Evolve HESI Medical Surgical Practice Exam Quizlet

Question 1 of 5

When monitoring a client who is receiving tissue plasminogen activator (t-PA), the nurse should have resuscitation equipment available because reperfusion of the cardiac tissue can result in which of the following?

A. Cardiac arrhythmias. B. Hypertension. C. Seizures. D. Hypothermia.

Correct Answer: A

Rationale: The correct answer is A: Cardiac arrhythmias. Reperfusion of cardiac tissue following t-PA administration can lead to cardiac arrhythmias, necessitating resuscitation equipment. Hypertension (choice
B) is a common side effect of t-PA but is not directly related to reperfusion. Seizures (choice
C) and hypothermia (choice
D) are not typically associated with reperfusion from t-PA administration.

Question 2 of 5

The client is scheduled to begin continuous ambulatory peritoneal dialysis (CAPD). Which of the following statements by the client indicates that more teaching is required?

A. I will need to limit my intake of protein. B. I can skip a dialysis session if I feel tired. C. I should increase my intake of potassium-rich foods. D. I can eat whatever I want, as long as I take my medications.

Correct Answer: B

Rationale: The correct answer is B. Skipping a dialysis session can lead to serious complications as it disrupts the treatment schedule and can result in the accumulation of waste products and fluid in the body. The client must understand the importance of adhering to the prescribed dialysis regimen to maintain optimal health.

Choices A, C, and D are incorrect because limiting protein intake, increasing potassium-rich foods, and taking medications do not pose the same risk as skipping dialysis sessions. These aspects are important in the management of peritoneal dialysis but do not outweigh the critical need for regular dialysis sessions to prevent complications.

Question 3 of 5

For a client with peripheral vascular disease (PVD) of the lower extremities who is trying to manage their condition well, which routine should the nurse evaluate as appropriate?

A. Resting with the legs elevated above the level of the heart. B. Walking slowly but steadily for 30 minutes twice a day. C. Minimizing activity. D. Wearing antiembolism stockings at all times when out of bed.

Correct Answer: B

Rationale: The correct answer is B. Walking slowly but steadily for 30 minutes twice a day is appropriate for clients with PVD as it helps stimulate collateral circulation and improve blood flow.
Choice A is incorrect because while elevating the legs can help with symptoms temporarily, it is not as effective as walking for improving circulation.
Choice C, minimizing activity, is not recommended as it can lead to further deconditioning and worsen symptoms.
Choice D, wearing antiembolism stockings, is not specifically indicated for PVD and may not address the underlying circulation issues.

Question 4 of 5

A young adult is burned when wearing a shirt that was splashed with lighter fluid and caught on fire while attempting to light a charcoal grill. The client ripped off the shirt immediately, without unbuttoning the sleeves, which caused circumferential burns to both wrists. When the client is admitted, which intervention should the nurse implement first?

A. Monitor pulse intensity. B. Evaluate extremity sensation. C. Assess range of motion. D. Place sterile bandage on both wrists.

Correct Answer: A

Rationale: Monitoring pulse intensity is the priority to ensure circulation is not compromised due to circumferential burns.

Question 5 of 5

A client diagnosed with a history of asthma and bronchitis arrives at the clinic with shortness of breath, productive cough with thickened, tenacious mucus, and the inability to walk up a flight of stairs without experiencing breathlessness. Which action is most important for the nurses to instruct the client about self-care?

A. Call the clinic if undesirable side effects of medications occur B. Avoid crowded enclosed areas to reduce pathogen exposure C. Increase the daily intake of oral fluids to liquefy secretions D. Teach anxiety reduction methods for feelings of suffocation

Correct Answer: C

Rationale: Increasing the daily intake of oral fluids is crucial for clients with asthma and bronchitis as it helps to liquefy thickened mucus, making it easier to clear the airways and manage symptoms. This self-care measure can improve the client's ability to breathe more effectively.
Choice A is not the most immediate concern when addressing thickened mucus and breathing difficulties. While avoiding crowded areas is beneficial to prevent respiratory infections, it is not directly related to managing thickened secretions. Teaching anxiety reduction methods is important for overall well-being, but it does not directly address the physiological issue of thickened mucus in the airways.

Nurselytic

HESI RN

HESI RN