HESI RN
Adult Health 1 HESI
1. A postoperative client has three different PRN analgesics prescribed for different levels of pain. The nurse inadvertently administers a dose that is not within the prescribed parameters. What actions should the nurse take first?
- A. Assess for side effects of the medication.
- B. Document the client's responses.
- C. Complete a medication error report.
- D. Determine if the pain was relieved.
Correct answer: A
Rationale: This is a medication error, and the first step in addressing it is to assess for any side effects of the medication on the patient. Some analgesics can cause respiratory depression, so it is crucial to monitor for vital sign changes or respiratory distress. Once the patient is stable, the next steps would include contacting the provider, documenting the response, and completing a medication error report. Choices B, C, and D are not the immediate priority when dealing with a medication error. While documenting the client's responses and completing a medication error report are important, assessing for side effects and ensuring patient safety come first.
2. A child is diagnosed with acquired aplastic anemia. The nurse knows that this child has the best prognosis with which treatment regimen?
- A. blood transfusion
- B. chemotherapy
- C. bone marrow transplantation
- D. immunosuppressive therapy
Correct answer: C
Rationale: In the case of acquired aplastic anemia, bone marrow transplantation offers the best chance of cure as it replaces the abnormal stem cells with healthy ones. Blood transfusion may provide temporary relief by replacing blood cells, but it does not address the root cause of the condition. Chemotherapy may be used in some cases, but it is not the preferred treatment for acquired aplastic anemia. While immunosuppressive therapy can be effective, especially in patients who are not candidates for a bone marrow transplant, it is not the first-line treatment and does not offer the same potential for a cure as bone marrow transplantation.
3. A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct answer: A
Rationale: The patient's pH is below the normal range (7.35-7.45), and the HCO3 is also below the normal range (22-26 mEq/L), indicating an acidic environment, which is consistent with metabolic acidosis. The ABGs provided do not support respiratory acidosis or alkalosis, as the PaCO2 is within the normal range (35-45 mm Hg) despite the patient's deep, rapid respirations. Therefore, the correct interpretation is metabolic acidosis.
4. A patient with renal failure has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion. The patient arrives for outpatient hemodialysis and is unresponsive to questions and has decreased deep tendon reflexes. Which action should the dialysis nurse take first?
- A. Notify the patient’s health care provider.
- B. Obtain an order to draw a potassium level.
- C. Review the magnesium level on the patient’s chart.
- D. Teach the patient about the risk of magnesium-containing antacids
Correct answer: A
Rationale: The health care provider should be notified immediately. The patient has a history and manifestations consistent with hypermagnesemia. The nurse should check the chart for a recent serum magnesium level and make sure that blood is sent to the laboratory for immediate electrolyte and chemistry determinations. Dialysis should correct the high magnesium levels. The patient needs teaching about the risks of taking magnesium-containing antacids. Monitoring of potassium levels also is important for patients with renal failure, but the patient’s current symptoms are not consistent with hyperkalemia.
5. The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to the procedure?
- A. Experiences facial swelling after eating crab
- B. Reports left chest wall pain prior to the admission
- C. Verbalizes a fear of being in a confined space
- D. Drank a glass of water
Correct answer: A
Rationale: The correct answer is A. Allergy to shellfish can indicate a potential allergy to iodine, which is used in contrast dye for the procedure. This must be explored further to prevent an allergic reaction. Choice B is not directly related to the angioplasty procedure. Choice C pertains to claustrophobia, which can be addressed but is not directly related to the safety of the procedure. Choice D is a routine activity and does not pose a risk to the client during the procedure.
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