HESI ADULT HEALTH 2
Low GFR and low cardiac output = - ANSWER Elevated BUN
COPD intervention - ANSWER Chantix
Severe hearing deficit and anxious = - ANSWER provide sensory stimulation
Macular degeneration patho and tx - ANSWER loss of central vision in retina
OT
Normal suction level for adult - ANSWER -20cm
RA intervention - ANSWER OT
intermittent claudication tx - ANSWER sit with legs dependent
duodenal ulcer - ANSWER pain 2-3 hrs after eating and night, better with food
right sided
melena
Low or high fiber for UC? - ANSWER low
The 28-year-old client diagnosed with testicular cancer is scheduled for a unilateral
orchiectomy. Which
intervention should have priority in the client's plan of care?
1. Encourage the client to bank his sperm.
2. Discuss completing an advance directive.
3. Explain follow-up chemotherapy and radiation.
4. Allow the client to express his feelings regarding having cancer. - ANSWER 1
With a remaining testicle, the client will be able to maintain sexual potency, but radiation
and chemotherapy may cause the client to become sterile. Therefore, banking his
sperm will allow him to father a child later in life.
The client in the long-term care facility has severe osteoarthritis. Which nursing task
should the nurse delegate to the unlicensed assistive personnel (UAP)?
1. Feed the client the breakfast meal.
2. Give the client Maalox, an antacid.
3. Monitor the client's INR results.
4. Assist the client to the shower room. - ANSWER 4
The nurse should encourage the client to
maintain independent functioning, and delegating
, the UAP to feed the client would be
encouraging dependence.
2. Although this is an over-the-counter medication,
a UAP cannot administer any medication
to a client.
3. The UAP cannot assess or evaluate any of
the client's diagnostic information.
4. The UAP could assist the client to
ambulate to the shower room and
assist with morning care.
The primary nurse is applying antiembolism hose to the client who had a total hip
replacement. Which situation warrants immediate intervention by the charge nurse?
1. Two fingers can be placed under the top of the band.
2. The peripheral capillary refill time is 3 seconds.
3. There are wrinkles in the hose behind the knees.
4. The nurse does not place a hose on the foot with a venous ulcer. - ANSWER 3
3. There should be no wrinkles in the
hose after application. Wrinkles could
cause constriction in the area, resulting
in clot formation or skin breakdown;
therefore, this would warrant immediate
intervention by the charge nurse.
4. Antiembolism hose should not be put over
a wound; they would restrict the circulation
to the wound and cause a decrease in
wound healing.
The nurse identifies the problem "high risk for complications" for the client with a
right total hip replacement who is being discharged from the hospital. Which
problem would have the highest priority?
1. Self-care deficit.
2. Impaired skin integrity.
3. Abnormal bleeding.
4. Prosthetic infection. - ANSWER 4
The nurse is planning the care for the client with multiple stage IV pressure ulcers.
Which complication results from these pressure ulcers?
1. Wasting syndrome.
2. Osteomyelitis.
3. Renal calculi.
4. Cellulitis. - ANSWER 2
The client with a closed head injury is admitted to the neurointensive care unit
following a motor-vehicle accident. Which goal is an appropriate short-term goal
Low GFR and low cardiac output = - ANSWER Elevated BUN
COPD intervention - ANSWER Chantix
Severe hearing deficit and anxious = - ANSWER provide sensory stimulation
Macular degeneration patho and tx - ANSWER loss of central vision in retina
OT
Normal suction level for adult - ANSWER -20cm
RA intervention - ANSWER OT
intermittent claudication tx - ANSWER sit with legs dependent
duodenal ulcer - ANSWER pain 2-3 hrs after eating and night, better with food
right sided
melena
Low or high fiber for UC? - ANSWER low
The 28-year-old client diagnosed with testicular cancer is scheduled for a unilateral
orchiectomy. Which
intervention should have priority in the client's plan of care?
1. Encourage the client to bank his sperm.
2. Discuss completing an advance directive.
3. Explain follow-up chemotherapy and radiation.
4. Allow the client to express his feelings regarding having cancer. - ANSWER 1
With a remaining testicle, the client will be able to maintain sexual potency, but radiation
and chemotherapy may cause the client to become sterile. Therefore, banking his
sperm will allow him to father a child later in life.
The client in the long-term care facility has severe osteoarthritis. Which nursing task
should the nurse delegate to the unlicensed assistive personnel (UAP)?
1. Feed the client the breakfast meal.
2. Give the client Maalox, an antacid.
3. Monitor the client's INR results.
4. Assist the client to the shower room. - ANSWER 4
The nurse should encourage the client to
maintain independent functioning, and delegating
, the UAP to feed the client would be
encouraging dependence.
2. Although this is an over-the-counter medication,
a UAP cannot administer any medication
to a client.
3. The UAP cannot assess or evaluate any of
the client's diagnostic information.
4. The UAP could assist the client to
ambulate to the shower room and
assist with morning care.
The primary nurse is applying antiembolism hose to the client who had a total hip
replacement. Which situation warrants immediate intervention by the charge nurse?
1. Two fingers can be placed under the top of the band.
2. The peripheral capillary refill time is 3 seconds.
3. There are wrinkles in the hose behind the knees.
4. The nurse does not place a hose on the foot with a venous ulcer. - ANSWER 3
3. There should be no wrinkles in the
hose after application. Wrinkles could
cause constriction in the area, resulting
in clot formation or skin breakdown;
therefore, this would warrant immediate
intervention by the charge nurse.
4. Antiembolism hose should not be put over
a wound; they would restrict the circulation
to the wound and cause a decrease in
wound healing.
The nurse identifies the problem "high risk for complications" for the client with a
right total hip replacement who is being discharged from the hospital. Which
problem would have the highest priority?
1. Self-care deficit.
2. Impaired skin integrity.
3. Abnormal bleeding.
4. Prosthetic infection. - ANSWER 4
The nurse is planning the care for the client with multiple stage IV pressure ulcers.
Which complication results from these pressure ulcers?
1. Wasting syndrome.
2. Osteomyelitis.
3. Renal calculi.
4. Cellulitis. - ANSWER 2
The client with a closed head injury is admitted to the neurointensive care unit
following a motor-vehicle accident. Which goal is an appropriate short-term goal
