INTERPRETED ADULT HEALTH
HESI EXAM REVIEW
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 ywith yheparin. yOption yA ywill ynot yaffect ythe ydecision yto
yadminister ythe ymedication yand yis ynot ya ypriority. yAdministration yof ythe ymedication ySTAT yis yof
ygreater ypriority ythan yoptionyB.
A yclient yis yready yfor ydischarge yfollowing ythe ycreation yof yan yileostomy. yWhich yinstruction yshould
ythe ynurseyinclude yin ydischarge yteaching?
,A. Replace ythe ystoma yappliance yevery yday.
B. Use ywarm ytap ywater yto yirrigate ythe yileostomy.
C. Change ythe ybag ywhen ythe yseal yis ybroken.
D. Measure yand yrecord ythe yileostomy youtput. y- yCORRECT yANSWER y-Answer- yC
Rationale- yA yseal ymust ybe ymaintained yto yprevent yleakage yof yirritating yliquid ystool yonto ythe
yskin. yOption yAyis yexcessive yand ycan ycause yskin yirritation yand ybreakdown. yIleostomies yproduce
yliquid yfecal ydrainage, yso yoption yB yis ynot ynecessary. yOption yD yis ynot yneeded.
An yolder ymale yclient ycomes yto ythe youtpatient yclinic ycomplaining yof ypain yin yhis yleft ycalf. yThe
ynurse ynoticesya yreddened yarea yon ythe ycalf yof yhis yright yleg ythat yis ywarm yto ythe ytouch, yand ythe
ynurse ysuspects ythat ythe yclient ymay yhave ythrombophlebitis. yWhich yadditional yassessment yis
ymost yimportant yfor ythe ynurse yto yperform?
A. Measure ythe yclient's ycalf ycircumference.
B. Auscultate ythe yclient's ybreath ysounds.
C. Observe yfor yecchymosis yand ypetechiae.
, D. Obtain ythe yclient's yblood ypressure. y- yCORRECT yANSWER y-Answer- yB
Rationale- yAll ythese ytechniques yprovide yuseful yassessment ydata. yThe ymost yimportant yis yto
yauscultate ytheyclient's ybreath ysounds ybecause ythe yclient ymay yhave ya ypulmonary yembolus
ysecondary yto ythe ythrombophlebitis. yOption yA ymay yprovide ydata ythat ysupport ythe ynurse's
ysuspicion yof ythrombophlebitis.
Option yC yis ythe yleast yhelpful yassessment ybecause ybruising yis ynot ya ytypical yfinding yassociated
ywith ythrombophlebitis. yOption yD yis yalways yuseful yin yevaluating ythe yclient's yresponse yto ya
yproblem ybut yis yof ylessyimmediate ypriority ythan ybreath ysound yauscultation.
The ynurse yis ycaring yfor ya ycritically yill yclient ywith ycirrhosis yof ythe yliver ywho yhas ya ynasogastric
ytube ydrainingybright yred yblood. yThe ynurse ynotes ythat ythe yclient's yserum yhemoglobin yand
yhematocrit ylevels yare ydecreased. yWhich yadditional ychange yin ylaboratory ydata yshould ythe ynurse
yexpect?
A. Increased yserum yalbumin ylevel
B. Decreased yserum ycreatinine
C. Decreased yserum yammonia ylevel
D. Increased yliver yfunction ytest yresults y- yCORRECT yANSWER y-Answer- yC
Rationale- yThe ybreakdown yof yglutamine yin ythe yintestine yand ythe yincreased yactivity yof ycolonic
ybacteria yfrom ythe ydigestion yof yproteins yincrease yammonia ylevels yin yclients ywith yadvanced yliver
ydisease, yso yremoval yof yblood, ya yprotein ysource, yfrom ythe yintestine yresults yin ya yreduced ylevel
yof yammonia. yOptions yA,yB, yand yD ywill ynot ybe ysignificantly yaffected yby ythe yremoval yof yblood.
