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.
, 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
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.
, 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
