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Bundle for ADULT HEALTH HESI exam 2023 update/verified
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Adult Health HESI review questions and answers latest 2023
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 ... [Show More] 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. 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. 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. 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 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 Blood pressure medication with high toxicity Signs of hyperkalemia 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. A. Reduce the daily intake of animal fat to 10% of the diet within 6 weeks. B. Exhibit regular, soft-formed stool within 1 month. C. Demonstrate the irrigation procedure correctly within 1 week. D. Attend an ostomy support group within 2 weeks. Answer- D, attend an ostomy support group within 2 weeks Rationale- Attending a support group will be beneficial to the client and should be encouraged because adaptation to the ostomy can be difficult. This goal is attainable and is measurable. Option A is not specifically related to ileostomy care. The client with an ileostomy will not be able to accomplish option B. Option C is not necessary. The nurse is administering a nystatin suspension for stomatitis. Which instruction will the nurse provide to the client when administering this medication? A. "Hold the medication in your mouth for a few minutes before swallowing it." B. "Do not drink or eat milk products for 1 hour prior to taking this medication." C. "Dilute the medication with juice to reduce the unpleasant taste and odor." D. "Take the medication before meals to promote increased absorption." Answer- A Rationale- Nystatin suspension is prescribed for fungal infections of the mouth. The client should swish the medication in the mouth for 2 minutes and then swallow. Option B does not affect administration of this medication. The medication should not be diluted because this will reduce its effectiveness. Option D is not necessary. Which data would the nurse expect to find when reviewing laboratory values of an 80-year-old man who is in good health overall? A. Complete blood count reveals increased white blood cell (WBC) and decreased red blood cell (RBC) counts. B. Chemistries reveal an increased serum bilirubin level with slightly increased liver enzyme levels. C. Urinalysis reveals slight protein in the urine and bacteriuria, with pyuria. D. Serum electrolytes reveal a decreased sodium level and increased potassium level. Answer- C Rationale- In older adults, the protein found in urine slightly rises, probably as a result of kidney changes or subclinical urinary tract infections, and clients frequently experience asymptomatic bacteriuria and pyuria as a result of incomplete bladder emptying. Laboratory findings in options A, B, and D are not considered to be normal findings in an older adult. An older client is admitted with a diagnosis of bacterial pneumonia. Which symptom should the nurse report to the health care provider after assessing the client? A. Leukocytosis and febrile B. Polycythemia and crackles C. Pharyngitis and sputum production D. Confusion and tachycardia Answer- D Rationale- The onset of pneumonia in the older client may be signaled by general deterioration, confusion, increased heart rate, and/or increased respiratory rate. Options A, B, and C are often absent in the older client with bacterial pneumonia. The nurse is assessing a male client with acute pancreatitis. Which finding requires the most immediate intervention by the nurse? A. The client's amylase level is three times higher than the normal level. B. While the nurse is taking the client's blood pressure, he has a carpal spasm. C. On a 1 to 10 scale, the client tells the nurse that his epigastric pain is at 7. D. The client states that he will continue to drink alcohol after going home. Answer- B Rationale- A positive Trousseau sign indicates hypocalcemia and always requires further assessment and intervention, regardless of the cause (40% to 75% of those with acute pancreatitis experience hypocalcemia, which can have serious, systemic effects). A key diagnostic finding of pancreatitis is serum amylase and lipase levels that are two to five times higher than the normal value. Severe boring pain is an expected symptom for this diagnosis, but dealing with the hypocalcemia is a priority over administering an analgesic. Long-term planning and teaching do not have the same immediate importance as a positive Trousseau sign. A male client has just undergone a laryngectomy and has a cuffed tracheostomy tube in place. When initiating bolus tube feedings postoperatively, when should the nurse inflate the cuff? A. Immediately after feeding B. Just prior to tube feeding C. Continuous inflation is required D. Inflation is not required Answer- B Rationale- The cuff should be inflated before the feeding to block the trachea and prevent food from entering if oral feedings are started while a cuffed tracheostomy tube is in place. It should remain inflated throughout the feeding to prevent aspiration of food into the respiratory system. Options A and D place the client at risk for aspiration. Option C places the client at risk for tracheal wall necrosis. [Show Less]
