MED SURG HESI 4 VERSIONS 200 PLUS
QUESTIONS AND CORRECT DETAILED ANSWERS
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MED SURG) UPDATE
Terms in this set (201)
1. A nurse is reviewing the B. has fewer red blood cells than normal.The Hct is the
hematologic test results for measure of the volume of red blood cells in whole
a patient in whom the blood expressed as a percentage. This test is useful in
hematocrit (Hct) is reported the diagnosis of anemia, polycythemia, and abnormal
at a reading of 30%. Based hydration states. Patients who are susceptible to
on this result, the nurse bleeding disorders likely will have a low platelet count.
should interpret that the The inflammatory response may best be evaluated by
patient examination of results that include the white blood cell
A. is susceptible to count with differential analysis. Acute hemolytic crisis
bleeding disorders. develops in patients receiving blood components in
B. has fewer red blood cells which incompatibility occurs or in patients with bleeding
than normal. C. is disorders or conditions that promote cellular damage,
experiencing an such as damage associated with shock.
inflammatory response.
D. is experiencing an acute
hemolytic crisis.
,1. The arterial blood gas D. 50 mm Hg and bicarbonate level of 30 mEq/L. If
(ABG) readings that indicate compensation is present, carbon dioxide and
compensated respiratory bicarbonate are abnormal (or nearly so) in opposite
acidosis are a PaCO2 of directions (e.g., one is acidotic and the other alkalotic).
A. 30 mm Hg and
bicarbonate level of 24
mEq/L.
B. 30 mm Hg and
bicarbonate level of 30
mEq/L.
C. 50 mm Hg and
bicarbonate level of 20
mEq/L.
D. 50 mm Hg and
bicarbonate level of 30
mEq/L.
1. When assessing a patient's A. Inspect the skin for petechiae. Any changes in the
nutritional-metabolic skin's texture or color should be explored when
pattern related to assessing the patient's nutritional-metabolic pattern
hematologic health, the related to hematologic health. The presences of
nurse would: petechiae or ecchymotic areas could be indicative of
A. Inspect the skin for hematologic deficiencies related to poor nutritional
petechiae. intake or related causes.
B. Ask the patient about
joint pain.
C. Assess for vitamin C
deficiency.
D. Determine if the patient
can perform ADLs.
,2. A patient admitted to the B. severe hypotension. Mediastinal shift may cause
emergency department compression of the lung in the direction of the shift and
with tension pneumothorax compression, traction, torsion, or kinking of the great
and mediastinal shift vessels. Blood return to the heart is dangerously
following an automobile impaired and causes a subsequent decrease in cardiac
crash is most likely to output and blood pressure. Tachycardia is a clinical
exhibit A. bradycardia. manifestation of tension pneumothorax. An uncovered
B. severe hypotension. opened pneumothorax is associated with a sucking
C. mediastinal flutter. chest wound and mediastinal flutter.
D. a sucking chest wound.
2. The nurse is caring for a B. 5 minutes Following obtaining an arterial blood gas,
patient with COPD and the nurse should hold pressure on the puncture site for 5
pneumonia who has an minutes by the clock to be sure that bleeding has
order for arterial blood stopped. An artery is an elastic vessel under higher
gases to be drawn. Which pressure than veins, and significant blood loss or
of the following is the hematoma formation could occur if the time is
minimum length of time the insufficient.
nurse should plan to hold
pressure on the puncture
site?
A. 2 minutes
B. 5 minutes
C. 10 minutes
D. 15 minutes
, 2. When assessing lab D. Increased bands in the WBC differential (shift to the
values on a patient left) When infections are severe, such as in septicemia,
admitted with septicemia, more granulocytes are released from the bone marrow
the nurse would expect to as a compensatory mechanism. To meet the increased
find: demand, many young, immature polymorphonuclear
A. Increased platelets neutrophils (bands) are released into circulation. WBCs
B. Decreased red blood are usually reported in order of maturity, with the less
cells mature forms on the left side of a written report. Hence,
C. Decreased erythrocyte the term "shift to the left" is used to denote an increase
sedimentation rate (ESR) in the number of bands.
D. Increased bands in the
WBC differential (shift to
the left)
2. Which of the following is B. Large hemorrhoids Gastrointestinal (GI) tract bleeding
a factor significant in the is a common etiologic factor in men and may result from
development of anemia in peptic ulcers, hiatal hernia, gastritis, cancer,
men? hemorrhoids, diverticula, ulcerative colitis, or salicylate
A. Condom use poisoning.
B. Large hemorrhoids
C. A diet high in cholesterol
D. Smoking one pack of
cigarettes daily
3. Following a patient's A. Application of firm pressure to the site After a bone
bone marrow aspiration, marrow aspiration procedure, a nurse should apply
which of the following pressure to the aspiration site until bleeding stops.
nursing interventions should Application of a warm, moist compress will not alter the
a nurse anticipate? potential for bleeding. Positioning the patient to assume
A. Application of firm a supine or prone position also will not address the need
pressure to the site B. to control bleeding from the aspiration site.
Positioning the patient in a
prone position
C. Positioning the patient in
a supine position
D. Application of a warm,
moist compress to the site
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