HESI ADULT HEALTH D444 Latest
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A client is admitted with acute congestive heart failure (CHF). Which exam finding will the nurse most
likely assess in this client?
,A. Rales and crackles in the bilateral lower lobes upon auscultation
B. 1+ edema of bilateral ankles
C. Weight loss of 2 pounds since previous hospitalization
D. Blood pressure 160/100 mm Hg - correct ans:A. Rales and crackles in the bilateral lower lobes upon
auscultation
Rationale: Clients with acute heart failure (CHF) will have evidence of fluid retention due to decreased
cardiac output and subsequent overactivation of RAAS system (renin-angiotensin-aldosterone system) in
the kidneys. Rales and crackles in the bilateral lower lobes are signs of pulmonary edema, a common
finding in clients with acute congestive heart failure (CHF). Pulmonary edema develops due to decreased
forward outflow (due to decreased contractility of the left ventricle) and subsequent increased pressure
in the pulmonary circulation.
A client is admitted with multiple injuries following a motor vehicle collision. Which injury should the
nurse address first?
A. Active bleeding from a lower leg wound and BP 100/60 mmHg
B. Scalp lacerations and Glasgow Coma Scale of 10
C. Absent breath sounds over the left lung, distended neck veins, RR 27/min and pulse 120 bpm.
D. Fractured humerus with lack of sensation in the lower arm and hand. - correct ans:C. Absent breath
sounds over the left lung, distended neck veins, RR 27/min and pulse 120 bpm.
Rationale: Absent breath sounds, distended neck veins, tachypnea, and tachycardia are signs of tension
pneumothorax, a life threatening condition requiring immediate decompression. In this case, the leg
wound bleeding is not massive and the client's BP is stable, so airway/breathing takes precedence under
ABC trauma guidelines.
A client is diagnosed with acute respiratory distress syndrome (ARDS) is demonstrating atelectasis.
Which nursing diagnosis should the nurse list as the priority for this client?
A. Ineffective airway clearance
B. Impaired gas exchange
C. Alteration in comfort
D. Fluid volume overload
, Rationale: The nursing diagnosis "Impaired gas exchange" is the nursing diagnosis with the highest
priority in a client with ARDS and atelectasis. Atelectasis, which is a collapse of the alveoli, will impair gas
exchange in the lungs and can cause a drop in oxygen saturation levels - correct ans:B. Impaired gas
exchange
The nurse raises the head of the bed encourages a client recovering from abdominal surgery to take
deep breaths. What should the nurse identify as the primary goal of these interventions?
A. Increase blood flow to the lower extremities
B. Reduce post operative bleeding
C. Reduce the retention of carbon dioxide
D. Decrease intracranial pressure - correct ans:C. Reduce the retention of carbon dioxide
Rationale: Raising the head of the bed and encouraging deep breaths are post-operative interventions
aimed at reducing carbon dioxide retention and increasing lung expansion. Blowing off CO2 following
anesthesia is important to prevent drowsiness. Increased lung expansion will prevent the onset of acute
respiratory distress syndrome (ARDS)
A client diagnosed with gastric cancer asks the nurse how he developed the disease. Which assessment
finding will provide the most information regarding the development of gastric in this client?
A. Ingests 1 alcoholic beverage each day
B. Takes cimetidine (Tagamet) for chronic urticaria every day for years in a row
C. Eats pickled veggies and salted fish several times a week
D. Family history of colon cancer - correct ans:C. Eats pickled veggies and salted fish several times a
week
Rationale: Diets high in salted, pickled, or smoked foods have been associated with an increased risk of
gastric cancer. The process of pickling and salting, especially in the case of fish and vegetables, can lead
to the formation of potentially carcinogenic substances. This dietary pattern has been observed to
correlate with higher rates of gastric cancer in certain populations.
A client is prescribed to receive 1000 ml of Dextrose 5% and 0.45% normal saline to infuse over 8 hours.
