ADULT HEALTH 1 HESI TEST BANK EXAM NEWEST 2024-2025 ACTUAL EXAM COMPLETE 250 QUESTIONS
AND CORRECT DETAILED 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. - (answer) 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.
,ADULT HEALTH 1 HESI TEST BANK EXAM NEWEST 2024-2025 ACTUAL EXAM COMPLETE 250 QUESTIONS
AND CORRECT DETAILED ANSWERS
D. Measure and record the ileostomy output. - (answer) 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. - (answer) 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.
,ADULT HEALTH 1 HESI TEST BANK EXAM NEWEST 2024-2025 ACTUAL EXAM COMPLETE 250 QUESTIONS
AND CORRECT DETAILED ANSWERS
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 additional change in laboratory data should the nurse expect?
A. Increased serum albumin level
B. Decreased serum creatinine
C. Decreased serum ammonia level
D. Increased liver function test results - (answer) Answer- C
Rationale- The breakdown of glutamine in the intestine and the increased activity of colonic bacteria
from the digestion of proteins increase ammonia levels in clients with advanced liver disease, so removal
of blood, a protein source, from the intestine results in a reduced level of ammonia. Options A, B, and D
will not be significantly affected by the removal of blood.
What is digoxin - (answer) Blood pressure medication with high toxicity
Signs of hyperkalemia - (answer) Tall/spiked T waves, prolonged QT interval, widening QRS wave
The breakdown of glutamine in the intestine and the increased activity of colonic bacteria from the
digestion of proteins increase ammonia levels in clients with advanced liver disease, so removal of blood,
a protein source, from the intestine results in a reduced level of ammonia. Options A, B, and D will not
be significantly affected by the removal of blood.
A. Reduce the daily intake of animal fat to 10% of the diet within 6 weeks.
, ADULT HEALTH 1 HESI TEST BANK EXAM NEWEST 2024-2025 ACTUAL EXAM COMPLETE 250 QUESTIONS
AND CORRECT DETAILED ANSWERS
B. Exhibit regular, soft-formed stool within 1 month.
C. Demonstrate the irrigation procedure correctly within 1 week.
D. Attend an ostomy support group within 2 weeks. - (answer) Answer- D, attend an ostomy support
group within 2 weeks
Rationale- Attending a support group will be beneficial to the client and should be encouraged because
adaptation to the ostomy can be difficult. This goal is attainable and is measurable. Option A is not
specifically related to ileostomy care. The client with an ileostomy will not be able to accomplish option
B. Option C is not necessary.
The nurse is administering a nystatin suspension for stomatitis. Which instruction will the nurse provide
to the client when administering this medication?
A. "Hold the medication in your mouth for a few minutes before swallowing it."
B. "Do not drink or eat milk products for 1 hour prior to taking this medication."
C. "Dilute the medication with juice to reduce the unpleasant taste and odor."
D. "Take the medication before meals to promote increased absorption." - (answer) Answer- A
Rationale- Nystatin suspension is prescribed for fungal infections of the mouth. The client should swish
the medication in the mouth for 2 minutes and then swallow. Option B does not affect administration of
this medication. The medication should not be diluted because this will reduce its effectiveness. Option
D is not necessary.
AND CORRECT DETAILED 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. - (answer) 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.
,ADULT HEALTH 1 HESI TEST BANK EXAM NEWEST 2024-2025 ACTUAL EXAM COMPLETE 250 QUESTIONS
AND CORRECT DETAILED ANSWERS
D. Measure and record the ileostomy output. - (answer) 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. - (answer) 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.
,ADULT HEALTH 1 HESI TEST BANK EXAM NEWEST 2024-2025 ACTUAL EXAM COMPLETE 250 QUESTIONS
AND CORRECT DETAILED ANSWERS
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 additional change in laboratory data should the nurse expect?
A. Increased serum albumin level
B. Decreased serum creatinine
C. Decreased serum ammonia level
D. Increased liver function test results - (answer) Answer- C
Rationale- The breakdown of glutamine in the intestine and the increased activity of colonic bacteria
from the digestion of proteins increase ammonia levels in clients with advanced liver disease, so removal
of blood, a protein source, from the intestine results in a reduced level of ammonia. Options A, B, and D
will not be significantly affected by the removal of blood.
What is digoxin - (answer) Blood pressure medication with high toxicity
Signs of hyperkalemia - (answer) Tall/spiked T waves, prolonged QT interval, widening QRS wave
The breakdown of glutamine in the intestine and the increased activity of colonic bacteria from the
digestion of proteins increase ammonia levels in clients with advanced liver disease, so removal of blood,
a protein source, from the intestine results in a reduced level of ammonia. Options A, B, and D will not
be significantly affected by the removal of blood.
A. Reduce the daily intake of animal fat to 10% of the diet within 6 weeks.
, ADULT HEALTH 1 HESI TEST BANK EXAM NEWEST 2024-2025 ACTUAL EXAM COMPLETE 250 QUESTIONS
AND CORRECT DETAILED ANSWERS
B. Exhibit regular, soft-formed stool within 1 month.
C. Demonstrate the irrigation procedure correctly within 1 week.
D. Attend an ostomy support group within 2 weeks. - (answer) Answer- D, attend an ostomy support
group within 2 weeks
Rationale- Attending a support group will be beneficial to the client and should be encouraged because
adaptation to the ostomy can be difficult. This goal is attainable and is measurable. Option A is not
specifically related to ileostomy care. The client with an ileostomy will not be able to accomplish option
B. Option C is not necessary.
The nurse is administering a nystatin suspension for stomatitis. Which instruction will the nurse provide
to the client when administering this medication?
A. "Hold the medication in your mouth for a few minutes before swallowing it."
B. "Do not drink or eat milk products for 1 hour prior to taking this medication."
C. "Dilute the medication with juice to reduce the unpleasant taste and odor."
D. "Take the medication before meals to promote increased absorption." - (answer) Answer- A
Rationale- Nystatin suspension is prescribed for fungal infections of the mouth. The client should swish
the medication in the mouth for 2 minutes and then swallow. Option B does not affect administration of
this medication. The medication should not be diluted because this will reduce its effectiveness. Option
D is not necessary.
