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2020 HESI MEDICAL-SURGICAL RN NURSING V2
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  • NRSE 3230 Medical Surgical Nursing
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  • Ohio University Chillicothe

2020 HESI MEDICAL-SURGICAL RN NURSING V2 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 Rationa...

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  • February 24, 2022
  • 31
  • 2021/2022
  • Exam (elaborations)
  • Questions & answers

Subjects

  • nrse 3230 medical surgical nursing
  • 2020 hesi medical surgical rn nursing v2
  • hesi medical surgical rn nursing v2
  • hesi medical surgical rn nursing v2 a grade

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  • Ohio University Chillicothe
  • NRSE 3230 Medical Surgical Nursing
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2020 HESI MEDICAL-SURGICAL RN NURSING V2
Question 1 Rationale 4: The manifestations reported are not
indicative of cardiac failure in this patient.
When caring for an elderly patient who is
intermittently confused, what is the nurse‘s primary
concern regarding fluid and electrolytes?
Question 3
1. Risk of dehydration
A pregnant patient is admitted with excessive thirst,
2. Risk of kidney damage increased urination, and a medical diagnosis of
diabetes insipidus. The nurse chooses which
3. Risk of stroke nursing diagnosis as most appropriate?
4. Risk of bleeding 1. Risk for Imbalanced Fluid Volume
Correct Answer: 1 2. Excess Fluid Volume
Rationale 1: As an adult ages, the perception of 3. Imbalanced Nutrition
thirst declines. In an older patient with an altered
level of consciousness, there is an increased risk of 4. Ineffective Tissue Perfusion
dehydration and high serum osmolality.
Correct Answer: 1
Rationale 2: The risk of kidney damage is not
specifically related to aging or fluid and electrolyte Rationale 1: The patient with excessive thirst,
issues. increased urination, and a medical diagnosis of
diabetes insipidus is at risk for Imbalanced Fluid
Rationale 3: The risk of stroke is not specifically Volume due to excess volume loss that can
related to aging or fluid and electrolyte issues. increase the serum levels of sodium.

Rationale 4: The risk of bleeding is not specifically Rationale 2: Excess Fluid Volume is not an issue for
related to aging or fluid and electrolyte issues. patients with diabetes insipidus, especially during
the early stages of treatment.

Rationale 3: Imbalanced Nutrition is not supported
Question 2 by the assessment data provided.
A patient experiencing multisystem fluid volume Rationale 4: Ineffective Tissue Perfusion is not
deficit has tachycardia and decreased urine output. supported by the assessment data provided.
The nurse realizes these findings are most likely a
direct result of which factor?

1. The body‘s natural compensatory mechanisms Question 4

2. Pharmacologic effects of a diuretic An adult patient recovering from surgery has an
indwelling urinary catheter. The nurse would
3. Effects of rapidly infused intravenous fluids contact the patient‘s primary health care provider
4. Cardiac failure with which 24-hour urine output volume?

Correct Answer: 1 1. 600 milliliters

Rationale 1: The body‘s vasoconstrictive 2. 750 milliliters
compensatory reactions are responsible for the 3. 1,000 milliliters
symptoms. The body naturally attempts to conserve
fluid internally specifically for the brain and heart. 4. 1,200 milliliters

Rationale 2: A diuretic would cause further fluid Correct Answer: 1
loss and is contraindicated.
Rationale 1: A urine output of less than 30 milliliters
Rationale 3: Rapidly infused intravenous fluids per hour must be reported to the primary health
would not cause a decrease in urine output. care provider. This indicates inadequate renal

,perfusion, which places the patient at increased 4. Hypocalcemia
risk for acute renal failure and inadequate tissue
perfusion. A minimum of 720 milliliters over a 24- Correct Answer: 1
hour period is desired (30 milliliters multiplied by 24 Rationale 1: Hyperkalemia is defined as serum
hours equals 720 milliliters per 24 hours). potassium level greater than 5.0 mEq/L. Decreased
Rationale 2: 750 mL is above the minimum desired potassium excretion is seen with potassium-sparing
level of 30 mL per hour. diuretics such as spironolactone. Common
manifestations of hyperkalemia are muscle
Rationale 3: 1,000 mL is above the minimum desired weakness and ECG changes.
level of 30 mL per hour.
Rationale 2: Hypokalemia is seen in nonpotassium
Rationale 4: 1,200 mL is above the minimum desired sparing diuretics such as furosemide.
level of 30 mL per hour.
Rationale 3: Hypercalcemia has been associated
with thiazide diuretics.

