Adult Health HESI review questions ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
exam with correct answers
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
A central venous catheter has been inserted via a jugular
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
vein, and a radiograph has confirmed placement of the ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
catheter. A prescription has been received for a ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
medication STAT, but IV fluids have not yet been started. ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Which action should the nurse take prior to administering ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
the prescribed medication? ||\\||\\ ||\\||\\
A. Assess for signs of jugular venous distention.
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
||\\||\\
||\\||\\ B. Obtain the needed intravenous solution.
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
||\\||\\
||\\||\\ C. Flush the line with heparinized solution.
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
||\\||\\
D. Flush the line with normal saline. - correct answers
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
✔✔Answer, D ||\\||\\
,Rationale- Medication can be administered via a central ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
line without additional IV fluids. The line should first be
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
flushed with a normal saline solution to ensure patency. ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Insufficient evidence exists on the effectiveness of ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
flushing catheters with heparin. Option A will not affect ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
the decision to administer the medication and is not a
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
priority. Administration of the medication STAT is of ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
greater priority than option B. ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
A client is ready for discharge following the creation of an
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
ileostomy. Which instruction should the nurse include in ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
discharge teaching? ||\\||\\
A. Replace the stoma appliance every day.
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
||\\||\\
||\\||\\ B. Use warm tap water to irrigate the ileostomy.
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
||\\||\\
||\\||\\ C. Change the bag when the seal is broken.
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
||\\||\\
,D. Measure and record the ileostomy output. - correct
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
answers ✔✔Answer- C ||\\||\\ ||\\||\\
Rationale- A seal must be maintained to prevent leakage ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
of irritating liquid stool onto the skin. Option A is excessive
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
and can cause skin irritation and breakdown. Ileostomies
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
produce liquid fecal drainage, so option B is not necessary. ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Option D is not needed.
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
An older male client comes to the outpatient clinic
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
complaining of pain in his left calf. The nurse notices a ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
reddened area on the calf of his right leg that is warm to ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
the touch, and the nurse suspects that the client may have
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
thrombophlebitis. Which additional assessment is most
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
important for the nurse to perform? ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
A. Measure the client's calf circumference.
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
||\\||\\
||\\||\\ B. Auscultate the client's breath sounds.
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
, ||\\||\\
||\\||\\ C. Observe for ecchymosis and petechiae.
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
||\\||\\
D. Obtain the client's blood pressure. - correct answers
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
✔✔Answer- B ||\\||\\
Rationale- All these techniques provide useful assessment ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
data. The most important is to auscultate the client's
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
breath sounds because the client may have a pulmonary ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
embolus secondary to the thrombophlebitis. Option A ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
may provide data that support the nurse's suspicion of
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
thrombophlebitis. Option C is the least helpful assessment ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
because bruising is not a typical finding associated with
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
thrombophlebitis. Option D is always useful in evaluating ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
the client's response to a problem but is of less immediate
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
priority than breath sound auscultation.
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
The nurse is caring for a critically ill client with cirrhosis of
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
the liver who has a nasogastric tube draining bright red
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
blood. The nurse notes that the client's serum ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
hemoglobin and hematocrit levels are decreased. Which ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
exam with correct answers
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
A central venous catheter has been inserted via a jugular
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
vein, and a radiograph has confirmed placement of the ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
catheter. A prescription has been received for a ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
medication STAT, but IV fluids have not yet been started. ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Which action should the nurse take prior to administering ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
the prescribed medication? ||\\||\\ ||\\||\\
A. Assess for signs of jugular venous distention.
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
||\\||\\
||\\||\\ B. Obtain the needed intravenous solution.
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
||\\||\\
||\\||\\ C. Flush the line with heparinized solution.
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
||\\||\\
D. Flush the line with normal saline. - correct answers
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
✔✔Answer, D ||\\||\\
,Rationale- Medication can be administered via a central ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
line without additional IV fluids. The line should first be
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
flushed with a normal saline solution to ensure patency. ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Insufficient evidence exists on the effectiveness of ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
flushing catheters with heparin. Option A will not affect ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
the decision to administer the medication and is not a
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
priority. Administration of the medication STAT is of ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
greater priority than option B. ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
A client is ready for discharge following the creation of an
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
ileostomy. Which instruction should the nurse include in ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
discharge teaching? ||\\||\\
A. Replace the stoma appliance every day.
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
||\\||\\
||\\||\\ B. Use warm tap water to irrigate the ileostomy.
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
||\\||\\
||\\||\\ C. Change the bag when the seal is broken.
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
||\\||\\
,D. Measure and record the ileostomy output. - correct
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
answers ✔✔Answer- C ||\\||\\ ||\\||\\
Rationale- A seal must be maintained to prevent leakage ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
of irritating liquid stool onto the skin. Option A is excessive
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
and can cause skin irritation and breakdown. Ileostomies
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
produce liquid fecal drainage, so option B is not necessary. ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Option D is not needed.
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
An older male client comes to the outpatient clinic
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
complaining of pain in his left calf. The nurse notices a ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
reddened area on the calf of his right leg that is warm to ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
the touch, and the nurse suspects that the client may have
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
thrombophlebitis. Which additional assessment is most
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
important for the nurse to perform? ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
A. Measure the client's calf circumference.
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
||\\||\\
||\\||\\ B. Auscultate the client's breath sounds.
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
, ||\\||\\
||\\||\\ C. Observe for ecchymosis and petechiae.
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
||\\||\\
D. Obtain the client's blood pressure. - correct answers
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
✔✔Answer- B ||\\||\\
Rationale- All these techniques provide useful assessment ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
data. The most important is to auscultate the client's
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
breath sounds because the client may have a pulmonary ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
embolus secondary to the thrombophlebitis. Option A ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
may provide data that support the nurse's suspicion of
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
thrombophlebitis. Option C is the least helpful assessment ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
because bruising is not a typical finding associated with
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
thrombophlebitis. Option D is always useful in evaluating ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
the client's response to a problem but is of less immediate
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
priority than breath sound auscultation.
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
The nurse is caring for a critically ill client with cirrhosis of
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
the liver who has a nasogastric tube draining bright red
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
blood. The nurse notes that the client's serum ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
hemoglobin and hematocrit levels are decreased. Which ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
