HESI MED SURG Nursing Test Banks( 45 Answered Questions)

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1. A patient with gastrointestinal bleeding is awake, alert, and oriented and has vital sign measurements of: blood pressure 130/90 mm Hg, pulse 118 beats/minute, respirations 18/minute, and temperatu... re 98.6°F (37°C). Which finding should the nurse consider as a possible sign of early shock? a. Respirations 18/min b. Heart rate 118 beats/min c. Temperature 98.6°F (37°C) d. Blood pressure 130/90 mm Hg 2. A patient with gastrointestinal bleeding has hemoglobin of 8.5 g/dL. While receiving care the patient be- comes anxious and irritable and bright red drainage appears through the nasogastric tube. The patient’s vital sign measurements are pulse 130 beats/minute, blood pressure 105/55 mm Hg, and respirations 28/minute. What should the nurse recognize as causing the changes in the patient’s vital signs? a. Patient anxiety b. Early Shock c. Progressive shock d. Parasympathetic response 3. A patient involved in a motor vehicle accident has pale mucous membranes, diaphoresis, confusion, blood pressure 88/48 mm Hg, irregular heart rhythm, and metabolic acidosis. Which finding should the nurse recognize as the likely cause of acidosis? a. Hyperventilation b. Aerobic metabolism c. Inadequate ventilation d. Anaerobic metabolism 4. A patient with progressive shock is diaphoretic and confused. The most recent blood pressure measure- ment was 82/40 mm Hg and a urinary catheter output was 10 mL for 1 hour. Intravenous (IV) fluids are infusing at 150 mL/hr. Which action should the nurse take related to the urine output? [Show More]

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