HESI RN
Adult Health 2 HESI Quizlet
1. A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider?
- A. The patient is experiencing laryngeal stridor.
- B. The patient complains of generalized fatigue.
- C. The patient has not had a bowel movement for 4 days.
- D. The patient has numbness and tingling of the lips.
Correct answer: A
Rationale: The correct answer is A - 'The patient is experiencing laryngeal stridor.' Hypocalcemia can cause laryngeal stridor, which may lead to respiratory arrest. Rapid action is required to correct the patient’s calcium level to prevent a life-threatening situation. Choices B, C, and D are also symptoms of hypocalcemia, but laryngeal stridor takes precedence due to its potential to quickly progress to a critical condition.
2. A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse?
- A. The patient’s radial pulse is 105 beats/minute.
- B. There is sediment and blood in the patient’s urine.
- C. The blood pressure increases from 120/80 to 142/94.
- D. There are crackles audible throughout both lung fields.
Correct answer: D
Rationale: Crackles throughout both lungs suggest that the patient may be experiencing pulmonary edema, a life-threatening adverse effect of hypertonic solutions. The increased pulse rate and blood pressure and the presence of sediment and blood in the urine should also be reported, but they are not as immediately dangerous as the presence of fluid in the alveoli, which compromises gas exchange and can lead to respiratory failure.
3. When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the patient’s food tray?
- A. Grape juice
- B. Milk carton
- C. Mixed green salad
- D. Fried chicken breast
Correct answer: B
Rationale: The correct answer is B: Milk carton. Foods high in phosphate, like milk and other dairy products, are restricted on low-phosphate diets to manage renal failure. Green, leafy vegetables, high-fat foods, and fruits/juices are not high in phosphate and are not restricted. Therefore, grape juice, mixed green salad, and fried chicken breast do not need to be removed from the patient's food tray.
4. A patient who has small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the healthcare provider about which assessment finding?
- A. Reported weight gain
- B. Serum hematocrit of 42%
- C. Serum sodium level of 120 mEq/L
- D. Total urinary output of 280 mL during the past 8 hours
Correct answer: C
Rationale: The correct answer is C, a serum sodium level of 120 mEq/L. Hyponatremia is the most important finding to report in SIADH. SIADH causes water retention and a decrease in serum sodium levels. Hyponatremia can lead to confusion and other central nervous system effects and requires treatment. Adequate kidney function is indicated by a urinary output of at least 30 mL/hr. A hematocrit level of 42% is normal. Weight gain is expected due to water retention in SIADH.
5. An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately?
- A. K+ 3.4 mEq/L (3.4 mmol/L)
- B. Ca+2 7.8 mg/dL (1.95 mmol/L)
- C. Na+ 154 mEq/L (154 mmol/L)
- D. PO4-3 4.8 mg/dL (1.55 mmol/L)
Correct answer: C
Rationale: The correct answer is C. The elevated serum sodium level (154 mEq/L) is consistent with the patient's neurologic symptoms of restlessness, agitation, and weakness, indicating a need for immediate action to prevent complications like seizures. The potassium level (3.4 mEq/L) and calcium level (7.8 mg/dL) are slightly off from normal but do not require immediate action. The phosphate level (4.8 mg/dL) is normal and not related to the symptoms presented by the patient.
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