Adult Health 1 HESI

HESI RN

1. An adult who has recurrent episodes of depression tells the nurse that the prescribed antidepressant needs to be discontinued because the client is feeling better after taking the medication for the past couple of weeks and does not like the side effects. Which response is best for the nurse to provide?

A. Remind the client that feeling better is the therapeutic effect of the medication.
B. Inform the client that gradual tapering must be used to discontinue the medication.
C. Tell the client to discuss the medication side effects with the healthcare provider.
D. Tell the client that the medication side effects will most likely diminish over time.

Correct answer: B

Rationale: The best response for the nurse is to inform the client that gradual tapering must be used to discontinue the medication. Abrupt cessation of antidepressants can lead to withdrawal symptoms or a recurrence of depressive symptoms. Choice A is not the best response as it does not address the need for a proper discontinuation plan. Choice C is not the best response as it focuses solely on the side effects and does not address the discontinuation process. Choice D is not the best response because while side effects may diminish over time, the focus here should be on the safe discontinuation of the medication to prevent adverse effects.

2. 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.

3. 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.

4. A client who has a body mass index (BMI) of 30 is requesting information on the initial approach to a weight loss plan. Which action should the nurse recommend first?

A. Plan low-carbohydrate and high-protein meals
B. Engage in moderate physical activity for an hour daily
C. Keep a record of food and drinks consumed daily
D. Participate in a group exercise class 3 times a week

Correct answer: C

Rationale: A BMI of 30 indicates the patient is obese. The first step in a weight loss plan should be to keep a food journal to track calorie intake, which can help in meal planning and creating a workout routine. Choice (A) suggests a dietary approach, which is important but not the first step. Choice (B) recommends strenuous activity, which may not be suitable for everyone and is not the initial step. Choice (D) involves group exercise, which can be beneficial but is not the primary action to take at the beginning of a weight loss plan.

5. A patient who is taking a potassium-wasting diuretic for the treatment of hypertension complains of generalized weakness. It is most appropriate for the nurse to take which action?

A. Assess for facial muscle spasms.
B. Ask the patient about loose stools.
C. Suggest that the patient avoid orange juice with meals.
D. Ask the healthcare provider to order a basic metabolic panel.

Correct answer: D

Rationale: Generalized weakness is a sign of hypokalemia, a potential side effect of potassium-wasting diuretics. By requesting a basic metabolic panel, the nurse can assess the patient's potassium levels. Facial muscle spasms are associated with hypocalcemia, not hypokalemia. Advising the patient to avoid orange juice, which is high in potassium, would be counterproductive if the patient is hypokalemic. Loose stools are typically seen in hyperkalemia, not hypokalemia.