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HESI Adult Health Exam Prep Document 2026/2027
||Verified Exam!!|| Medical-Surgical Nursing, NCLEX
Readiness & NGN Clinical Judgment || Verified
Questions with Detailed Rationales
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. - Answer-Answer- B
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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
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C. Decreased serum ammonia level
D. Increased liver function test results - 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.
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.
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B. Obtain the needed intravenous solution.
C. Flush the line with heparinized solution.
D. Flush the line with normal saline. - 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.
HESI Adult Health Exam Prep Document 2026/2027
||Verified Exam!!|| Medical-Surgical Nursing, NCLEX
Readiness & NGN Clinical Judgment || Verified
Questions with Detailed Rationales
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. - Answer-Answer- B
,2|Page
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
,3|Page
C. Decreased serum ammonia level
D. Increased liver function test results - 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.
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.
, 4|Page
B. Obtain the needed intravenous solution.
C. Flush the line with heparinized solution.
D. Flush the line with normal saline. - 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.
