HESI Med Surg III Final Exam
(5 Sets of Final Exam’s)
HESI Med Surg III Final Exam Set 1
- The nurse is providing care to an older adult patient who is
experiencing bradycardia. When educating the patient about this disorder,
which age-re- lated cardiovascular change should the nurse include✔✔
Reduced number of pacemaker cells in the SA node
Rationale: A reduced number of pacemaker cells in the SA node
causes the maximum heart rate to decrease with age, leading to
bradycardia. - The nurse is providing care to an older adult patient who is diagnosed
with congestive heart failure (CHF). When educating the patient about this
disor- der, which age-related cardiovascular change should the nurse
include✔✔ In- creased size of the left atrium
Rationale: Left atrial enlargement causes a fourth heart sound to be
auscultated and is also responsible for an increased risk for
hypertension and congestive heart failure (CHF).
- The nurse is providing care to an older adult patient who is diagnosed
with atrial fibrillation. When educating the patient about this disorder,
which age-related cardiovascular change should the nurse include✔✔
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Decreased cardiac responsiveness to beta-adrenergic stimuli
Rationale: Decreased cardiac responsiveness to beta-adrenergic
stimuli increases the risk for arrhythmias, atrial fibrillation, and
reduced heart rate control when exposed to stressors.
- Which electrolyte imbalance should the nurse monitor an older adult
patient for due to impaired renal diluting capacity and concentrating
abili- ty✔✔ Hyponatremia
Rationale: Sodium imbalances occur due to impaired renal diluting
capacity and concentrating ability. - Which clinical manifestation does the nurse anticipate when providing
care to an older adult patient diagnosed with failure to thrive (FTT)✔✔
Skin that loses elasticity with poor turgor
Rationale: Dehydration, manifested with decreased elasticity and
turgor of the skin, supports the diagnosis of FTT. - The nurse is providing care to a patient who is diagnosed with acute
respiratory distress syndrome (ARDS). Which clinical manifestation does
the
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nurse anticipate for this patient who is experiencing hypoxia as a result
of the ARDS diagnosis✔✔ Dyspnea
Rationale: Dyspnea is a clinical manifestation that patients
experiencing hypoxia secondary to ARDS.
- The nurse is providing care to a patient with an infected leg wound. The
patient is exhibiting symptoms of a systemic infection and is receiving
intravenous antibiotics. The patient states to the nurse, “I am having
trouble breathing.” Based on this data, which does the nurse suspect the
patient is experiencing✔✔ Acute respiratory distress syndrome
Rationale: Sepsis is the most common cause of acute respiratory
distress syn- drome (ARDS). The patient has a systemic infection,
which is sepsis, and is complaining that it is getting hard to breathe.
The nurse should suspect the patient is developing acute respiratory - A patient with a respiratory rate of eight breaths per minute has an
oxygen saturation of 82%. Which nursing diagnosis is a priority for this
patient✔✔ Im- paired Spontaneous Ventilation
Rationale: A priority nursing diagnosis for a patient with a respiratory
rate of eight breaths per minutes and an oxygen saturation of 82% is
Impaired Spontaneous Ventilation. If the current pattern continues
without intervention, the patient could experience respiratory arrest. - A patient with acute respiratory distress syndrome (ARDS) is being
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