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Adult Health 2 Hesi correctly answered 2023
A female patient's complex symptomatology over the past year has culminated in a diagnosis of systemic lupus erythematosus (SLE). Which of the patient's fo... [Show More] llowing statements demonstrates the need for further teaching about the disease? A. "I'll try my best to stay out of the sun this summer." B. "I know that I probably have a high chance of getting arthritis." C. "I'm hoping that surgery will be an option for me in the future." D. "I understand that I'm going to be vulnerable to getting infections." c. SLE carries an increased risk of infection, sun damage, and arthritis. Surgery is not a key treatment modality for SLE. Midazolam (Versed) has been ordered for a patient to be administered by injection 30 minutes prior to a colonoscopy. The nurse informs the patient that one of the most common side effects of this medication is which effect? A. Decreased heart rate B. Amnesia C. Constipation D. Dry mouth b. Versed is known to cause amnesia and anxiolysis as well as sedation and is therefore commonly used prior to certain procedures. The nurse is caring for a patient admitted with a spinal cord injury following a motor vehicle accident. The patient exhibits a complete loss of motor, sensory, and reflex activity below the injury level. The nurse recognizes this condition as which of the following? A. Central cord syndrome B. Spinal shock syndrome C. Anterior cord syndrome D. Brown-Séquard syndrome b. About 50% of people with acute spinal cord injury experience a temporary loss of reflexes, sensation, and motor activity that is known as spinal shock. Central cord syndrome is manifested by motor and sensory loss greater in the upper extremities than the lower extremities. Anterior cord syndrome results in motor and sensory loss but not reflexes. Brown-Séquard syndrome is characterized by ipsilateral loss of motor function and contralateral loss of sensory function. Which of the following clinical manifestations would the nurse interpret as representing neurogenic shock in a patient with acute spinal cord injury? A. Bradycardia B. Hypertension C. Neurogenic spasticity D. Bounding pedal pulses a. Neurogenic shock is due to the loss of vasomotor tone caused by injury and is characterized by hypotension and bradycardia. Loss of sympathetic innervation causes peripheral vasodilation, venous pooling, and a decreased cardiac output. The nurse is caring for a patient admitted 1 week ago with an acute spinal cord injury. Which of the following assessment findings would alert the nurse to the presence of autonomic dysreflexia? A. Tachycardia B. Hypotension C. Hot, dry skin D. Throbbing headache d. Autonomic dysreflexia is related to reflex stimulation of the sympathetic nervous system reflected by hypertension, bradycardia, throbbing headache, and diaphoresis. When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis is the highest priority? A. Risk for impairment of tissue integrity caused by paralysis B. Altered patterns of urinary elimination caused by quadriplegia C. Altered family and individual coping caused by the extent of trauma D. Ineffective airway clearance caused by high cervical spinal cord injury d. Maintaining a patent airway is the most important goal for a patient with a high cervical fracture. Although all of these are appropriate nursing diagnoses for a patient with a spinal cord injury, respiratory needs are always the highest priority. Remember the ABCs. The nurse is providing care for a patient who has been diagnosed with Guillain-Barré syndrome. Which of the following assessments should the nurse prioritize? A. Pain assessment B. Glasgow Coma Scale C. Respiratory assessment D. Musculoskeletal assessment c. Although all of the assessments are necessary in the care of patients with Guillain-Barré syndrome, the acute risk of respiratory failure necessitates vigilant monitoring of the patient's respiratory status. Which of the following signs and symptoms in a patient with a T4 spinal cord injury should alert the nurse to the possibility of autonomic dysreflexia? A. Headache and rising blood pressure B. Irregular respirations and shortness of breath C. Decreased level of consciousness or hallucinations D. Abdominal distention and absence of bowel sounds a. Among the manifestations of autonomic dysreflexia are hypertension (up to 300 mm Hg systolic) and a throbbing headache. Respiratory manifestations, decreased level of consciousness, and gastrointestinal manifestations are not characteristic. Which of the following interventions should the nurse perform in the acute care of a patient with autonomic dysreflexia? A. Urinary catheterization B. Administration of benzodiazepines C. Suctioning of the patient's upper airway D. Placement of the patient in the Trendelenburg position a. Because the most common cause of autonomic dysreflexia is bladder irritation, immediate catheterization to relieve bladder distention may be necessary. The patient should be positioned upright. Benzodiazepines are contraindicated and suctioning is likely unnecessary. Which of the following characteristics of a patient's recent