HESI RN
Adult Health 2 HESI Quizlet
1. A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction and is complaining of anxiety and incisional pain. The patient’s respiratory rate is 32 breaths/minute and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first?
- A. Discontinue the nasogastric suction.
- B. Give the patient the PRN IV morphine sulfate 4 mg.
- C. Notify the health care provider about the ABG results.
- D. Teach the patient how to take slow, deep breaths when anxious.
Correct answer: B
Rationale: The patient’s respiratory alkalosis is caused by the increased respiratory rate associated with pain and anxiety. The nurse’s first action should be to medicate the patient for pain. Although the nasogastric suction may contribute to the alkalosis, it is not appropriate to discontinue the tube when the patient needs gastric suction. The health care provider may be notified about the ABGs but is likely to instruct the nurse to medicate for pain. The patient will not be able to take slow, deep breaths when experiencing pain.
2. A client who is receiving long-term steroid therapy complains of blurred vision. Which intervention should the nurse implement first?
- A. Instruct the client to use artificial tears to lubricate the eyes
- B. Administer an ophthalmic antibiotic as prescribed
- C. Arrange for the client to see an optometrist for an eye exam
- D. Notify the healthcare provider immediately
Correct answer: D
Rationale: The correct answer is to notify the healthcare provider immediately (Option D). Blurred vision in a client on long-term steroid therapy can be a sign of serious conditions like cataracts or glaucoma, which need urgent medical evaluation and management. Instructing the client to use artificial tears (Option A) may help with dry eyes but does not address the underlying cause of blurred vision. Administering an ophthalmic antibiotic (Option B) is not indicated unless there is a specific infection present. Referring the client to an optometrist for an eye exam (Option C) may delay necessary medical intervention by the healthcare provider, who should be involved promptly in this situation.
3. A client is undergoing hemodialysis. The client’s blood pressure at the beginning of the procedure was 136/88 mm Hg, and now it is 110/54 mm Hg. What actions should the nurse perform to maintain blood pressure? (Select all that apply.)
- A. Adjust the rate of extracorporeal blood flow.
- B. Place the client in the Trendelenburg position.
- C. Administer a 250-mL bolus of normal saline.
- D. All of the above
Correct answer: D
Rationale: During hemodialysis, a drop in blood pressure can occur due to fluid removal. To maintain blood pressure, the nurse should consider adjusting the rate of extracorporeal blood flow to optimize fluid removal without causing hypotension. Placing the client in the Trendelenburg position can help improve venous return and cardiac output. Administering a bolus of normal saline can help increase intravascular volume and support blood pressure. Therefore, all the actions listed in choices A, B, and C are appropriate measures to maintain blood pressure during hemodialysis. Choice D, 'All of the above,' is the correct answer as it encompasses all the relevant actions to address the dropping blood pressure effectively. Choices A, B, and C, when implemented together, can help manage hypotension during hemodialysis.
4. The healthcare provider is assessing a client with hypothyroidism. Which of the following clinical findings would the healthcare provider expect?
- A. Tachycardia
- B. Weight loss
- C. Cold intolerance
- D. Diaphoresis
Correct answer: C
Rationale: Cold intolerance is a classic symptom of hypothyroidism. In hypothyroidism, the body's metabolic rate is decreased, leading to a reduced ability to regulate body temperature. As a result, individuals with hypothyroidism often feel cold, especially in their extremities. Tachycardia (A) is more commonly associated with hyperthyroidism due to the increased metabolic rate. Weight loss (B) is also a typical finding in hyperthyroidism, as the body burns calories at a faster rate. Diaphoresis (D), excessive sweating, is not a typical symptom of hypothyroidism.
5. The nurse is monitoring a client who is receiving continuous ambulatory peritoneal dialysis. The nurse should notify the physician of which of the following findings?
- A. Clear dialysate outflow.
- B. Cloudy dialysate outflow.
- C. Decreased urine output.
- D. Increased blood pressure.
Correct answer: B
Rationale: Cloudy dialysate outflow is an indication of peritonitis, a serious complication of peritoneal dialysis that requires immediate medical attention. Clear dialysate outflow is a normal finding indicating proper dialysis function and should not raise concern. Decreased urine output may be expected in a client undergoing dialysis due to the removal of excess fluids from the body. Increased blood pressure is a common complication in clients with kidney disease but is not directly related to cloudy dialysate outflow.