
strip shown is obtained. The nurse pal- Because the client has chronic alcoholism, she is
pates a heart rate of 160 beats/min, likely to have hypomagnesemia. (B) is the rec-
and the client's blood pressure is 90/54 ommended drug for torsades de pointes, which
mm Hg. Based on these findings, which is a form of polymorphic ventricular tachycardia
IV medication should the nurse admin- (VT) usually associated with a prolonged QT in-
ister? terval that occurs with hypomagnesemia. (A and
A. D) increase the QT interval, which can cause the
Amiodarone (Cordarone) torsades to worsen. (C) is the antiarrhythmic of
B. choice in most cases of drug-induced monomor-
Magnesium sulfate phic VT, not torsades.
C.
Lidocaine (Xylocaine)
D.
Procainamide (Pronestyl)
4. When developing a discharge teach- D.
ing plan for a client after the insertion The client states that changes in the pulse and
of a permanent pacemaker, the nurse feelings of dizziness are significant changes.
writes a goal of "The client will verbal-
ize symptoms of pacemaker failure." Rationale:
Which behavior indicates that the goal Changes in pulse rate and/or rhythm may indicate
has been met? pacer failure. Feelings of dizziness may be caused
A. by a decreased heart rate, leading to decreased
The client demonstrates the proce- cardiac output (D). The rate of a pacemaker is
dures to change the rate of the pace- not changed by a client, although the client may
maker using a magnet. be familiar with this procedure as explained by
B. his health care provider (A). (B) is an important
The client carries a card in his wallet step in preparing the client for discharge but does
stating the type and serial number of not demonstrate knowledge of the symptoms of
the pacemaker. pacer failure. (C) indicates symptoms of possible
C.
, HESI Med Surg 1
Study online at https://quizlet.com/_9cxqk1
The client tells the nurse that it is im- incisional infection or irritation but do not indicate
portant to report redness and tender- pacer failure.
ness at the insertion site.
D.
The client states that changes in the
pulse and feelings of dizziness are sig-
nificant changes.
5. The nurse teaches a client with type B
2 diabetes nutritional strategies to de- Salmon
crease obesity. Which food item(s) cho-
sen by the client indicates understand- C
ing of the teaching? (Select all that ap- Broccoli
ply.)
E.
A.
Banana
White bread
B.
Rationale:
Salmon
(B, C, and E) provide fresh fruits, lean meats and
C.
fish, vegetables, whole grains, and low-fat dairy
Broccoli
products. All are recommended by the American
D.
Diabetes Association (ADA) and are a part of the
Whole milk
My Plate guidelines recommended by the U.S.
E.
Department of Agriculture (USDA). Whole milk (D)
Banana
is high in fat and is not recommended by ADA.
White bread is milled, a process that removes
the essential nutrients. It should be avoided for
weight loss and is a poor choice for the client with
diabetes (A).
6. A client diagnosed with angina pectoris A.
complains of chest pain while ambulat- Support the client to a sitting position.
ing in the hallway. Which action should
, HESI Med Surg 1
Study online at https://quizlet.com/_9cxqk1
the nurse implement first? Rationale:
A. The nurse should safely assist the client to a rest-
Support the client to a sitting position. ing position (A) and then perform (C and D). The
B. client must cease all activity immediately, which
Ask the client to walk slowly back to the will decrease the oxygen requirement of the my-
room. ocardial muscle. After these interventions are im-
C. plemented, the client can be escorted back to the
Administer a sublingual nitroglycerin room via wheelchair or stretcher (B).
tablet.
D.
Provide oxygen via nasal cannula.
7. After attending a class on reducing A.
cancer risk factors, a client selects bran Switch to skim milk.
flakes with 2% milk and orange slices
from a breakfast menu. In evaluating Rationale:
the client's learning, the nurse affirms Dietary recommendations to reduce cancer risk
that the client has made good choices include reduced consumption of fats, with in-
and makes what additional recommen- creased consumption of fruits, vegetables, and
dation? fiber. (A) promotes reduced fat consumption. Or-
A. ange slices provide more fiber than orange juice
Switch to skim milk. (B, C, and D) are not standard recommendations
B. for reducing cancer risk.
Switch to orange juice.
C.
Add a source of protein.
D.
Add herbal tea.
8. A nurse is assisting an 82-year-old B.
client with ambulation and is con- Upper torso
cerned that the client may fall. Which
Study online at https://quizlet.com/_9cxqk1
1. The nurse observes ventricular fibrilla- B.
tion on telemetry and, on entering the Start cardiopulmonary resuscitation.
client's bathroom, finds the client un-
conscious on the floor. Which interven- Rationale:
tion should the nurse implement first? Ventricular fibrillation is a life-threatening dys-
A. rhythmia, and CPR should be started immediately
Administer an antidysrhythmic med- (B). (A and C) are appropriate, but CPR is the
ication. priority action. The client is dying, and (D) does
B. not address the seriousness of this situation.
Start cardiopulmonary resuscitation.
C.
Defibrillate the client at 200 J.
D.
Assess the client's pulse oximetry.