seizure is congruent with a partial seizure? A. The patient lost consciousness during the seizure. B. The seizure involved lip smacking and repetitive movements. C. The patient fell to the ground and became stiff for 20 seconds. D. The etiology of the seizure involved both sides of the patient's brain. b. The most common complex partial seizure involves lip smacking and automatisms (repetitive movements that may not be appropriate). Loss of consciousness, bilateral brain involvement, and a tonic phase are associated with generalized seizure activity. Which of the following measures should the nurse prioritize when providing care for a patient with a diagnosis of multiple sclerosis (MS)? A. Vigilant infection control and adherence to standard precautions B. Careful monitoring of neurologic vital signs and frequent reorientation C. Maintenance of a calorie count and hourly assessment of intake and output D. Assessment of blood pressure and monitoring for signs of orthostatic hypotension a. Infection control is a priority in the care of patients with MS, since infection is the most common precipitator of an exacerbation of the disease. Decreases in cognitive function are less likely, and MS does not typically result in hypotension or fluid volume excess or deficit. A male patient with a diagnosis of Parkinson's disease (PD) has been admitted recently to a long-term care facility. Which of the following actions should the health care team take in order to promote adequate nutrition for this patient? A. Provide multivitamins with each meal. B. Provide a diet that is low in complex carbohydrates and high in protein. C. Provide small, frequent meals throughout the day that are easy to chew and swallow. D. Provide the patient with a minced or pureed diet that is high in potassium and low in sodium. c. Nutritional support is a priority in the care of individuals with PD. Such patients may benefit from meals that are smaller and more frequent than normal and that are easy to chew and swallow. Multivitamins are not necessary at each meal, and vitamin intake, along with protein intake, must be monitored to prevent contraindications with medications. It is likely premature to introduce a minced or pureed diet, and a low carbohydrate diet is not indicated. Which of the following nursing diagnoses is likely to be a priority in the care of a patient with myasthenia gravis (MG)? A. Acute confusion B. Bowel incontinence C. Activity intolerance D. Disturbed sleep pattern c. The primary feature of MG is fluctuating weakness of skeletal muscle. Bowel incontinence and confusion are unlikely signs of MG, and although sleep disturbance is likely, activity intolerance is usually of primary concern. The nurse who has administered a dose of risperidone (Risperdal) to a patient with delirium assesses for which of the following intended effects of the medication? A. Lying quietly in bed B. Alleviation of depression C. Reduction in blood pressure D. Disappearance of confusion a. Risperidone is an antipsychotic drug that reduces agitation and produces a restful state in patients with delirium. However, it should be used with caution. When providing community health care teaching regarding the early warning signs of Alzheimer?s disease, which of the following signs would the nurse advise family members to report (select all that apply)? A. Misplacing car keys B. Losing sense of time C. Difficulty performing familiar tasks D. Problems with performing basic calculations E. Becoming lost in a usually familiar environment b, c, d, e. [Show Less]
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Focus on Adult Health Exam with correct answers 2023
A nurse is monitoring a client who is taking spironolactone for the treatment of hypertension. Which findings denote adverse effects of the medication? Sel... [Show More] ect all that apply. Tall T waves Prolonged PR interval Hyperactive bowel sounds Rationale: Spironolactone is a potassium-sparing diuretic. Potassium-sparing diuretics can cause hyperkalemia. Cardiovascular manifestations of hyperkalemia include tall T waves, widened QRS complexes, prolonged PR intervals, and flat P waves. Other cardiovascular manifestations include an irregular heart rate, decreased blood pressure, and ectopic heartbeats. Muscle twitches occur in hyperkalemia. Hyperactive bowel sounds and diarrhea also occur in hyperkalemia. Constipation, hyporeflexia, and shallow respirations are signs of hypokalemia. A nurse is providing dietary instructions to a client with chronic obstructive pulmonary disease (COPD) who is experiencing a loss of appetite and complains of feeling "too full to eat." What does the nurse encourage the client to do? Select all that apply. Avoid drinking fluids before and during meals Select foods that are easy to chew and are not gas forming Rationale: COPD is a progressive and irreversible condition characterized by diminished inspiratory and expiratory capacity of the lungs. Instruct the client who complains of feeling too full to eat, to avoid drinking fluids before and during the meal. Dry foods such as crackers stimulate coughing; foods such as milk and chocolate may increase the thickness of saliva and secretions. Cheese is constipating and should also be avoided by the client. The nurse should