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HESI FOCUS ON ADULT HEALTH TEST BANK||
ACTUAL EXAM ALL QUESTIONS AND 100%
CORRECT ANSWERS WITH RATIONALES
ALREADY GRADED A+|| LATEST AND FULLY
COVERED UPDATE 2025 WITH VERIFIED
SOLUTIONS|| ASSURED PASS!!!
ID: 9477061444
. A nurse is monitoring a client who is taking spironolactone for the treatment
of hypertension. Which findings denote adverse effects of the medication? Select
all that apply.
A. Constipation
B. Tall T waves Correct
C. Hyporeflexia
D. Shallow respirations
E. Prolonged PR interval Correct
F. Hyperactive bowel sounds Correct
. Rationale: Spironolactone is a potassium-sparing diuretic. Potassium-sparing
diuretics can cause hyperkalemia. Cardiovascular manifestations of hyperkalemia
include tall T waves, widened QRS complexes, prolonged PR intervals, and flat P
waves. Other cardiovascular manifestations include an irregular heart rate,
decreased blood pressure, and ectopic heartbeats. Muscle twitches occur in
hyperkalemia. Hyperactive bowel sounds and diarrhea also occur in hyperkalemia.
Constipation, hyporeflexia, and shallow respirations are signs of hypokalemia.
. Test-Taking Strategy: The knowledge that spironolactone is a potassium-
sparing diuretic will assist you in determining that hyperkalemia is an adverse
effect of the medication. Recalling the manifestations of hyperkalemia will direct
you to the correct options. Also, note that the incorrect options are comparable or
alike in that they indicate a slowed body response or function. Review the adverse
effects of spironolactone and the manifestations of hyperkalemia if you had
difficulty with this question.
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. Level of Cognitive Ability: Analyzing
. Client Needs: Physiological Integrity
. Integrated Process: Nursing Process/Assessment
. Content Area: Adult Pharmacology
. Giddens Concepts: Clinical Judgment, Fluid and Electrolytes
. HESI Concepts: Clinical Decision-Making/Clinical Judgment, Fluids and
Electrolytes
. Reference: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug
handbook 2015. (pp. 1125-1127) St. Louis: Saunders.
. Awarded 3.0 points out of 3.0 possible points.
2.ID: 9477057138
. A nurse is providing dietary instructions to a client with chronic obstructive
pulmonary disease (COPD) who is experiencing a loss of appetite and complains
of feeling “too full to eat.” What does the nurse encourage the client to do? Select
all that apply.
A. Avoid drinking fluids before and during meals Correct
B. Eat a variety of dark-green vegetables, such as broccoli
C. Have snacks, such as crackers and cheese, between meals
D. Select foods that are easy to chew and are not gas forming Correct
E. Consume high-calorie drinks, such as milkshakes, between meals
. Rationale: COPD is a progressive and irreversible condition characterized by
diminished inspiratory and expiratory capacity of the lungs. Instruct the client who
complains of feeling too full to eat, to avoid drinking fluids before and during the
meal. Dry foods such as crackers stimulate coughing; foods such as milk and
chocolate may increase the thickness of saliva and secretions. Cheese is
constipating and should also be avoided by the client. The nurse should also teach
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the client about foods that are easy to chew and do not encourage the formation of
gas; for this reason, broccoli, which is a gas-forming food, should be avoided.
Test-Taking Strategy: Use the process of elimination. Recalling that milk
may increase the thickness of saliva will assist you in eliminating the option that
encourages the consumption of milkshakes. Eliminate the option in which the
consumption of broccoli is encouraged, because it is a gas-forming food. To select
from the remaining options, note the strategic words “too full to eat” in the
question and the option that encourages the client to avoid fluids before and during
meals; this will direct you to the correct answers. Review dietary measures for the
client with COPD if you had difficulty with this question.
. Level of Cognitive Ability: Applying
. Client Needs: Physiological Integrity
. Integrated Process: Teaching and Learning
. Content Area: Adult Health/Respiratory
. Giddens Concepts: Gas Exchange, Nutrition
. HESI Concepts: Oxygenation/Gas Exchange, Metabolism – Nutrition
. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014).
