HESI RN
Adult Health 1 HESI
1. A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor while the patient is receiving this infusion?
- A. Lung sounds
- B. Urinary output
- C. Peripheral pulses
- D. Peripheral edema
Correct answer: A
Rationale: The correct answer is A: Lung sounds. Hypertonic solutions like 3% NaCl can cause water retention, leading to fluid excess. Monitoring lung sounds is crucial as crackles may indicate pulmonary edema, a serious manifestation of fluid excess. While monitoring urinary output, peripheral pulses, and peripheral edema are also important when administering hypertonic solutions, they do not provide immediate clues to acute respiratory or cardiac decompensation like lung sounds.
2. A patient with renal failure has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion. The patient arrives for outpatient hemodialysis and is unresponsive to questions and has decreased deep tendon reflexes. Which action should the dialysis nurse take first?
- A. Notify the patient’s health care provider.
- B. Obtain an order to draw a potassium level.
- C. Review the magnesium level on the patient’s chart.
- D. Teach the patient about the risk of magnesium-containing antacids
Correct answer: A
Rationale: The health care provider should be notified immediately. The patient has a history and manifestations consistent with hypermagnesemia. The nurse should check the chart for a recent serum magnesium level and make sure that blood is sent to the laboratory for immediate electrolyte and chemistry determinations. Dialysis should correct the high magnesium levels. The patient needs teaching about the risks of taking magnesium-containing antacids. Monitoring of potassium levels also is important for patients with renal failure, but the patient’s current symptoms are not consistent with hyperkalemia.
3. 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.
4. The nurse is teaching the parent of a child newly diagnosed with a latex allergy. Which information by the parents indicates a need for further teaching?
- A. Rubber-free toys, such as wooden building blocks, are good choices for the child.
- B. Only foil balloons will be used for the child's birthday party.
- C. A diet of healthy fruits, such as bananas and kiwis, is best for the child.
- D. An epinephrine auto-injector will be on hand to treat allergic reactions.
Correct answer: C
Rationale: The correct answer is C. Bananas and kiwis are foods that can cross-react with latex allergy, indicating that the parents need further teaching on managing latex allergies. Choices A, B, and D are correct as rubber-free toys, using foil balloons, and having an epinephrine auto-injector are appropriate measures to prevent and manage allergic reactions in a child with a latex allergy.
5. 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.
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