also teach the client about foods that are easy to chew and do not encourage the formation of gas; for this reason, broccoli, which is a gas-forming food, should be avoided. A tuberculin skin test (TST) is administered to a client with a diagnosis of HIV infection. Forty-eight hours after administration, the nurse checks the test site (see image). Positive Rationale: The tuberculin, or TST, test is a reliable determinant of tuberculosis (TB) infection. A reaction measuring 5 mm or more in diameter is considered positive in a client with HIV infection. A reaction measuring 10 mm or more in diameter is considered positive in a non-immunosuppressed client. In this instance, the area of induration measures 9 mm, indicating a positive reaction. A positive reaction does not mean that active disease is present, but it does indicate exposure to TB or the presence of inactive (dormant) disease. A nurse is interpreting a central venous pressure (CVP) reading from a client in whom right ventricular failure has been diagnosed. From this diagnosis, the nurse would expect that the most likely result is a pressure of 14 cm H2O Rationale: CVP measurements are used to monitor blood volume and the adequacy of venous return to the heart. The CVP measures pressures from the right atrium or central veins. The normal CVP is 7 to 12 cm H2O. An increased CVP reading may indicate right ventricular failure. A low CVP reading may indicate hypovolemia. A reading of 4 cm H2O is low. Readings of 8 and 11 cm H2O are normal. A reading of 14 cm H2O is increased. A nurse is caring for a client who has just undergone thyroidectomy. Which technique is the best way for the nurse to assess the surgical site for bleeding? Checking for moisture on the back of the dressing over the client's neck and shoulders Rationale: Thyroid surgery may be complicated by hemorrhage, respiratory distress, parathyroid gland injury (resulting in hypocalcemia and tetany), damage to the laryngeal nerves, and thyroid storm. Hemorrhage is most likely during the 24 hours after surgery. If the client is bleeding after surgery, gravity will cause the blood to seep down the sides of the dressing and drain onto the underlying bed linens even as the top of the dressing remains clean and dry. Asking the client whether the dressing feels wet and replacing the dry sterile dressing every 2 hours are not the best actions. Replacing the dressing frequently when it is not warranted could also increase the risk of infection. A client who sustained a major burn injury is beginning to take an oral diet again. Which between-meal menu selections meet the client's needs for wound healing and tissue repair? Select all that apply. Whole-milk shake and granola Baked potato topped with cheese Cheese and whole-wheat crackers Rationale: To facilitate healing and meet continued high metabolic needs, the client with a major burn should eat a diet high in calories, protein, and carbohydrates. This type of diet also keeps the client in positive nitrogen balance. Foods such as milkshakes, granola, cheese, and whole-wheat products are acceptable choices. Though fresh fruits and vegetables and skim milk are high in nutrients, higher-calorie foods, including versions of dairy products prepared with whole milk, are preferable in this situation. A client is found to have hypoparathyroidism. Which nutritional supplement does the nurse, teaching the client about measures to manage the disorder, tell the client to take on a daily basis? Calcium carbonate with vitamin D Rationale: Hypoparathyroidism is an endocrine disorder in which parathyroid function is decreased. The client with hypoparathyroidism is likely to have low calcium and high phosphate levels and should consume a diet high in calcium but low in phosphorus. Additionally, the generally used treatment is calcium supplementation (either as calcium carbonate or calcium citrate) coupled with vitamin D supplementation. Vitamin C supplementation is not a treatment measure for this disorder. Beta-carotene is incorrect, because a client with hypoparathyroidism typically has an increased phosphorus level A nurse participating in a free health screening at the local mall obtains a random blood glucose level of 190 mg/dL (10.6 mmol/L) and a total cholesterol level of 210 mg/dL (5.4 mmol/L) in an otherwise healthy client. What should the nurse tell the client to do next? Call his health care provider to have these values rechecked as soon as possible Rationale: Adult diabetes mellitus may be diagnosed on the basis of symptoms (e.g., polydipsia, polyuria, polyphagia) or laboratory values. An abnormal glucose tolerance test, a random plasma glucose level greater than 200 mg/dL (11.1 mmol/L), and a fasting plasma glucose level greater than 140 mg/dL (7.8 mmol/L) on two separate occasions are all diagnostic of diabetes mellitus. The total cholesterol should be less than 200 mg/dL (5.2 mmol/L). Confirmation of this client's results is needed to ensure appropriate diagnosis and therapy. Levothyroxine sodium is prescribed for a client with hypothyroidism, and the nurse provides information to the client about the medication. Which occurrences does the nurse tell the client to report to the health care provider? Select all that apply. Chest pain Palpitations Rapid