HESI - Medical Surgical Nursing Exam Latest Updated 2024 With Rationale

HESI - Medical Surgical Nursing Exam Latest Updated 2024 With Rationale


The nurse is working at a first aid booth for a spring training game on a hot day. A spectator comes in, reporting that he is not feeling well. Vital signs are temp 104.1 F, pulse 132 BPM, respirs 26 breaths/min, and blood pressure 106/66 mm Hg. He trips over his feet as the nurse leads him to a cot. What is the priory action of the nurse?

a. admin tylenol 650 mg orally
b. encourage rest, and reassess in 15 minutes
c. sponge the victim with cool water and remove his shirt
d. encourage drinking of cool water or sports drink - C

The spectator shows signs of heat stroke, which is a medical emergency. The spectator should be transported to the ED ASAP. The nurs should take actions to lower his body temp in teh meantime by removing his shirt and sponging his body with cool water. Lowering body temp by drinking cool fluids or taking acetaminophen is not as effective in an emergency situation. The client needs to be cooled quickly and is a priority for treatment

The client is receiving an IV of 60 mEq of potassium chloride ina 1000 mL solution of dextrose 5% in 0.45% saline. The client states that the area around the IV site burns. What intervention does the nurse perform first?

a. assess for a blood return
b. notify the physician
c. document the finding
d. stop the IV infusion - D

Potassium is a severe tissue irritant. The safest action is to discontinue the solution that contains the potassium and discontinue the IV altogether, in which case the client would need another site started. Assessing for a blood return may or may not be successful. The solution could be diluted (less potassium) and the rate could be slowed once it is determined that the needle is in the vein.

A nurse is caring for an older adult client who lives alone. Which economic situation presents the most serious problem for this client?

a. costs of creating a living will
b. stock market fluctuations
c. increased provider benefits
d. social security as the basis of income - D

Older adults on fixed incomes are unable to adjust their income to meet rising costs associated with meeting basic needs

When describing patient education approaches, the nurse educator would explain that informal teaching is an approach that

a. follows formalized plans
b. has standardized content
c. often occurs one-to-one
d. addresses group needs - C. Informal teaching is individualized one on one teaching which represents the majority of patient education done by nurses that occurs when an intervention is explained or a question is answered. Group needs are often the focus of formal patient education courses or classes. Informal teaching does not necessarily follow a specific formalized plan. It may be planned with specific content, but it is individualized responses to patient needs. Formal teaching involves the use of a curriculum/course plan with standardized content.

A patient expresses a strong interest in returning to their work, family, and hobbies after having a stroke. Which theory type would the nurse use to develop a plan of care for the best results of this patient's motivation style?

a. field
b. biological
c. cognitive
d. sociologic - C. Cognitive theorists believe that attention, relevance, confidence, and satisfaction (ARCS) are the conditions that, when integrated, motivate someone to learn. Field theorists place significance on how achievement, power, the need for affiliation, and avoidance motives influence individual behavior. Sociologic theories are not involved in motivation.