HESI ADULT HEALTH 2 ALL 4 VERSIONS (VERSION
1,2,3 AND 4 -LATEST UPDATE WITH ALLQUESTIONS
FROM PAST ACTUAL EXAMS AND DETAILED
CORRECT ANSWERS
A client with acute renal injury (AKI) weighs 50 kg and has potassium level of 6.7 is
admitted to the hospital. Which prescribed medication should the nurse administer first?
Rationale:A potassium level of 6.7 mEq/L is dangerously high. **Sodium polystyrene
sulfonate (Kayexalate)** helps lower potassium by exchanging sodium for potassium in
the intestines. - CORRECT ANSWERS-Sodium polystyrene sulfonate 15 grams by
mouth
A client with gouty arthritis reports tenderness and swelling of the ankle and great
toe. The nurse observes the area of inflammation extends above the ankle area. The
client receives prescriptions for colchicine and indomethacin. Which instruction should
the nurse include in the discharge teaching? Drinking plenty of water helps prevent
urate crystal formation and aids in excreting uric acid, reducing the risk of gout attacks. -
CORRECT ANSWERS-drink at least 8 cups of water per day
A client receives a prescription for 1 liter of lactated ringer's intravenously to be infused
over 6 hours. How many mL/hr should the nurse program the infusion pump to
deliver?Rationale Infusion rate = Total volume ÷ Time
Infusion rate = 1000 mL ÷ 6 hours = 166.67 mL/hr - CORRECT ANSWERS-167
A client with a history of peptic ulcer disease is admitted after vomiting bright red blood
several times over the course of 2 hours. In reviewing the laboratory results, the nurse
finds the client's hemoglobin is 12 and the hematocrit is 35%. Which action should the
nurse prepare to take? Rationale:
The client with a history of peptic ulcer disease and vomiting bright red blood likely has
an upper gastrointestinal (GI) bleed. Vomiting bright red blood suggests active bleeding,
which can lead to hypovolemic shock. The hemoglobin level of 12 and hematocrit of
35% are not critically low, but they may drop further if bleeding continues. - CORRECT
ANSWERS-Administer 1,000 mL (1L) normal saline
An obese client with emphysema who smokes at least a pack of cigarettes daily is
admitted after experiencing a sudden increase in dyspnea and activity intolerance.
Oxygen therapy is initiated and it is determined that the client will be discharged with
oxygen. Which information is most important for the nurse to emphasize in the
discharge teaching plan?Rationale:Proper use of oxygen is essential to prevent
complications like oxygen toxicity or carbon dioxide retention, especially given the
client's increased dyspnea and activity intolerance.
a. Methods for weight loss
b. guidelines for oxygen use
c. Approaches to conserve energy
, d. Strategies for smoking cessation - CORRECT ANSWERS-guidelines for oxygen use
A nurse is caring for a client with DI. Which data warrants the most immediate
intervention by the nurse? Rationale:The most immediate concern is **serum sodium of
185** (option a). A sodium level this high indicates severe hypernatremia, which can be
life-threatening and requires urgent treatment.
a. Serum sodium of 185
b. Dry skin with inelastic turgor
c. Apical rate of 110 beats per minute
d. Polyuria and excessive thirst - CORRECT ANSWERS-a. Serum sodium of 185
The nurse is obtaining the admission history for a client with suspected peptic ulcer
disease (PUD). Which subjective data reported by the client supports this medical
diagnosis? Rationale:This type of pain is characteristic of PUD, as it often occurs in the
upper abdomen and is described as gnawing, burning, or hunger-like, typically
worsened by an empty stomach and relieved by eating or antacids.
a. Frequent use of chewable and liquid antacids for indigestion
b. severe abdominal cramps and diarrhea after eating spicy foods
c. upper mid-abdominal pain described as gnawing and burning.
d. Marked loss of weight and appetite over the last 3 or 4 months - CORRECT
ANSWERS-c. upper mid-abdominal pain described as gnawing and burning.
The nurse assess a client who is newly diagnosed with hyperthyroidism and observes
that the client's eyeballs are protuberant, causing a wide-eyed appearance and eye
discomfort. Based on this finding, which action should the nurse include in this client's
plan of care? Rationale:The client's symptoms—protuberant eyeballs (exophthalmos)
and eye discomfort—are characteristic of Graves' disease, a common cause of
hyperthyroidism. Exophthalmos can lead to dryness and irritation of the eyes, and
artificial tear drops can help relieve discomfort and protect the corneas from damage
due to decreased eyelid closure.
a. Assess for signs of increased intracranial pressure
b. Prepare to administer intravenous levothyroxine
c. Review the client's serum electrolyte values
d. Obtain a prescription for artificial tear drops - CORRECT ANSWERS-d. Obtain a
prescription for artificial tear drops
To reduce the risk for pulmonary complication for a client with Amyotrophic Lateral
Sclerosis (ALS), which interventions should the nurse implement? (Select all)
a. Perform chest physiotherapy
b. Teach the client breathing exercises
c. Initiate passive range of motion exercises
d. Establish a regular bladder routine
e. Encourage use of incentive spirometer - CORRECT ANSWERS-a. Perform chest
physiotherapy
b. Teach the client breathing exercises
e. Encourage use of incentive spriometer
1,2,3 AND 4 -LATEST UPDATE WITH ALLQUESTIONS
FROM PAST ACTUAL EXAMS AND DETAILED
CORRECT ANSWERS
A client with acute renal injury (AKI) weighs 50 kg and has potassium level of 6.7 is
admitted to the hospital. Which prescribed medication should the nurse administer first?