heart rate Rationale: The client taking levothyroxine sodium may have manifestations of hypothyroidism if the dosage is inadequate or may experience manifestations of hyperthyroidism if the dosage is too high. Thyroid preparations increase metabolic rate, oxygen demands, and demands on the heart, which may result in angina and cardiac dysrhythmias. The client should be instructed to report chest pain, palpitations, or a rapid heart rate immediately. Lethargy, constipation, and weight gain are symptoms of hypothyroidism, which should improve with medication therapy (e.g., levothyroxine sodium). A nurse is developing a plan of care for an older client with diabetic neuropathy of the lower extremities resulting from type 2 diabetes mellitus. Which problem does the nurse recognize as the highest priority for this client? Increased risk for injury Rationale: The client with diabetic neuropathy of the lower extremities has a diminished sensation in the legs and feet. This client is at risk for tissue injury and for falls as a result of this nervous system impairment. Therefore the highest priority nursing problem is increased risk for injury. Increased risk of depression and change in body image are more psychosocial in nature and, as such, are secondary needs. A lower level of physical activity may be a problem but is not the priority. The nurse is teaching a client with newly diagnosed diabetes mellitus who has been prescribed NPH insulin how to recognize the signs of hypoglycemia. The client states that he must look for certain signs and symptoms in the late afternoon, indicating to the nurse that he has understood the instructions. What are these signs and symptoms? Select all that apply. Shakiness Blurred vision Feelings of hunger Rationale: The client taking NPH insulin experiences peak medication effects 6 to 12 hours after administration. When the medication's action peaks, the client is at risk of hypoglycemia if food intake is insufficient. The nurse teaches the client to be alert for signs and symptoms of hypoglycemia, including anxiety, confusion, difficulty concentrating, blurred vision, cold sweats, headache, increased pulse, shakiness, and hunger. The other options are signs and symptoms of hyperglycemia Glargine insulin is prescribed for a client with type 1 diabetes mellitus. What does the nurse tell the client about this type of insulin? Select all that apply It does not have a peak effect. It is usually given once daily, at bedtime. It usually has a 24-hour duration of action Rationale: Glargine insulin, a long-acting basal insulin analog, has an onset of action of 1 to 2 hours, with no peak effect, and a duration of action of more than 24 hours. It is usually given once daily, preferably at bedtime. Glargine insulin may not be mixed in a syringe with other insulin. A client arrives in the emergency department after sustaining a chemical splash to the eye. The nurse immediately flushes the eye with copious amounts of normal saline solution for 15 minutes and then tests the pH of eye, using litmus paper. The nurse should continue the saline flushes until the pH test reads: 7.40 Rationale: First aid after a chemical burn to the eye consists of irrigation of the eye with copious amounts of tap water for at least 5 minutes. As soon as the initial irrigation is complete, the victim should be rushed to the nearest medical facility. On arrival, eye irrigation should be resumed with water or normal saline for 15 to 20 minutes or until all invasive material is gone and litmus paper reveals a pH of about 7.40. A quick test with litmus can be performed before, during, and after irrigations to determine the pH and to ascertain whether the substance was acid or alkaline. The normal body pH is 7.40. A nurse educator conducts an informational session for emergency department nurses about smallpox. Which statements by the nurse educator are correct? Select all that apply. Early clinical manifestations include influenza-like symptoms. Vaccinating within 3 days of exposure lowers the risk of active disease. Th infected person is infectious from the onset of the rash until the scabs separate. Rationale: Clinical manifestations of smallpox include sudden onset of influenza-like symptoms, including fever, malaise, headache, prostration, severe back pain, and, less often, abdominal pain and vomiting. Two to 3 days later, the temperature falls and the client feels somewhat better, at which time the characteristic rash appears, first on the face, hands, and forearms and then, after a few days, on the trunk. Lesions also develop in the mucous membranes of the nose and mouth and ulcerate very soon after their formation, releasing large amounts of virus into the mouth and throat. Smallpox is transmitted from person to person in infected aerosols and air droplets, especially if the symptoms include coughing. A person is considered infectious at the onset of the rash and until the rash scabs over, which is approximately 3 weeks. Airborne precautions are required even if the nurse has been vaccinated against smallpox, because the vaccine does not give reliable lifelong immunity. Those vaccinated within 2 or 3 days of exposure have a lesser risk of active disease. A nurse educator conducts an informational session for hospital