HESI EXAM REVIEW
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 ywith yheparin. yOption yA ywill ynot yaffect ythe ydecision yto
yadminister ythe ymedication yand yis ynot ya ypriority. yAdministration yof ythe ymedication ySTAT yis yof
ygreater ypriority ythan yoptionyB.
A yclient yis yready yfor ydischarge yfollowing ythe ycreation yof yan yileostomy. yWhich yinstruction yshould
ythe ynurseyinclude yin ydischarge yteaching?
,A. Replace ythe ystoma yappliance yevery yday.
B. Use ywarm ytap ywater yto yirrigate ythe yileostomy.
C. Change ythe ybag ywhen ythe yseal yis ybroken.
D. Measure yand yrecord ythe yileostomy youtput. y- yCORRECT yANSWER y-Answer- yC
Rationale- yA yseal ymust ybe ymaintained yto yprevent yleakage yof yirritating yliquid ystool yonto ythe
yskin. yOption yAyis yexcessive yand ycan ycause yskin yirritation yand ybreakdown. yIleostomies yproduce
yliquid yfecal ydrainage, yso yoption yB yis ynot ynecessary. yOption yD yis ynot yneeded.
An yolder ymale yclient ycomes yto ythe youtpatient yclinic ycomplaining yof ypain yin yhis yleft ycalf. yThe
ynurse ynoticesya yreddened yarea yon ythe ycalf yof yhis yright yleg ythat yis ywarm yto ythe ytouch, yand ythe
ynurse ysuspects ythat ythe yclient ymay yhave ythrombophlebitis. yWhich yadditional yassessment yis
ymost yimportant yfor ythe ynurse yto yperform?
A. Measure ythe yclient's ycalf ycircumference.
B. Auscultate ythe yclient's ybreath ysounds.
C. Observe yfor yecchymosis yand ypetechiae.
, D. Obtain ythe yclient's yblood ypressure. y- yCORRECT yANSWER y-Answer- yB
Rationale- yAll ythese ytechniques yprovide yuseful yassessment ydata. yThe ymost yimportant yis yto
yauscultate ytheyclient's ybreath ysounds ybecause ythe yclient ymay yhave ya ypulmonary yembolus
ysecondary yto ythe ythrombophlebitis. yOption yA ymay yprovide ydata ythat ysupport ythe ynurse's
ysuspicion yof ythrombophlebitis.
Option yC yis ythe yleast yhelpful yassessment ybecause ybruising yis ynot ya ytypical yfinding yassociated
ywith ythrombophlebitis. yOption yD yis yalways yuseful yin yevaluating ythe yclient's yresponse yto ya
yproblem ybut yis yof ylessyimmediate ypriority ythan ybreath ysound yauscultation.
The ynurse yis ycaring yfor ya ycritically yill yclient ywith ycirrhosis yof ythe yliver ywho yhas ya ynasogastric
ytube ydrainingybright yred yblood. yThe ynurse ynotes ythat ythe yclient's yserum yhemoglobin yand
yhematocrit ylevels yare ydecreased. yWhich yadditional ychange yin ylaboratory ydata yshould ythe ynurse
yexpect?
A. Increased yserum yalbumin ylevel
B. Decreased yserum ycreatinine
C. Decreased yserum yammonia ylevel
D. Increased yliver yfunction ytest yresults y- yCORRECT yANSWER y-Answer- yC
Rationale- yThe ybreakdown yof yglutamine yin ythe yintestine yand ythe yincreased yactivity yof ycolonic
ybacteria yfrom ythe ydigestion yof yproteins yincrease yammonia ylevels yin yclients ywith yadvanced yliver
ydisease, yso yremoval yof yblood, ya yprotein ysource, yfrom ythe yintestine yresults yin ya yreduced ylevel
yof yammonia. yOptions yA,yB, yand yD ywill ynot ybe ysignificantly yaffected yby ythe yremoval yof yblood.
