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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 1 / 4

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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