nurses about skin anthrax. Which statements by the nurse educator are correct? Select all that apply. Skin anthrax can lead to septicemia if it goes untreated. Symptoms may appear as soon as 24 hours after exposure. Contact precautions are not always necessary with skin anthrax Rationale: Skin anthrax is transmitted through direct contact when spores from contaminated products enter the skin through cuts or abrasions. Person-to-person spread does not occur; therefore, contact precautions may not always be necessary. Symptoms may appear as early as 24 hours or as long as up to 7 days after exposure. Antibiotic treatment cures the skin infection, but, left untreated, skin anthrax results in overwhelming septicemia and death. Inhalation anthrax, transmitted through the inhalation of spores, begins with mild, nonspecific upper respiratory and flulike symptoms, including fever, muscle aches, and fatigue. A nurse is conducting an admission assessment of a client hospitalized with a diagnosis of Meniere's disease. Which question would elicit information specific to the attacks that occur with this disorder? "Do you have a feeling of fullness in your ear?" Rationale: Meniere's disease results from a disturbance in the fluid of the endolymphatic system. The cause of the disturbance is unknown. Attacks may be preceded by a feeling of fullness in the ear or by tinnitus. Headaches, difficulty speaking, and momentary losses of consciousness are not associated with this disorder. A nurse provides discharge instructions to a client who was hospitalized for an acute attack of Meniere's disease. Which statements by the nurse are correct? Select all that apply. Position changes should be made slowly. Underwater swimming should be avoided. It is best to switch to decaffeinated tea and coffee If an acute attack occurs, sit down and keep the eyes closed. Rationale: Meniere's disease results from a disturbance in the fluid of the endolymphatic system. The cause of the disturbance is unknown. If an acute attack of vertigo occurs, the client is instructed to immediately lie down on a firm surface if possible, loosen clothing, and close the eyes until the acute vertigo stops. Between attacks, the client may resume normal activities but should avoid underwater swimming, which may cause a loss of orientation. The nurse encourages the client to follow a low-salt diet and to avoid excessive use of caffeine, sugar, monosodium glutamate, and alcohol. The client should be taught to avoid sudden head movements or position changes. A client arrives at the emergency department and reports a buzzing sound in his ear. The client tells the nurse that an insect flew into the ear. Which intervention does the nurse take first to remove the insect? Instilling lidocaine into the ear Rationale: Insects that make their way into an ear are killed before removal unless they can be coaxed out with the use of a flashlight or a humming noise. Mineral oil, diluted alcohol, or lidocaine (not water) is instilled into the ear canal (or an ether-soaked cotton ball is placed in the ear) to suffocate the insect, which is then removed with the use of ear forceps. When the foreign object is vegetable matter, irrigation is not used, because this material expands with hydration, worsening the impaction becomes worse. Antibiotics may or may not be prescribed after removal of the insect. A home care nurse, assessing the skin of a client, notes the following rash beneath the skin: Which precaution will the nurse immediately institute before completing the assessment? Putting on a gown and gloves Rationale: Scabies presents as vesicle or pustule irritations, burrows, or rash of the skin, especially in the webbing between the fingers. When a client is infested with scabies, a gown and gloves should be worn for close contact. A mask and head covering are not necessary. Transmission by way of clothing and other inanimate objects is uncommon. Scabies is usually transmitted from person to person by way of direct skin contact. All of the client's contacts should be treated for the infestation at the same time. A nurse prepares to treat frostbite of the toes of a homeless man who was brought to the emergency department by the police. Which action by the nurse is appropriate? Continuously rewarming the toes in a warm-water bath for 15 to 20 minutes Rationale: Acute frostbite is ideally treated with rapid and continuous rewarming of the tissue in a warm-water bath (90˚ to 107˚ F [32.2 to 41.7˚C]) for 15 to 20 minutes or until flushing of the skin occurs. Slow thawing and interrupted periods of warmth are avoided because they contribute to increased cellular damage. Dry heat should never be applied, nor should the frostbitten areas be rubbed or massaged as part of the warming process; these actions may produce further tissue injury. [Show Less]
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HESI Patient Reviews--Adult Health-Hepatic-Biliary (Mrs. Bella) with complete solutions 2023