Medical-surgical nursing: Assessment and management of clinical problems (9th
ed., pp. 595-596). St. Louis: Mosby.
. Awarded 2.0 points out of 2.0 possible points.
. 3.ID: 9477057160
A tuberculin skin test (TST) is administered to a client with a diagnosis of HIV
infection. Forty-eight hours after administration, the nurse checks the test site (see
image).
The nurse documents the result of the test as:
A. Positive Correct
B. Negative
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C. Insignificant
D. Indeterminate
. Rationale: The tuberculin, or TST, test is a reliable determinant of
tuberculosis (TB) infection. A reaction measuring 5 mm or more in diameter is
considered positive in a client with HIV infection. A reaction measuring 10 mm or
more in diameter is considered positive in a non-immunosuppressed client. In this
instance, the area of induration measures 9 mm, indicating a positive reaction. A
positive reaction does not mean that active disease is present, but it does indicate
exposure to TB or the presence of inactive (dormant) disease.
. Test-Taking Strategy: Use the process of elimination. Eliminate the options
that are comparable or alike (negative and insignificant). To select from the
remaining options, note that the client has HIV, which will assist in directing you
to the correct option. An area of induration is present, so the test results are not
indeterminate. Review the tuberculin skin test and the procedure for interpreting
the results if you had difficulty with this question.
. Level of Cognitive Ability: Analyzing
. Client Needs: Physiological Integrity
. Integrated Process: Nursing Process/Assessment
. Content Area: Adult Health/Respiratory
. Giddens Concepts: Clinical Judgment, Evidence
. HESI Concepts: Clinical Decision-Making/Clinical Judgment, Evidence-
Based Practice/Evidence
. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014).
Medical-surgical nursing: Assessment and management of clinical problems (9th
ed., pp. 494, 530). St. Louis: Mosby.
. Awarded 1.0 points out of 1.0 possible points.
1|P a g e
HESI FOCUS ON ADULT HEALTH TEST BANK||
ACTUAL EXAM ALL QUESTIONS AND 100%
CORRECT ANSWERS WITH RATIONALES
ALREADY GRADED A+|| LATEST AND FULLY
COVERED UPDATE 2025 WITH VERIFIED
SOLUTIONS|| ASSURED PASS!!!
ID: 9477061444
. A nurse is monitoring a client who is taking spironolactone for the treatment
of hypertension. Which findings denote adverse effects of the medication? Select
all that apply.
A. Constipation
B. Tall T waves Correct
C. Hyporeflexia
D. Shallow respirations
E. Prolonged PR interval Correct
F. Hyperactive bowel sounds Correct
. Rationale: Spironolactone is a potassium-sparing diuretic. Potassium-sparing
diuretics can cause hyperkalemia. Cardiovascular manifestations of hyperkalemia
include tall T waves, widened QRS complexes, prolonged PR intervals, and flat P
waves. Other cardiovascular manifestations include an irregular heart rate,
decreased blood pressure, and ectopic heartbeats. Muscle twitches occur in
hyperkalemia. Hyperactive bowel sounds and diarrhea also occur in hyperkalemia.
Constipation, hyporeflexia, and shallow respirations are signs of hypokalemia.
. Test-Taking Strategy: The knowledge that spironolactone is a potassium-
sparing diuretic will assist you in determining that hyperkalemia is an adverse
effect of the medication. Recalling the manifestations of hyperkalemia will direct
you to the correct options. Also, note that the incorrect options are comparable or
alike in that they indicate a slowed body response or function. Review the adverse
effects of spironolactone and the manifestations of hyperkalemia if you had
difficulty with this question.
,MEDSTUDY.COM
2|P a g e
. Level of Cognitive Ability: Analyzing
. Client Needs: Physiological Integrity
. Integrated Process: Nursing Process/Assessment
. Content Area: Adult Pharmacology
. Giddens Concepts: Clinical Judgment, Fluid and Electrolytes
. HESI Concepts: Clinical Decision-Making/Clinical Judgment, Fluids and
Electrolytes
. Reference: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug
handbook 2015. (pp. 1125-1127) St. Louis: Saunders.