The administration set delivers 12 drops per milliliter. Calculate the rate in which the nurse should
regulate the drops per minute for this infusion. - correct ans:25
Verified Version And Frequently tested
Exam With Expected real Questions
With Well Elaborated Correct Answers
GRADED A+
Professional Academic Assistance Services
Services Offered
Proctored Exam Assistance
Online Class Management (Full Course Support)
Exam Preparation & Study Materials
Assignments and Coursework Support
Essays and Research Papers
Discussion Posts and Replies
A client is admitted with acute congestive heart failure (CHF). Which exam finding will the nurse most
likely assess in this client?
,A. Rales and crackles in the bilateral lower lobes upon auscultation
B. 1+ edema of bilateral ankles
C. Weight loss of 2 pounds since previous hospitalization
D. Blood pressure 160/100 mm Hg - correct ans:A. Rales and crackles in the bilateral lower lobes upon
auscultation
Rationale: Clients with acute heart failure (CHF) will have evidence of fluid retention due to decreased
cardiac output and subsequent overactivation of RAAS system (renin-angiotensin-aldosterone system) in
the kidneys. Rales and crackles in the bilateral lower lobes are signs of pulmonary edema, a common
finding in clients with acute congestive heart failure (CHF). Pulmonary edema develops due to decreased
forward outflow (due to decreased contractility of the left ventricle) and subsequent increased pressure
in the pulmonary circulation.
A client is admitted with multiple injuries following a motor vehicle collision. Which injury should the
nurse address first?
A. Active bleeding from a lower leg wound and BP 100/60 mmHg
B. Scalp lacerations and Glasgow Coma Scale of 10
C. Absent breath sounds over the left lung, distended neck veins, RR 27/min and pulse 120 bpm.
D. Fractured humerus with lack of sensation in the lower arm and hand. - correct ans:C. Absent breath
sounds over the left lung, distended neck veins, RR 27/min and pulse 120 bpm.
Rationale: Absent breath sounds, distended neck veins, tachypnea, and tachycardia are signs of tension
pneumothorax, a life threatening condition requiring immediate decompression. In this case, the leg
wound bleeding is not massive and the client's BP is stable, so airway/breathing takes precedence under
ABC trauma guidelines.
A client is diagnosed with acute respiratory distress syndrome (ARDS) is demonstrating atelectasis.
Which nursing diagnosis should the nurse list as the priority for this client?
A. Ineffective airway clearance
B. Impaired gas exchange
C. Alteration in comfort
D. Fluid volume overload
, Rationale: The nursing diagnosis "Impaired gas exchange" is the nursing diagnosis with the highest
priority in a client with ARDS and atelectasis. Atelectasis, which is a collapse of the alveoli, will impair gas
exchange in the lungs and can cause a drop in oxygen saturation levels - correct ans:B. Impaired gas
exchange
The nurse raises the head of the bed encourages a client recovering from abdominal surgery to take
deep breaths. What should the nurse identify as the primary goal of these interventions?
A. Increase blood flow to the lower extremities
B. Reduce post operative bleeding
C. Reduce the retention of carbon dioxide
D. Decrease intracranial pressure - correct ans:C. Reduce the retention of carbon dioxide
Rationale: Raising the head of the bed and encouraging deep breaths are post-operative interventions
aimed at reducing carbon dioxide retention and increasing lung expansion. Blowing off CO2 following
anesthesia is important to prevent drowsiness. Increased lung expansion will prevent the onset of acute
respiratory distress syndrome (ARDS)
A client diagnosed with gastric cancer asks the nurse how he developed the disease. Which assessment
finding will provide the most information regarding the development of gastric in this client?
A. Ingests 1 alcoholic beverage each day
B. Takes cimetidine (Tagamet) for chronic urticaria every day for years in a row
C. Eats pickled veggies and salted fish several times a week
D. Family history of colon cancer - correct ans:C. Eats pickled veggies and salted fish several times a
week
Rationale: Diets high in salted, pickled, or smoked foods have been associated with an increased risk of
gastric cancer. The process of pickling and salting, especially in the case of fish and vegetables, can lead
to the formation of potentially carcinogenic substances. This dietary pattern has been observed to
correlate with higher rates of gastric cancer in certain populations.
A client is prescribed to receive 1000 ml of Dextrose 5% and 0.45% normal saline to infuse over 8 hours.
The administration set delivers 12 drops per milliliter. Calculate the rate in which the nurse should
regulate the drops per minute for this infusion. - correct ans:25
