HESI RN
Adult Health 2 HESI Quizlet
1. A patient comes to the clinic complaining of frequent, watery stools for the last 2 days. Which action should the nurse take first?
- A. Obtain the baseline weight
- B. Check the patient’s blood pressure
- C. Draw blood for serum electrolyte levels
- D. Ask about any extremity numbness or tingling
Correct answer: B
Rationale: The correct answer is to check the patient’s blood pressure. Given the patient's symptoms of frequent, watery stools, there is a concern for fluid volume deficit. Assessing the blood pressure helps determine the patient's perfusion status, which is crucial in managing fluid volume deficits. While obtaining baseline weight, drawing blood for serum electrolyte levels, and asking about extremity numbness or tingling are important assessments, checking the blood pressure takes precedence as it provides immediate information on the patient's circulatory status.
2. A patient is admitted to the emergency department with severe fatigue and confusion. Laboratory studies are done. Which laboratory value will require the most immediate action by the nurse?
- A. Arterial blood pH is 7.32.
- B. Serum calcium is 18 mg/dL.
- C. Serum potassium is 5.1 mEq/L
- D. Arterial oxygen saturation is 91%.
Correct answer: B
Rationale: The correct answer is B. A serum calcium level of 18 mg/dL is significantly elevated, posing a high risk for cardiac dysrhythmias. Immediate action is required to initiate cardiac monitoring and notify the healthcare provider. While the abnormalities in arterial blood pH, serum potassium, and arterial oxygen saturation also need attention, they are not as immediately life-threatening as the critically high serum calcium level. Therefore, addressing the serum calcium level takes precedence in this scenario.
3. The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has a low serum total protein level. Which assessment finding indicates that the patient’s condition has improved?
- A. Hematocrit 28%
- B. Absence of skin tenting
- C. Decreased peripheral edema
- D. Blood pressure 110/72 mm Hg
Correct answer: C
Rationale: The decrease in peripheral edema indicates an improvement in the patient’s protein status. Edema is caused by low oncotic pressure in individuals with low serum protein levels. Good skin turgor is an indicator of fluid balance, not protein status. A low hematocrit could be caused by poor protein intake. Blood pressure does not provide a useful clinical tool for monitoring protein status.
4. A patient has a parenteral nutrition infusion of 25% dextrose. A student nurse asks the nurse why a peripherally inserted central catheter was inserted. Which response by the nurse is most appropriate?
- A. There is a decreased risk for infection when 25% dextrose is infused through a central line.
- B. The prescribed infusion can be given much more rapidly when the patient has a central line.
- C. The 25% dextrose is hypertonic and will be more rapidly diluted when given through a central line.
- D. The required blood glucose monitoring is more accurate when samples are obtained from a central line.
Correct answer: C
Rationale: The 25% dextrose solution is hypertonic. Shrinkage of red blood cells can occur when solutions with dextrose concentrations greater than 10% are administered IV. Blood glucose testing is not more accurate when samples are obtained from a central line. The infection risk is higher with a central catheter than with peripheral IV lines. Hypertonic or concentrated IV solutions are not given rapidly.
5. The nurse in the emergency department observes a colleague viewing the electronic health record (EHR) of a client who holds an elected position in the community. The client is not a part of the colleague's assignment. Which action should the nurse implement?
- A. Communicate the colleague's actions to the unit charge nurse
- B. Send an email to facility administration reporting the action
- C. Write an anonymous complaint to a professional website
- D. Post a comment about the action on a staff discussion board
Correct answer: A
Rationale: Viewing the EHR of a client who is not under your care is a violation of HIPAA regulations, regardless of the client's social status or your curiosity. The appropriate action to take in this situation is to communicate the colleague's actions to the unit charge nurse. The charge nurse can then escalate the issue through the appropriate channels within the organization. Reporting to the charge nurse ensures that the incident is handled internally and in accordance with organizational policies and procedures. Sending an email to facility administration, writing an anonymous complaint to a professional website, or posting a comment on a staff discussion board are not the recommended actions as they may not address the issue effectively and could potentially violate confidentiality further.
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