. Awarded 3.0 points out of 3.0 possible points.
2.ID: 9477057138
. A nurse is providing dietary instructions to a client with chronic obstructive
pulmonary disease (COPD) who is experiencing a loss of appetite and complains
of feeling “too full to eat.” What does the nurse encourage the client to do? Select
all that apply.
A. Avoid drinking fluids before and during meals Correct
B. Eat a variety of dark-green vegetables, such as broccoli
C. Have snacks, such as crackers and cheese, between meals
D. Select foods that are easy to chew and are not gas forming Correct
E. Consume high-calorie drinks, such as milkshakes, between meals
. Rationale: COPD is a progressive and irreversible condition characterized by
diminished inspiratory and expiratory capacity of the lungs. Instruct the client who
complains of feeling too full to eat, to avoid drinking fluids before and during the
meal. Dry foods such as crackers stimulate coughing; foods such as milk and
chocolate may increase the thickness of saliva and secretions. Cheese is
constipating and should also be avoided by the client. The nurse should also teach
,MEDSTUDY.COM
3|P a g e
the client about foods that are easy to chew and do not encourage the formation of
gas; for this reason, broccoli, which is a gas-forming food, should be avoided.
Test-Taking Strategy: Use the process of elimination. Recalling that milk
may increase the thickness of saliva will assist you in eliminating the option that
encourages the consumption of milkshakes. Eliminate the option in which the
consumption of broccoli is encouraged, because it is a gas-forming food. To select
from the remaining options, note the strategic words “too full to eat” in the
question and the option that encourages the client to avoid fluids before and during
meals; this will direct you to the correct answers. Review dietary measures for the
client with COPD if you had difficulty with this question.
. Level of Cognitive Ability: Applying
. Client Needs: Physiological Integrity
. Integrated Process: Teaching and Learning
. Content Area: Adult Health/Respiratory
. Giddens Concepts: Gas Exchange, Nutrition
. HESI Concepts: Oxygenation/Gas Exchange, Metabolism – Nutrition
. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014).
Medical-surgical nursing: Assessment and management of clinical problems (9th
ed., pp. 595-596). St. Louis: Mosby.
. Awarded 2.0 points out of 2.0 possible points.
. 3.ID: 9477057160
A tuberculin skin test (TST) is administered to a client with a diagnosis of HIV
infection. Forty-eight hours after administration, the nurse checks the test site (see
image).
The nurse documents the result of the test as:
A. Positive Correct
B. Negative
, MEDSTUDY.COM
4|P a g e
C. Insignificant
D. Indeterminate
. Rationale: The tuberculin, or TST, test is a reliable determinant of
tuberculosis (TB) infection. A reaction measuring 5 mm or more in diameter is
considered positive in a client with HIV infection. A reaction measuring 10 mm or
more in diameter is considered positive in a non-immunosuppressed client. In this
instance, the area of induration measures 9 mm, indicating a positive reaction. A
positive reaction does not mean that active disease is present, but it does indicate
exposure to TB or the presence of inactive (dormant) disease.
. Test-Taking Strategy: Use the process of elimination. Eliminate the options
that are comparable or alike (negative and insignificant). To select from the
remaining options, note that the client has HIV, which will assist in directing you
to the correct option. An area of induration is present, so the test results are not
indeterminate. Review the tuberculin skin test and the procedure for interpreting
the results if you had difficulty with this question.
. Level of Cognitive Ability: Analyzing
. Client Needs: Physiological Integrity
. Integrated Process: Nursing Process/Assessment
. Content Area: Adult Health/Respiratory
. Giddens Concepts: Clinical Judgment, Evidence
. HESI Concepts: Clinical Decision-Making/Clinical Judgment, Evidence-
Based Practice/Evidence
. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014).
Medical-surgical nursing: Assessment and management of clinical problems (9th
ed., pp. 494, 530). St. Louis: Mosby.
. Awarded 1.0 points out of 1.0 possible points.
