HESI RN
Adult Health 2 HESI Quizlet
1. How should the nurse interpret the following arterial blood gas results for a patient who had a tracheostomy placed after a motor vehicle crash: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct answer: D
Rationale: The patient's pH of 7.48 indicates alkalosis, and the low PaCO2 of 32 mm Hg suggests a respiratory cause. The HCO3 level is normal, ruling out metabolic causes. Therefore, the correct interpretation is respiratory alkalosis. Options A, B, and C are incorrect as they do not align with the pH and PaCO2 values provided.
2. The nurse requests a meal tray for a client who follows Mormon beliefs and who is on a clear liquid diet following abdominal surgery. Which menu items should the nurse request for this client? (Select all that apply)
- A. apple juice
- B. black coffee
- C. orange juice
- D. hot chocolate
Correct answer: A
Rationale: The correct answer is A: apple juice. Clear liquids like apple juice and orange juice are suitable for a client following a clear liquid diet and Mormon beliefs. Options B and D, black coffee and hot chocolate, contain caffeine, which may not align with the client's religious dietary restrictions. Therefore, these options should be avoided for this client.
3. 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.
4. A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the healthcare provider immediately that the patient is on which medication?
- A. Oral digoxin (Lanoxin) 0.25 mg daily
- B. Ibuprofen (Motrin) 400 mg every 6 hours
- C. Metoprolol (Lopressor) 12.5 mg orally daily
- D. Lantus insulin 24 U subcutaneously every evening
Correct answer: A
Rationale: The correct answer is A. Hypokalemia increases the risk for digoxin toxicity, which can lead to serious dysrhythmias. Therefore, with a low potassium level, the nurse should immediately alert the healthcare provider about the patient being on oral digoxin. Choices B, C, and D do not pose as much concern with the given potassium level. However, further assessment is still required for these medications.
5. The nurse is caring for a patient who has a central venous access device (CVAD). Which action by the nurse is appropriate?
- A. Avoid using friction when cleaning around the CVAD insertion site.
- B. Use the push-pause method to flush the CVAD after giving medications.
- C. Obtain an order from the healthcare provider to change the CVAD dressing.
- D. Position the patient’s face away from the CVAD during injection cap changes.
Correct answer: B
Rationale: The correct answer is B because using the push-pause method to flush the CVAD after giving medications helps remove debris from the CVAD lumen and decreases the risk for clotting. Choice A is incorrect because friction should be used when cleaning the CVAD insertion site to decrease infection risk. Choice C is incorrect because obtaining an order from the healthcare provider to change the CVAD dressing is not necessary; the dressing should be changed when damp, loose, or visibly soiled. Choice D is incorrect because the patient should face away from the CVAD during cap changes to minimize the risk of contamination.
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