HESI RN
Adult Health 1 HESI
1. When assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate, which finding should the nurse report to the health care provider immediately?
- A. The bibasilar breath sounds are decreased.
- B. The patellar and triceps reflexes are absent.
- C. The patient has been sleeping most of the day.
- D. The patient reports feeling 'sick to my stomach.'
Correct answer: B
Rationale: The correct answer is B because the absence of patellar and triceps reflexes indicates potential magnesium toxicity, requiring immediate intervention. Nausea and lethargy are common side effects of elevated magnesium levels and should be reported, but they are not as critical as the loss of deep tendon reflexes. Decreased breath sounds suggest the need for coughing and deep breathing to prevent atelectasis, which is important but not as urgent as addressing magnesium toxicity.
2. A client has a serum potassium level of 6.5 mmol/L, a serum creatinine level of 2 mg/dL, and a urine output of 350 mL/day. What is the best action by the nurse?
- A. Place the client on a cardiac monitor immediately.
- B. Teach the client to limit high-potassium foods.
- C. Continue to monitor the client’s intake and output.
- D. Ask to have the laboratory redraw the blood specimen.
Correct answer: A
Rationale: The best immediate action by the nurse in this situation is to place the client on a cardiac monitor immediately. A serum potassium level of 6.5 mmol/L indicates hyperkalemia, which can lead to life-threatening dysrhythmias. Monitoring the cardiac status is crucial to detect any potential arrhythmias promptly. Teaching the client to limit high-potassium foods (Choice B) may be important for long-term management, but it is not the priority at this moment. Continuing to monitor intake and output (Choice C) is important for assessing renal function but does not address the immediate risk of dysrhythmias. Asking to have the laboratory redraw the blood specimen (Choice D) is unnecessary since the current results indicate a critical situation that requires immediate action.
3. A client in a long term care facility complains of pain. The nurse collects data about the client's pain. The first step in pain assessment is for the nurse to
- A. have the client identify coping methods
- B. get the description of the location and intensity of the pain
- C. accept the client's report of pain
- D. determine the client's status of pain
Correct answer: B
Rationale: The correct answer is B: 'get the description of the location and intensity of the pain.' When a client complains of pain, the initial step in pain assessment is to gather information about the location and intensity of the pain. This helps the nurse understand the nature of the pain and lays the groundwork for further assessment and management. Choice A is incorrect because identifying coping methods comes later in the assessment process. Choice C is incorrect as accepting the client's report of pain is important, but not the first step. Choice D is incorrect as determining the client's pain status also comes after gathering information about the pain.
4. The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse?
- A. Blood pressure is 90/40 mm Hg.
- B. Urine output is 30 mL over the last hour.
- C. Oral fluid intake is 100 mL over the last 8 hours.
- D. There is prolonged skin tenting over the sternum.
Correct answer: A
Rationale: The correct answer is A: "Blood pressure is 90/40 mm Hg." A low blood pressure reading of 90/40 mm Hg indicates that the patient may be developing hypovolemic shock due to intravascular fluid loss from the burn injury. This finding is of utmost concern as it suggests systemic hypoperfusion, requiring immediate intervention to prevent complications. Choices B, C, and D also indicate signs of dehydration and the need to increase fluid intake; however, they are not as urgent as addressing the hypotension and potential shock presented in choice A.
5. The client with newly diagnosed type 1 diabetes mellitus is being taught about insulin administration by the nurse. Which statement indicates that the client needs further teaching?
- A. I will inject my insulin into my abdomen for the fastest absorption.
- B. I will rotate injection sites to prevent lipodystrophy.
- C. I will store my insulin in the refrigerator at all times.
- D. I will rotate injection sites to prevent lipodystrophy.
Correct answer: C
Rationale: The correct answer is C. Insulin should not be stored in the refrigerator at all times; it should be kept at room temperature when in use to avoid irritation at the injection site. Storing insulin in the refrigerator can cause it to thicken and may lead to discomfort upon injection. Choices A and D are correct statements as injecting insulin into the abdomen for faster absorption and rotating injection sites to prevent lipodystrophy are appropriate insulin administration techniques. Therefore, the client does not need further teaching on these aspects.