Rationale:A potassium level of 6.7 mEq/L is dangerously high. **Sodium polystyrene
sulfonate (Kayexalate)** helps lower potassium by exchanging sodium for potassium in
the intestines. - CORRECT ANSWERS-Sodium polystyrene sulfonate 15 grams by
mouth
A client with gouty arthritis reports tenderness and swelling of the ankle and great
toe. The nurse observes the area of inflammation extends above the ankle area. The
client receives prescriptions for colchicine and indomethacin. Which instruction should
the nurse include in the discharge teaching? Drinking plenty of water helps prevent
urate crystal formation and aids in excreting uric acid, reducing the risk of gout attacks. -
CORRECT ANSWERS-drink at least 8 cups of water per day
A client receives a prescription for 1 liter of lactated ringer's intravenously to be infused
over 6 hours. How many mL/hr should the nurse program the infusion pump to
deliver?Rationale Infusion rate = Total volume ÷ Time
Infusion rate = 1000 mL ÷ 6 hours = 166.67 mL/hr - CORRECT ANSWERS-167
A client with a history of peptic ulcer disease is admitted after vomiting bright red blood
several times over the course of 2 hours. In reviewing the laboratory results, the nurse
finds the client's hemoglobin is 12 and the hematocrit is 35%. Which action should the
nurse prepare to take? Rationale:
The client with a history of peptic ulcer disease and vomiting bright red blood likely has
an upper gastrointestinal (GI) bleed. Vomiting bright red blood suggests active bleeding,
which can lead to hypovolemic shock. The hemoglobin level of 12 and hematocrit of
35% are not critically low, but they may drop further if bleeding continues. - CORRECT
ANSWERS-Administer 1,000 mL (1L) normal saline
An obese client with emphysema who smokes at least a pack of cigarettes daily is
admitted after experiencing a sudden increase in dyspnea and activity intolerance.
Oxygen therapy is initiated and it is determined that the client will be discharged with
oxygen. Which information is most important for the nurse to emphasize in the
discharge teaching plan?Rationale:Proper use of oxygen is essential to prevent
complications like oxygen toxicity or carbon dioxide retention, especially given the
client's increased dyspnea and activity intolerance.
a. Methods for weight loss
b. guidelines for oxygen use
c. Approaches to conserve energy
, d. Strategies for smoking cessation - CORRECT ANSWERS-guidelines for oxygen use
A nurse is caring for a client with DI. Which data warrants the most immediate
intervention by the nurse? Rationale:The most immediate concern is **serum sodium of
185** (option a). A sodium level this high indicates severe hypernatremia, which can be
life-threatening and requires urgent treatment.
a. Serum sodium of 185
b. Dry skin with inelastic turgor
c. Apical rate of 110 beats per minute
d. Polyuria and excessive thirst - CORRECT ANSWERS-a. Serum sodium of 185
The nurse is obtaining the admission history for a client with suspected peptic ulcer
disease (PUD). Which subjective data reported by the client supports this medical
diagnosis? Rationale:This type of pain is characteristic of PUD, as it often occurs in the
upper abdomen and is described as gnawing, burning, or hunger-like, typically
worsened by an empty stomach and relieved by eating or antacids.
a. Frequent use of chewable and liquid antacids for indigestion
b. severe abdominal cramps and diarrhea after eating spicy foods
c. upper mid-abdominal pain described as gnawing and burning.
d. Marked loss of weight and appetite over the last 3 or 4 months - CORRECT
ANSWERS-c. upper mid-abdominal pain described as gnawing and burning.
The nurse assess a client who is newly diagnosed with hyperthyroidism and observes
that the client's eyeballs are protuberant, causing a wide-eyed appearance and eye
discomfort. Based on this finding, which action should the nurse include in this client's
plan of care? Rationale:The client's symptoms—protuberant eyeballs (exophthalmos)
and eye discomfort—are characteristic of Graves' disease, a common cause of
hyperthyroidism. Exophthalmos can lead to dryness and irritation of the eyes, and
artificial tear drops can help relieve discomfort and protect the corneas from damage
due to decreased eyelid closure.
a. Assess for signs of increased intracranial pressure
b. Prepare to administer intravenous levothyroxine
c. Review the client's serum electrolyte values
d. Obtain a prescription for artificial tear drops - CORRECT ANSWERS-d. Obtain a
prescription for artificial tear drops
To reduce the risk for pulmonary complication for a client with Amyotrophic Lateral
Sclerosis (ALS), which interventions should the nurse implement? (Select all)
a. Perform chest physiotherapy
b. Teach the client breathing exercises
c. Initiate passive range of motion exercises
d. Establish a regular bladder routine
e. Encourage use of incentive spirometer - CORRECT ANSWERS-a. Perform chest
physiotherapy
b. Teach the client breathing exercises
e. Encourage use of incentive spriometer