1. As you continue your assessment of Bell, you recall the pathophysiology of cirrhosis of the liver. Which statement best describes cirrhosis? Cirrhosis ... [Show More] is an irreversible loss of liver cells with scarring 2. Which situation about Bell's history increased her risk for cirrhosis of the liver? Chronic alcohol ingestion 3. Characteristic of advanced cirrhosis, Bell's abdomen is enlarged due to accumulation of fluid in the peritoneal cavity. This is called: Ascites 4. How does the HCP confirm that Bell has abdominal ascites? Percussion of dullness in dependent areas of the abdomen 5. In cirrhosis, which factors contribute to ascites? (Select 3) -Portal hypertension -Accumulation of antidiuretic hormone (ADH) -Hypoproteinemia 6. You and the HCP talk with Bell and examine her, checking for clinical signs of cirrhosis. What are the clinical signs of cirrhosis? (Select 5) -Nausea -Jaundice -Weight change -Ecchymosis -Peripheral edema 7. Bell has been hospitalized for less than a day. Assuming she was drinking heavily prior to admission, at this time she might exhibit signs and symptoms of early alcohol withdrawal. What are signs and symptoms of early alcohol withdrawal? (Select 5) -Anxiety -Agitation -Tremors -Irritability -Diaphoresis 8. The medical procedure that removes excess fluid from the peritoneal cavity is called: Paracentesis 9. How should you prepare Bell for the paracentesis? Ask her to void 10. After the HCP completes the paracentesis procedure, which nursing actions are indicated for Bell's care? (Select 2) -Monitor Bell's pulse and blood pressure frequently -Assess the procedure site and dressing 11. You work on Bell's plan of care. At this time, what is the major goal of nursing care for Bell? Improve Bell's nutritional status 12. The HCP's prescriptions reflect the need to carefully monitor Bell's fluid balance. Which of the following provides the most useful data for monitoring fluid loss or gain? Daily weights 13. You remind the HCP that she needs to prescribe a diet for Bell. Which diet is she likely to prescribe? High-carbohydrate, low-salt 14. When determining the extent of Bell's liver dysfunction, which blood tests are monitored? (Select 6) -Aspartate aminotransferase (AST) -Alanine aminotransferase (ALT) -Creatinine -Albumin -Ammonia -Prothrombin time (PT) 15. Bell's HCP is called away, but tells you she will return shortly to write more prescriptions. You anticipate that she will prescribe which medications? Propranolol or nadolol 16. Albumin is expected to alleviate Bell's ascites by which mechanism? Albumin will make the vascular compartment hypertonic, causing a fluid shift from the peritoneal cavity into the bloodstream 17. Until Bell's ascites is resolved, which position do you encourage her to take while she is in bed? Fowler's 18. Bell's skin and hair are dirty, and her skin is itchy from jaundice. Which action should the nurse take when bathing Bell and caring for her skin? Apply lotion to dry skin areas 19. After Bell is bathed, she uses a bedpan. Which of the following, if observed, should be reported? Melena 20. When a person with severe cirrhosis has esophageal or any other gastrointestinal (GI) bleeding, lactulose may be given. Which of the following are expected with administration of lactulose? (Select 2) -Onset of soft stools -Reduction of serum ammonia level 21. Bleeding from esophageal varices can be abrupt and massive. If a client at risk for varices started vomiting blood, which actions are important for the nurse to take? (Select 6) -Assess vital signs -Turn the client on her side -Prepare to administer oxygen -Prepare suctioning equipment -Insure an IV access -Prepare for insertion of a nasogastric tube [Show Less]
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Adult Health (HESI) final with complete solution 2023
An elderly patient has been put on a potentially toxic drug for treatment of arthritis. The patient and family have expressed concern about the drug. What ... [Show More] is the nurse's responsibility in this particular situation? provide information so that the patient can decide whether to accept or refuse the treatment The nurse is caring for a patient whose daughter wishes to pursue a career in nursing. The daughter wants to enroll in a program that is of short duration and makes her eligible to take the nursing license examination. Which educational program would the nurse recommend to this student? associates degree program in nursing The community health nurse is conducting a program on health and fitness awareness for medically under served people. Who would be categorized as medically under served? people of a poor socioeconomic status The nursing mentor observes that a nursing student is deficient in communication skills but is good at understanding nursing theories. How would the mentor intervene with respect to this student? help the student build nursing skills In a hospital, there is an acute shortage of nurses because of retirements. Which action would the remaining nurses take? Select all that apply. One, some, or all responses may be correct. -use the patient contact time efficiently -use the patient contact time professionally The nurse is caring for a patient with end-stage lung disease. The patient wants to go home on oxygen and be comfortable. The family wants the patient to have a new surgical procedure. The nurse explains the risks and benefits of the surgery to the family and discusses the patient's wishes with the family. Which role is the nurse playing for the patient? advocate Nurses are responsible for the