Adult Health HESI review questions with
correct answers
A central venous catheter has been inserted via a jugular vein, and a radiograph
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has confirmed placement of the catheter. A prescription has been received for a
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medication STAT, but IV fluids have not yet been started. Which action should the
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nurse take prior to administering the prescribed medication?
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A. Assess for signs of jugular venous distention.
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| B. Obtain the needed intravenous solution.
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| C. Flush the line with heparinized solution.
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| D. Flush the line with normal saline. - CORRECT ANSWER✔✔-Answer, D
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Rationale- Medication can be administered via a central line without additional IV
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fluids. The line should first be flushed with a normal saline solution to ensure
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patency. Insufficient evidence exists on the effectiveness of flushing catheters
| | | | | | | | | |
with heparin. Option A will not affect the decision to administer the medication
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,and is not a priority. Administration of the medication STAT is of greater priority
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than option B. | |
A client is ready for discharge following the creation of an ileostomy. Which
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instruction should the nurse include in discharge teaching?
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A. Replace the stoma appliance every day.
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| B. Use warm tap water to irrigate the ileostomy.
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| C. Change the bag when the seal is broken.
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| D. Measure and record the ileostomy output. - CORRECT ANSWER✔✔-Answer- C
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Rationale- A seal must be maintained to prevent leakage of irritating liquid stool
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onto the skin. Option A is excessive and can cause skin irritation and breakdown.
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Ileostomies produce liquid fecal drainage, so option B is not necessary. Option D
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is not needed.
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An older male client comes to the outpatient clinic complaining of pain in his left
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calf. The nurse notices a reddened area on the calf of his right leg that is warm to
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the touch, and the nurse suspects that the client may have thrombophlebitis.
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Which additional assessment is most important for the nurse to perform?
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,A. Measure the client's calf circumference.
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| B. Auscultate the client's breath sounds.
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| C. Observe for ecchymosis and petechiae.
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| D. Obtain the client's blood pressure. - CORRECT ANSWER✔✔-Answer- B
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Rationale- All these techniques provide useful assessment data. The most
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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
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helpful assessment because bruising is not a typical finding associated with
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thrombophlebitis. Option D is always useful in evaluating the client's response to
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a problem but is of less immediate priority than breath sound auscultation.
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The nurse is caring for a critically ill client with cirrhosis of the liver who has a
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nasogastric tube draining bright red blood. The nurse notes that the client's
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serum hemoglobin and hematocrit levels are decreased. Which additional change
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in laboratory data should the nurse expect?
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A. Increased serum albumin level
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, | B. Decreased serum creatinine
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| C. Decreased serum ammonia level
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| D. Increased liver function test results - CORRECT ANSWER✔✔-Answer- C
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Rationale- The breakdown of glutamine in the intestine and the increased activity
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of colonic bacteria from the digestion of proteins increase ammonia levels in
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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.
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What is digoxin - CORRECT ANSWER✔✔-Blood pressure medication with high
| | | | | | | | | |
toxicity
Signs of hyperkalemia - CORRECT ANSWER✔✔-Tall/spiked T waves, prolonged QT
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interval, widening QRS wave
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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.
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correct 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 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.
| | | | | | |
What is digoxin - CORRECT ANSWER✔✔-Blood pressure medication with high
| | | | | | | | | |
toxicity
Signs of hyperkalemia - CORRECT ANSWER✔✔-Tall/spiked T waves, prolonged QT
| | | | | | | | | |
interval, widening QRS wave
| | |
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.
| | | | | |
