ADULT HEALTH NURSING HESI ELABORATED QUESTIONS AND ANSWERS

ADULT HEALTH NURSING HESI ELABORATED QUESTIONS AND ANSWERS A central venous catheter has been inserted via a jugular vein, and a radiograph has confirmed placement of the catheter. A prescription has been received for a medication STAT, but IV fluids have not yet been started. Which action should the nurse take prior to administering the prescribed medication? A. Assess for signs of jugular venous distention. B. Obtain the needed intravenous solution. C. Flush the line with heparinized solution. D. Flush the line with normal saline. - CORRECT ANSWER -Answer, D Rationale- Medication can be administered via a central line without additional IV fluids. The line should first be flushed with a normal saline solution to ensure patency. Insufficient evidence exists on the effectiveness of flushing catheters with heparin. Option A will not affect the decision to administer the medication and is not a priority. Administration of the medication STAT is of greater priority than option B. A client is ready for discharge following the creation of an ileostomy. Which instruction should the nurse include in discharge teaching? A. Replace the stoma appliance every day. B. Use warm tap water to irrigate the ileostomy. C. Change the bag when the seal is broken. D. Measure and record the ileostomy output. - CORRECT ANSWER -Answer- C Rationale- A seal must be maintained to prevent leakage of irritating liquid stool onto the skin. Option A is excessive and can cause skin irritation and breakdown. Ileostomies produce liquid fecal drainage, so option B is not necessary. Option D is not needed. An older male client comes to the outpatient clinic complaining of pain in his left calf. The nurse notices a reddened area on the calf of his right leg that is warm to the touch, and the nurse suspects that the client may have thrombophlebitis. Which additional assessment is most important for the nurse to perform? A. Measure the client's calf circumference. B. Auscultate the client's breath sounds.