Adult Health 1 HESI

HESI RN

1. A patient is admitted for hypovolemia associated with multiple draining wounds. Which assessment would be the most accurate way for the nurse to evaluate fluid balance?

A. Skin turgor
B. Daily weight
C. Presence of edema
D. Hourly urine output

Correct answer: B

Rationale: Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor varies considerably with age and can be affected by various factors other than fluid balance. Presence of edema indicates excess fluid has moved into the interstitial space, which may not always be directly correlated with overall fluid balance. Hourly urine outputs, though important, do not provide a comprehensive picture of fluid balance as they do not consider fluid intake, insensible losses, or other sources of fluid loss.

2. When assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate, which finding should the nurse report to the health care provider immediately?

A. The bibasilar breath sounds are decreased.
B. The patellar and triceps reflexes are absent.
C. The patient has been sleeping most of the day.
D. The patient reports feeling 'sick to my stomach.'

Correct answer: B

Rationale: The correct answer is B because the absence of patellar and triceps reflexes indicates potential magnesium toxicity, requiring immediate intervention. Nausea and lethargy are common side effects of elevated magnesium levels and should be reported, but they are not as critical as the loss of deep tendon reflexes. Decreased breath sounds suggest the need for coughing and deep breathing to prevent atelectasis, which is important but not as urgent as addressing magnesium toxicity.

3. A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor while the patient is receiving this infusion?

A. Lung sounds
B. Urinary output
C. Peripheral pulses
D. Peripheral edema

Correct answer: A

Rationale: The correct answer is A: Lung sounds. Hypertonic solutions like 3% NaCl can cause water retention, leading to fluid excess. Monitoring lung sounds is crucial as crackles may indicate pulmonary edema, a serious manifestation of fluid excess. While monitoring urinary output, peripheral pulses, and peripheral edema are also important when administering hypertonic solutions, they do not provide immediate clues to acute respiratory or cardiac decompensation like lung sounds.

4. A female client's significant other has been at her bedside providing reassurances and support for the past 3 days, as desired by the client. The client's estranged husband arrives and demands that the significant other not be allowed to visit or be given condition updates. Which intervention should the nurse implement?

A. Obtain a court order to enforce visitation rights for the significant other
B. Request a consultation with the ethics committee for resolution of the situation
C. Suggest involving security to manage the conflict between the husband and the significant other
D. Discuss with the client the importance of setting clear boundaries with both individuals

Correct answer: B

Rationale: In this situation, where there is a conflict between the client's significant other and estranged husband, the most appropriate intervention is to request a consultation with the ethics committee for resolution. This ensures that an impartial body can assess the situation, consider the rights and preferences of all parties involved, and provide guidance on how to proceed in a fair and ethical manner. Obtaining a court order (Choice A) may be a legal option but should be considered after exhausting other conflict resolution methods. Involving security (Choice C) may escalate the situation and should only be considered if there is a risk of harm. Discussing boundaries with the client (Choice D) is important but may not immediately address the current conflict between the significant other and the husband.

5. What is the first action the nurse should take when a patient complains of acute chest pain and dyspnea soon after insertion of a centrally inserted IV catheter?

A. Notify the health care provider.
B. Offer reassurance to the patient.
C. Auscultate the patient’s breath sounds
D. Give the prescribed PRN morphine sulfate IV

Correct answer: C

Rationale: The correct first action for the nurse to take when a patient complains of acute chest pain and dyspnea after the insertion of a centrally inserted IV catheter is to auscultate the patient's breath sounds. This is important to assess for any potential complications such as embolism or pneumothorax, which can present with such symptoms. Auscultation can provide immediate information on the patient's respiratory status and guide further interventions. Notifying the health care provider, offering reassurance, or administering morphine should only be considered after assessing the patient's condition through auscultation.