HESI ADULT HEALTH HESI REVIEW
Questions and Answers
1.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
medica- tion?
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.: 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.
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44
,Administration of the medication STAT is of greater priority than option
B.
2.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.: 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.
3.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
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44
,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.: 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.
4.The nurse is caring for a critically ill client with cirrhosis of
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44
, 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: 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.
5.What is digoxin: Blood pressure medication with high toxicity
6.Signs of hyperkalemia: Tall/spiked T waves, prolonged QT
interval, widening QRS wave
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44
Questions and Answers
1.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
medica- tion?
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.: 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.
1/
44
,Administration of the medication STAT is of greater priority than option
B.
2.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.: 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.
3.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
2/
44
,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.: 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.
4.The nurse is caring for a critically ill client with cirrhosis of
3/
44
, 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: 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.
5.What is digoxin: Blood pressure medication with high toxicity
6.Signs of hyperkalemia: Tall/spiked T waves, prolonged QT
interval, widening QRS wave
4/
44
