HESI RN
Adult Health 1 HESI
1. 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.
2. Which task can the registered nurse (RN) caring for a critically ill patient with multiple IV lines delegate to an experienced licensed practical/vocational nurse (LPN/LVN)?
- A. Administer IV antibiotics through the implantable port.
- B. Monitor the IV sites for redness, swelling, or tenderness.
- C. Remove the patient’s nontunneled subclavian central venous catheter.
- D. Adjust the flow rate of the 0.9% normal saline in the peripheral IV line.
Correct answer: B
Rationale: An experienced LPN/LVN can monitor IV sites for signs of infection because it falls within their education, experience, and scope of practice. Administering IV antibiotics through an implantable port, adjusting infusion rates, and removing central catheters are tasks that require RN level education and scope of practice. These activities involve a higher level of assessment, critical thinking, and potential complications that are typically within the RN's domain.
3. The nurse requests a meal tray for a client who follows Mormon beliefs and who is on a clear liquid diet following abdominal surgery. Which menu items should the nurse request for this client? (Select all that apply)
- A. apple juice
- B. black coffee
- C. orange juice
- D. hot chocolate
Correct answer: A
Rationale: The correct answer is A: apple juice. Clear liquids like apple juice and orange juice are suitable for a client following a clear liquid diet and Mormon beliefs. Options B and D, black coffee and hot chocolate, contain caffeine, which may not align with the client's religious dietary restrictions. Therefore, these options should be avoided for this client.
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. 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.
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