HESI RN
Adult Health 2 HESI Quizlet
1. A client with bladder cancer had surgical placement of a ureteroileostomy (ileal conduit) yesterday. Which postoperative assessment finding should the nurse report to the healthcare provider immediately?
- A. red and edematous stoma appearance
- B. liquid brown drainage from stoma
- C. stoma output of 40ml in the last hour
- D. mucous strings floating in the drainage
Correct answer: C
Rationale: Stoma output of only 40ml in the last hour may indicate a problem, such as dehydration or blockage, and should be reported immediately. A red and edematous stoma appearance could be due to inflammation, which is expected in the early postoperative period. Liquid brown drainage from the stoma is a normal finding. Mucous strings floating in the drainage are also a common occurrence postoperatively and do not typically require immediate reporting.
2. A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. What should the nurse do first?
- A. Suction the oral and nasal passages.
- B. Give oxygen by positive pressure.
- C. Stimulate the infant to cry.
- D. Turn the infant onto the right side.
Correct answer: A
Rationale: In a situation where an infant regurgitates and turns cyanotic, the priority action should be to clear any potential airway obstruction. Suctioning the oral and nasal passages is crucial to ensure the infant's airway is clear and allow for proper breathing. This intervention takes precedence over providing oxygen, stimulating the infant to cry, or repositioning the infant.
3. During an annual physical at a corporate clinic, a male employee tells the nurse that his high-stress job is causing trouble in his personal life. He further explains that he often gets so angry while driving to and from work that he has considered “getting even” with other drivers. How should the nurse respond?
- A. “Anger is contagious and could result in a major confrontation.”
- B. “Try not to let your anger cause you to act impulsively.”
- C. “Expressing your anger to a stranger could result in an unsafe situation.”
- D. “It sounds as if there are many situations that make you feel angry.”
Correct answer: B
Rationale: The correct response is to encourage the client to manage their anger and avoid impulsive actions, as stated in choice B. This approach helps the individual recognize the potential consequences of acting on their anger impulsively. Choice A is not the best response because it focuses on the contagious nature of anger rather than addressing the individual's behavior. Choice C is incorrect as it only highlights the potential dangers of expressing anger to a stranger without providing guidance on managing the underlying issue. Choice D acknowledges the client's feelings but does not offer practical advice on how to address the anger and potential impulsive actions.
4. A client who has been prescribed multiple antihypertensive medications experiences syncope and has a blood pressure of 70/40. What is the rationale for the nurse to hold the next scheduled antihypertensive dose?
- A. Increased urinary clearance of the medications has produced diuresis, lowering the blood pressure.
- B. The antagonistic interaction of the medications has reduced their effectiveness.
- C. The synergistic effect of the medications has resulted in drug toxicity, causing hypotension.
- D. The additive effect of the medications has lowered the blood pressure too much.
Correct answer: D
Rationale: The additive effect of multiple antihypertensive medications can cause hypotension, leading to dangerously low blood pressure. In this scenario, the client experiencing syncope with a blood pressure of 70/40 indicates severe hypotension, likely due to the combined action of the antihypertensive medications. Holding the next scheduled dose is essential to prevent further lowering of blood pressure and potential complications. Choices A, B, and C provide inaccurate explanations and do not align with the client's presentation and the need to manage hypotension caused by the additive effect of the medications.
5. A client with pneumonia is prescribed antibiotics. What is the most important teaching point for the nurse to provide?
- A. Instruct the client to rest as much as possible.
- B. Encourage increased fluid intake to thin secretions.
- C. Explain the importance of completing the entire course of antibiotics.
- D. Instruct the client to stop taking antibiotics once symptoms subside.
Correct answer: C
Rationale: The correct answer is C. Antibiotics must be taken for the entire prescribed duration to ensure that the infection is completely eradicated. Stopping antibiotics early, even if symptoms improve, can lead to a recurrence of the infection or antibiotic resistance. Choice A is incorrect because though rest is important, completing the antibiotic course is crucial. Choice B is incorrect as while hydration is beneficial, completing the antibiotics is the priority. Choice D is incorrect as stopping antibiotics prematurely can have negative consequences.