quality of care provided to patients. Which will help nurses practice safe nursing? Select all that apply. One, some, or all responses may be correct. -acquiring knowledge -improving competencies -acquiring technical skills The nurse usually is assigned multiple patients at one time. Which action would the nurse take to ensure individual patient satisfaction? select all that apply. One, some, or all responses may be correct. -provide quality care to each patient -ensure that patients leave with a positive image of nursing -manage time, and approach all patients with compassion A 40 y/o man is diagnosed with colon cancer. While interacting with the patient, the nurse learns that he has a twin brother. Which nursing action is appropriate for the patient's brother? select all that apply. One, some, or all responses may be correct. -educate the patient's brother on reasons to get a colonoscopy -encourage the patient's brother to get an annual stool test The nurse is being appointed as nurse educator in a nursing school. Which responsibilities fall under the role of the nurse educator? provide student with practical and theoretical knowledge The senior nurse is explaining to the nurse who holds an associate degree in nursing about next steps in advanced nursing education. Which educational option would be included? Select all that apply. One, some, or all responses may be correct. -bachelor of science in nursing (BSN) -Bachelor in Nursing (BN) [Show Less]
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HESI-Focus on Adult Health with correct answers latest 2023
A nurse is monitoring a client who is taking spironolactone for the tx of HTN. Which findings denote adverse effects of this med SATA a) constipation b) ... [Show More] tall T waves c) hyporeflexia d) shallow resp e) prolonged PR interval f) hyperactive bowel sounds b, e, f a nurse is providing dietary instructions to a client with COPD who is experiencing a loss of appetitie and complains of feeling "too full to eat". What does the nurse encourage the client to do SATA a) avoid drinking fluids before and during meal b) eat a variety of dark-green vegetables such as broccoli c) have snacks, such as crackers and cheese, b/w meals d) select foods that are easy to chew and are not gas forming e) consume high-calorie drinks, such as milkshakes b/w meals a, d a nurse is interpreting a CVP reading from a client in whom right ventricular failure has been diagnosed. From this dx, the nurse would expect that the most likely results is a pressure of 14 cm H2O a nurse is caring for a client who has just undergone thyroidectomy. Which technique is the best way for the nurse to assess the surgical site for bleeding checking for moisture on the back of the dressing over the client's neck and shoulders a client who sustained a major burn is beginning to take an oral diet again. Which b/w meal menu selections meet the client's needs for wound healing and tissue repair SATA a) apple slices and skim milk b) whole milk a shake and granola c) baked potato topped with cheese d) cheese and whole wheat crackers e) cauliflower with low fat ranch dip b-d a client is found to have hypoparathyroidism. Which nutritional supplement does the nurse, teaching the client about measures to manage the disorder, tell the client to take on a daily basis calcium carbonate with vitamin D A nurse participating in a free health screening at the local mall obtains a random blood glucose level of 200 mg/dL on an otherwise healthy client. The nurse tells the client to do which of the following as a next step? call his HCP to have these values rechecked ASAP Levothyroxine sodium is prescribed for a client with hypothyroidism, and the nurse provides information to the client about the med. Which occurrences does the nurse tell the client to report to the HCP SATA a) lethargy b) chest pain c) palpitations d) weight gain e) constipation f) rapid heart rate b, c, f a nurse is developing a plan of care for an older client with diabetic neuropathy of the lower extremities resulting from type 2 DM. Which problem does the nurse recognize as the highest priority for this client increased risk for injury the nurse is teaching a client with newly diagnosed DM who has been prescribed NPH insulin how to recognize s/s of hypoglycemia. The client states that he must look for certain s/s in the late afternoon, indicating to the nurse that he has understood the instructions. What are these s/s SATA a) shakiness b) drowsiness c) blurred vision d) increased thirst e) feelings of hunger f) N&V a, c, e Glargine insulin is prescribed for a client with type 1 DM. What does the nurse tell the client about this type of insulin SATA a) it does not have a peak effect b) it is usually given once daily, at bedtime c) it usually has a 24 hour duration of action d) it may be mixed in a syringe with regular insulin e) its onset of action comes 4 hours after administration a-c a client arrives in the ED after sustaining a chemical splash to the eye. The nurse immediately flushes the eye with copious amounts of normal saline sltn for 15min and then tests the pH of the eye, using litmus paper. The nurse should continue the saline flushes until the pH test reads 7.40 [Show Less]
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