Question 5 Rationale 4: Hypocalcemia is seen in patients who
have received many units of citrated blood and is
A patient is diagnosed with severe hyponatremia. not associated with diuretic use.
The nurse realizes this patient will mostly likely
need which precautions implemented?

1. Seizure precautions Question 7

2. Infection precautions The nurse is planning care for a patient with fluid
volume overload and hyponatremia. Which
3. Neutropenic precautions intervention should be included in this patient‘s
4. High-risk fall precautions plan of care?

Correct Answer: 1 1. Restrict fluids.

Rationale 1: Severe hyponatremia can lead to 2. Administer intravenous fluids.
seizures. Seizure precautions would include a quiet 3. Provide Kayexalate.
environment, raised side rails, and having an oral
airway at the bedside. 4. Administer intravenous normal saline with
furosemide.
Rationale 2: Infection precautions are not
specifically indicated for a patient with Correct Answer: 1
hyponatremia.
Rationale 1: The nursing care for a patient with
Rationale 3: Neutropenic precautions are not hyponatremia depends on the cause. Restriction of
specifically indicated for a patient with fluids to 1,000 mL/day is usually implemented to
hyponatremia. assist sodium increase and to prevent the sodium
level from dropping further due to dilution.
Rationale 4: High-risk fall precautions are not
specifically indicated for a patient with Rationale 2: The administration of intravenous fluids
hyponatremia. would be indicated in fluid volume deficit and
hypernatremia.

Rationale 3: Kayexalate is used in patients with
Question 6 hyperkalemia.
A patient prescribed spironolactone is Rationale 4: Normal saline with furosemide is
demonstrating ECG changes and complaining of administered to increase calcium secretion.
muscle weakness. The nurse realizes this patient is
exhibiting signs of which imbalance?

1. Hyperkalemia Question 8

2. Hypokalemia When caring for a patient diagnosed with
hypocalcemia, the nurse would also assess for
3. Hypercalcemia which other finding?

,1. Other electrolyte disturbances Question 10

2. Hypertension When analyzing an arterial blood gas report of a
patient with COPD and respiratory acidosis, the
3. Visual disturbances nurse anticipates that compensation will develop
4. Drug toxicity through which mechanism?

Correct Answer: 1 1. The kidneys retain bicarbonate.

Rationale 1: The patient diagnosed with 2. The kidneys excrete bicarbonate.
hypocalcemia may also have high phosphorus or 3. The lungs will retain carbon dioxide.
decreased magnesium levels.
4. The lungs will excrete carbon dioxide.
Rationale 2: The patient with hypocalcemia may
exhibit hypotension, not hypertension. Correct Answer: 1

Rationale 3: Visual disturbances do not occur with Rationale 1: The kidneys will compensate for a
hypocalcemia. respiratory disorder by retaining bicarbonate.

Rationale 4: Hypercalcemia is more commonly Rationale 2: Excreting bicarbonate causes acidosis
caused by drug toxicities. to develop.

Rationale 3: Retaining carbon dioxide causes
respiratory acidosis.
Question 9
Rationale 4: Excreting carbon dioxide causes
A patient with a history of stomach ulcers is respiratory alkalosis.
diagnosed with hypophosphatemia. Which
intervention should the nurse include in this
patient‘s plan of care?
Question 11
1. Request a dietitian consult to select foods high in
phosphorous. The nurse is caring for a patient diagnosed with
renal failure. Which compensation does the nurse
2. Provide aluminum hydroxide antacids as expect for the acid-base disturbance found in
prescribed. patients with renal failure?

3. Instruct the patient to avoid poultry, peanuts, and 1. The patient breathes rapidly to eliminate carbon
seeds. dioxide.

4. Instruct the patient to avoid the intake of sodium 2. The patient will retain bicarbonate in excess of
phosphate. normal.

