Hesi Adult Care| Questions and Answers with Rationales| Latest 2022/2023

Hesi Adult Care| Questions and Answers with Rationales| Latest 2022/2023 1. The nurse is preparing to instill medication into a client's nasogastric tube. Which actions should the nurse take before instilling the medication? Select all that apply. 1. Check the residual volume. 2. Aspirate the stomach contents. 3. Turn off the suction to the nasogastric tube. 4. Remove the tube and place it in the other nostril. 5. Check the stomach contents for a pH of less than 3.5. ~ Answer: 1. Check the residual volume. ~ 2. Aspirate the stomach contents. ~ 3. Turn off the suction to the nasogastric tube. ~ Check the stomach contents for a pH of less than 3.5.  Rationale: By aspirating stomach contents the residual volume can be determined and the pH checked. A pH less than 3.5 verifies gastric placement. The suction should be turned off before the tubing is disconnected to check for residual volume; in addition, suction should remain off for 30 to 60 minutes following medication administration to allow for medication absorption. There is no need to remove the tube and place it in the other nostril in order to administer a feeding; in fact, this is an invasive procedure and is unnecessary. 2. The nurse is preparing to administer medication through a nasogastric tube that is connected to suction. To administer the medication, the nurse should take which action? a) Position the client supine to assist in medication absorption. b) Aspirate the nasogastric tube after medication administration to maintain patency. c) Clamp the nasogastric tube for 30 to 60 minutes following administration of the medication. d) Change the suction setting to low intermittent suction for 30 minutes after medication administration. ~ Answer: c) Clamp the nasogastric tube for 30 to 60 minutes following administration of the medication.  Rationale: If a client has a nasogastric tube connected to suction, the nurse should wait 30 to 60 minutes before reconnecting the tube to the suction apparatus to allow adequate time for medication absorption. The client should not be placed in the supine position because of the risk for aspiration. Aspirating the nasogastric tube will remove the medication just administered. Low intermittent suction also will remove the medication just administered. 3. The nurse is assessing for correct placement of a nasogastric tube. The nurse aspirates the stomach contents and checks the gastric pH. The nurse verifies correct tube placement if which pH value is noted? a) 3.5 b) 7.0 c) 7.35 d) 7.5 ~ Answer: a) 3.5 4. The registered nurse is preparing to insert a nasogastric tube in an adult client. To determine the accurate measurement of the length of the tube to be inserted, the nurse should take which action? a) Mark the tube at 10 inches. b) Mark the tube at 32 inches. c) Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process. d) Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the top of the sternum. ~ Answer: c) Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process.  Rationale: Measuring the length of a nasogastric tube needed is done by placing the tube at the tip of the client's nose and extending the tube to the earlobe and then down to the xiphoid process. The average length for an adult is about 22 to 26 inches. The remaining options identify incorrect procedures for measuring the length of the tube. 5. The nurse checks for residual before administering a bolus tube feeding to a client with a nasogastric tube and obtains a residual amount of 150 mL. What is the most appropriate action for the nurse to take? a) Hold the feeding. b) Reinstill the amount and continue with administering the feeding. c) Elevate the client's head at least 45 degrees and administer the feeding. d) Discard the residual amount and proceed with administering the feeding ~ Answer: a) Hold the feeding.  Rationale: Unless specifically indicated, residual amounts more than 100 mL require holding the feeding. In addition, the feeding is not discarded unless its contents are abnormal in color or characteristics. 6. The nurse is inserting a nasogastric tube in an adult client. During the procedure, the client begins to cough and has difficulty breathing. What is the most appropriate nursing action? a) Quickly insert the tube. b) Notify the health care provider immediately. c) Remove the tube and reinsert when the respiratory distress subsides. d) Pull back on the tube and wait until the respiratory distress subsides. ~ Answer: d) Pull back on the tube and wait until the respiratory distress subsides.  Rationale: During the insertion of a nasogastric tube, if the client experiences difficulty breathing or any respiratory distress, withdraw the tube slightly, stop the tube advancement, and wait until the distress subsides. It is not necessary to notify the health care provider immediately or remove the tube completely. Quickly inserting the tube is not an appropriate action because, in this situation, it may be likely that the tube has entered the bronchus. 7. The nurse is providing an educational session to new employees, and the topic is abuse of the older client. The nurse helps the employees identify which client as most typically a victim of abuse? a) A 75-year-old man who has moderate hypertension b) A 68-year-old man who has newly diagnosed cataracts c) A 90-year-old woman who has advanced Parkinson's disease d) A 70-year-old woman who has early diagnosed Lyme disease ~ Answer: c) A 90-year-old woman who has advanced Parkinson's disease  Rationale: Elder abuse includes physical, sexual, or psychological abuse, misuse of property, and violation of rights. The typical abuse victim is a woman of advanced age with few social contacts and at least one physical or mental impairment that limits her ability to perform activities of daily living. In addition, the client usually lives alone or with the abuser and depends on the abuser for care. 8. The home health nurse is visiting a client for the first time. While assessing the client's medication history, it is noted that there are 19 prescriptions and several over-the-counter medications that the client has been taking. Which intervention should the nurse take first? a) Check for medication interactions. b) Determine whether there are medication duplications. c) Call the prescribing health care provider (HCP) and report polypharmacy. d) Determine whether a family member supervises medication administration. ~ Answer: b) Determine whether there are medication duplications.  Rationale: Polypharmacy is a concern in the older client. Duplication of medications needs to be identified before medication interactions can be determined because the nurse needs to know what the client is taking. Asking about medication administration supervision may be part of the assessment but is not a first action. The phone call to the HCP is the intervention after all other information has been collected. 9. The nurse is providing medication instructions to a parent. Which statement by the parent indicates a need for further instruction? a) "I should cuddle my child after giving the medication." b) "I can give my child a frozen juice bar after he swallows the medication." c) "I should mix the medication in the baby food and give it when I feed my child." d) "If my child does not like the taste of the medicine, I should encourage him to pinch his nose and drink the medication through a straw." ~ Answer: c) "I should mix the medication in the baby food and give it when I feed my child."  Rationale: The nurse would teach the parent to avoid putting medications in foods because it may give an unpleasant taste to the food, and the child may refuse to accept the same food in the future. In addition, the child may not consume the entire serving and would not receive the required medication dosage. The mother should provide comfort measures immediately after medication administration, such as touching, holding, cuddling, and providing a favorite toy. The mother should offer juice, a soft drink, or a frozen juice bar to the child after the child swallows the medication. If the taste of the medication is unpleasant, the child should pinch the nose and drink the medication through a straw.