2. The nurse assesses a client who has D.
been prescribed furosemide (Lasix) for Presence of a U wave
cardiac disease. Which electrocardio-
graphic change would be a concern for Rationale:
a client taking a diuretic? A U wave (D) is a positive deflection following the
A. T wave and is often present with hypokalemia (low
Tall, spiked T waves potassium level). (A, B, and C) are all signs of
B. hyperkalemia.
A prolonged QT interval
C.
A widening QRS complex
D.
Presence of a U wave
3. A 43-year-old homeless, malnourished B.
female client with a history of alco- Magnesium sulfate
holism is transferred to the ICU. She is
, HESI Med Surg 1
Study online at https://quizlet.com/_9cxqk1
placed on telemetry, and the rhythm Rationale:
strip shown is obtained. The nurse pal- Because the client has chronic alcoholism, she is
pates a heart rate of 160 beats/min, likely to have hypomagnesemia. (B) is the rec-
and the client's blood pressure is 90/54 ommended drug for torsades de pointes, which
mm Hg. Based on these findings, which is a form of polymorphic ventricular tachycardia
IV medication should the nurse admin- (VT) usually associated with a prolonged QT in-
ister? terval that occurs with hypomagnesemia. (A and
A. D) increase the QT interval, which can cause the
Amiodarone (Cordarone) torsades to worsen. (C) is the antiarrhythmic of
B. choice in most cases of drug-induced monomor-
Magnesium sulfate phic VT, not torsades.
C.
Lidocaine (Xylocaine)
D.
Procainamide (Pronestyl)
4. When developing a discharge teach- D.
ing plan for a client after the insertion The client states that changes in the pulse and
of a permanent pacemaker, the nurse feelings of dizziness are significant changes.
writes a goal of "The client will verbal-
ize symptoms of pacemaker failure." Rationale:
Which behavior indicates that the goal Changes in pulse rate and/or rhythm may indicate
has been met? pacer failure. Feelings of dizziness may be caused
A. by a decreased heart rate, leading to decreased
The client demonstrates the proce- cardiac output (D). The rate of a pacemaker is
dures to change the rate of the pace- not changed by a client, although the client may
maker using a magnet. be familiar with this procedure as explained by
B. his health care provider (A). (B) is an important
The client carries a card in his wallet step in preparing the client for discharge but does
stating the type and serial number of not demonstrate knowledge of the symptoms of
the pacemaker. pacer failure. (C) indicates symptoms of possible
C.
, HESI Med Surg 1
Study online at https://quizlet.com/_9cxqk1
The client tells the nurse that it is im- incisional infection or irritation but do not indicate
portant to report redness and tender- pacer failure.
ness at the insertion site.
D.
The client states that changes in the
pulse and feelings of dizziness are sig-
nificant changes.
5. The nurse teaches a client with type B
2 diabetes nutritional strategies to de- Salmon
crease obesity. Which food item(s) cho-
sen by the client indicates understand- C
ing of the teaching? (Select all that ap- Broccoli
ply.)
E.
A.
Banana
White bread
B.
Rationale:
Salmon
(B, C, and E) provide fresh fruits, lean meats and
C.
fish, vegetables, whole grains, and low-fat dairy
Broccoli
products. All are recommended by the American
D.
Diabetes Association (ADA) and are a part of the
Whole milk
My Plate guidelines recommended by the U.S.
E.
Department of Agriculture (USDA). Whole milk (D)
Banana
is high in fat and is not recommended by ADA.
White bread is milled, a process that removes
the essential nutrients. It should be avoided for
weight loss and is a poor choice for the client with
diabetes (A).
6. A client diagnosed with angina pectoris A.
complains of chest pain while ambulat- Support the client to a sitting position.
ing in the hallway. Which action should
, HESI Med Surg 1
Study online at https://quizlet.com/_9cxqk1
the nurse implement first? Rationale:
A. The nurse should safely assist the client to a rest-
Support the client to a sitting position. ing position (A) and then perform (C and D). The
B. client must cease all activity immediately, which
Ask the client to walk slowly back to the will decrease the oxygen requirement of the my-
room. ocardial muscle. After these interventions are im-
C. plemented, the client can be escorted back to the
Administer a sublingual nitroglycerin room via wheelchair or stretcher (B).
tablet.
D.
Provide oxygen via nasal cannula.
7. After attending a class on reducing A.
cancer risk factors, a client selects bran Switch to skim milk.
flakes with 2% milk and orange slices
from a breakfast menu. In evaluating Rationale:
the client's learning, the nurse affirms Dietary recommendations to reduce cancer risk
that the client has made good choices include reduced consumption of fats, with in-
and makes what additional recommen- creased consumption of fruits, vegetables, and
dation? fiber. (A) promotes reduced fat consumption. Or-
A. ange slices provide more fiber than orange juice
Switch to skim milk. (B, C, and D) are not standard recommendations
B. for reducing cancer risk.
Switch to orange juice.
C.
Add a source of protein.
D.
Add herbal tea.
8. A nurse is assisting an 82-year-old B.
client with ambulation and is con- Upper torso
cerned that the client may fall. Which
