ADULT HEALTH HESI REVIEW
QUESTIONS & ACCURATE ANSWERS
RATED 100% CORRECT
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.
C. Observe for ecchymosis and petechiae.
D. Obtain the client's blood pressure. - CORRECT ANSWER Answer- B
Rationale- All these techniques provide useful assessment data. The most important is
to auscultate the client's breath sounds because the client may have a pulmonary
embolus secondary to the thrombophlebitis. Option A may provide data that support the
nurse's suspicion of thrombophlebitis. Option C is the least helpful assessment because
bruising is not a typical finding associated with thrombophlebitis. Option D is always
useful in evaluating the client's response to a problem but is of less immediate priority
than breath sound auscultation.
The nurse is caring for a critically ill client with cirrhosis of the liver who has a
nasogastric tube draining bright red blood. The nurse notes that the client's serum
hemoglobin and hematocrit levels are decreased. Which additional change in laboratory
data should the nurse expect?
A. Increased serum albumin level
B. Decreased serum creatinine
C. Decreased serum ammonia level
D. Increased liver function test results - CORRECT ANSWER Answer- C
Rationale- The breakdown of glutamine in the intestine and the increased activity of
colonic bacteria from the digestion of proteins increase ammonia levels in clients with
advanced liver disease, so removal of blood, a protein source, from the intestine results
, in a reduced level of ammonia. Options A, B, and D will not be significantly affected by
the removal of blood.
What is digoxin - CORRECT ANSWER Blood pressure medication with high toxicity
Signs of hyperkalemia - CORRECT ANSWER Tall/spiked T waves, prolonged QT
interval, widening QRS wave
The breakdown of glutamine in the intestine and the increased activity of colonic
bacteria from the digestion of proteins increase ammonia levels in clients with advanced
liver disease, so removal of blood, a protein source, from the intestine results in a
reduced level of ammonia. Options A, B, and D will not be significantly affected by the
removal of blood.
A. Reduce the daily intake of animal fat to 10% of the diet within 6 weeks.
B. Exhibit regular, soft-formed stool within 1 month.
C. Demonstrate the irrigation procedure correctly within 1 week.
D. Attend an ostomy support group within 2 weeks. - CORRECT ANSWER Answer- D,
attend an ostomy support group within 2 weeks
Rationale- Attending a support group will be beneficial to the client and should be
encouraged because adaptation to the ostomy can be difficult. This goal is attainable
and is measurable. Option A is not specifically related to ileostomy care. The client with
an ileostomy will not be able to accomplish option B. Option C is not necessary.
The nurse is administering a nystatin suspension for stomatitis. Which instruction will
the nurse provide to the client when administering this medication?
A. "Hold the medication in your mouth for a few minutes before swallowing it."
B. "Do not drink or eat milk products for 1 hour prior to taking this medication."
C. "Dilute the medication with juice to reduce the unpleasant taste and odor."
D. "Take the medication before meals to promote increased absorption." - CORRECT
ANSWER Answer- A
QUESTIONS & ACCURATE ANSWERS
RATED 100% CORRECT
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.
C. Observe for ecchymosis and petechiae.
D. Obtain the client's blood pressure. - CORRECT ANSWER Answer- B
Rationale- All these techniques provide useful assessment data. The most important is
to auscultate the client's breath sounds because the client may have a pulmonary
embolus secondary to the thrombophlebitis. Option A may provide data that support the
nurse's suspicion of thrombophlebitis. Option C is the least helpful assessment because
bruising is not a typical finding associated with thrombophlebitis. Option D is always
useful in evaluating the client's response to a problem but is of less immediate priority
than breath sound auscultation.
The nurse is caring for a critically ill client with cirrhosis of the liver who has a
nasogastric tube draining bright red blood. The nurse notes that the client's serum
hemoglobin and hematocrit levels are decreased. Which additional change in laboratory
data should the nurse expect?
A. Increased serum albumin level
B. Decreased serum creatinine
C. Decreased serum ammonia level
D. Increased liver function test results - CORRECT ANSWER Answer- C
Rationale- The breakdown of glutamine in the intestine and the increased activity of
colonic bacteria from the digestion of proteins increase ammonia levels in clients with
advanced liver disease, so removal of blood, a protein source, from the intestine results
, in a reduced level of ammonia. Options A, B, and D will not be significantly affected by
the removal of blood.
What is digoxin - CORRECT ANSWER Blood pressure medication with high toxicity
Signs of hyperkalemia - CORRECT ANSWER Tall/spiked T waves, prolonged QT
interval, widening QRS wave
The breakdown of glutamine in the intestine and the increased activity of colonic
bacteria from the digestion of proteins increase ammonia levels in clients with advanced
liver disease, so removal of blood, a protein source, from the intestine results in a
reduced level of ammonia. Options A, B, and D will not be significantly affected by the
removal of blood.
A. Reduce the daily intake of animal fat to 10% of the diet within 6 weeks.
B. Exhibit regular, soft-formed stool within 1 month.
C. Demonstrate the irrigation procedure correctly within 1 week.
D. Attend an ostomy support group within 2 weeks. - CORRECT ANSWER Answer- D,
attend an ostomy support group within 2 weeks
Rationale- Attending a support group will be beneficial to the client and should be
encouraged because adaptation to the ostomy can be difficult. This goal is attainable
and is measurable. Option A is not specifically related to ileostomy care. The client with
an ileostomy will not be able to accomplish option B. Option C is not necessary.
The nurse is administering a nystatin suspension for stomatitis. Which instruction will
the nurse provide to the client when administering this medication?
A. "Hold the medication in your mouth for a few minutes before swallowing it."
B. "Do not drink or eat milk products for 1 hour prior to taking this medication."
C. "Dilute the medication with juice to reduce the unpleasant taste and odor."
D. "Take the medication before meals to promote increased absorption." - CORRECT
ANSWER Answer- A