Correct Answer: 1 3. The pH will decrease from the present value.

Rationale 1: Treatment of hypophosphatemia 4. The patient‘s oxygen saturation level will
includes treating the underlying cause and improve.
promoting a high-phosphate diet, especially milk if
it is tolerated. Other foods high in phosphate are Correct Answer: 1
dried beans and peas, eggs, fish, organ meats, Rationale 1: In metabolic acidosis, compensation is
Brazil nuts and peanuts, poultry, seeds, and whole accomplished through increased ventilation or
grains. ―blowing off‖ CO2. This raises the pH by eliminating
Rationale 2: Phosphate-binding antacids, such as the volatile respiratory acid and compensates for
aluminum hydroxide, should be avoided. the acidosis.

Rationale 3: Poultry, peanuts, and seeds are part of Rationale 2: Because compensation must be
a high-phosphate diet. performed by the system other than the affected
system, the patient cannot retain bicarbonate; the
Rationale 4: Mild hypophosphatemia may be manifestation of metabolic acidosis of renal failure
corrected with oral supplements, such as sodium is a lower than normal bicarbonate value.
phosphate.

, Rationale 3: Metabolic acidosis of renal failure paper bag will help the patient retain carbon
causes a low pH; this is the manifestation of the dioxide and lower oxygen levels to normal,
disease process, not the compensation. correcting the cause of the problem.

Rationale 4: Oxygenation disturbance is not part of Rationale 2: The oxygen levels are high, so oxygen
the acid-base status of the patient with renal failure. is not indicated and would exacerbate the problem
if given.

Rationale 3: Not enough information is given to
Question 12 determine the need for intravenous fluids.
The nurse would assess specifically for metabolic
alkalosis in which patient?
Question 14
1. A patient admitted for treatment of bulimia
An elderly patient does not complain of thirst.
2. A patient who has been on dialysis for 2 months Which information would the nurse evaluate to
3. A patient with a nonhealing venous stasis ulcer determine if the patient is dehydrated?

4. A patient with newly diagnosed with COPD 1. Magnesium level

Correct Answer: 1 2. Chest X-ray

Rationale 1: Metabolic alkalosis is caused by 3. Urine osmolality
vomiting, diuretic therapy, or nasogastric suction, 4. Brain scan
among others. A patient with bulimia may engage in
vomiting or the indiscriminate use of diuretics. Correct Answer: 3

Rationale 2: A patient receiving dialysis has kidney Rationale 1: The magnesium level is not a sensitive
failure, which causes metabolic acidosis. indicator of fluid status.

Rationale 3: A venous stasis ulcer does not lead to Rationale 2: A chest X-ray would be more useful in
an acid-base disorder. discovering if the patient is overhydrated.

Rationale 4: The patient diagnosed with COPD Rationale 3: The thirst mechanism declines with
typically has hypercapnea and respiratory acidosis. aging, which makes older adults more vulnerable to
dehydration and hyperosmolality. Urine osmolality
would help to determine the need for more detailed
Question 13 or invasive testing.

The nurse is caring for a patient who is anxious and Rationale 4: There is no data to support the need for
dizzy following a traumatic experience. The arterial a brain scan.
blood gas findings include: pH 7.48, PaO2 110,
PaCO2 25, and HCO3 24. The nurse would
anticipate which initial intervention to correct this Question 15
problem?
A clinic patient is short of breath and has ankle
1. Encourage the patient to breathe in and out edema. Today‘s weight is 8 pounds heavier that last
slowly into a paper bag. week‘s weight. The nurse determines that the
patient could have retained pints of fluid.
2. Immediately administer oxygen via a mask and
monitor oxygen saturation. Correct Answer: 8

3. Start an intravenous fluid bolus using isotonic Rationale : Each pint of fluid weighs 1 pound.
fluids.

4. Administer intravenous sodium bicarbonate.
Question 16
Correct Answer: 1
A postoperative patient is diagnosed with fluid
Rationale 1: This patient is exhibiting signs of volume overload. Which assessment would the
hyperventilation, which is confirmed with the blood nurse attribute to this diagnosis?
gas results of respiratory alkalosis. Breathing into a

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