Adult Health 2 HESI
A nurse is caring for a client with DI. Which data warrants the most immediate intervention by the
nurse?
a. Serum sodium of 185
b. Dry skin with inelastic turgor
c. Apical rate of 110 beats per minute
d. Polyuria and excessive thirst - (correct Answer) - a. Serum sodium of 185
The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD).
Which subjective data reported by the client supports this medical diagnosis?
a. Frequent use of chewable and liquid antacids for indigestion
b. severe abdominal cramps and diarrhea after eating spicy foods
c. upper mid-abdominal pain described as gnawing and burning.
d. Marked loss of weight and appetite over the last 3 or 4 months - (correct Answer) - c. upper mid-
abdominal pain described as gnawing and burning.
The nurse assess a client who is newly diagnosed with hyperthyroidism and observes that the client's
eyeballs are protuberant, causing a wide-eyed appearance and eye discomfort. Based on this finding,
which action should the nurse include in this client's plan of care?
a. Assess for signs of increased intracranial pressure
b. Prepare to administer intravenous levothyroxine
c. Review the client's serum electrolyte values
d. Obtain a prescription for artificial tear drops - (correct Answer) - d. Obtain a prescription for artificial
tear drops
To reduce the risk for pulmonary complication for a client with Amyotrophic Lateral Sclerosis (ALS),
which interventions should the nurse implement? (Select all)
a. Perform chest physiotherapy
, b. Teach the client breathing exercises
c. Initiate passive range of motion exercises
d. Establish a regular bladder routine
e. Encourage use of incentive spriometer - (correct Answer) - a. Perform chest physiotherapy
b. Teach the client breathing exercises
e. Encourage use of incentive spriometer
A client hospitalized with heart failure (HF). Which intervention should the nurse implement to improve
ventilation and reduce venous return?
a. Perform passive range of motion exercises
b. Place the client in high fowler position
c. Administer oxygen per nasal canula
d. Increase the client's activity level - (correct Answer) - b. Place the client in high fowler position
A client who was involved in a motor vehicle collision is admitted with a fractured left femur which is
immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF).
The nurse determines that the client's distal pulses are diminished in the left foot. Which interventions
should the nurse implement? (select all)
a. Verify pedal pulses using a doppler pulse device
b. Evaluate the application of the splint to the left leg.
c. Offer ice chips and oral clear liquids.
d. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure
3. Administer oral antispasmodics and narcotic analgesics - (correct Answer) - a. Verify pedal pulses
using a doppler pulse device
b. Evaluate the application of the splint to the left leg
d. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure
The healthcare provider prescribes diagnostic tests for a client whose chest X-ray indicates pneumonia.
Which diagnostic test should the nurse review for implementation in the most therapeutic treatment of
the pneumonia?
a. Sputum culture and sensitivity
A nurse is caring for a client with DI. Which data warrants the most immediate intervention by the
nurse?
a. Serum sodium of 185
b. Dry skin with inelastic turgor
c. Apical rate of 110 beats per minute
d. Polyuria and excessive thirst - (correct Answer) - a. Serum sodium of 185
The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD).
Which subjective data reported by the client supports this medical diagnosis?
a. Frequent use of chewable and liquid antacids for indigestion
b. severe abdominal cramps and diarrhea after eating spicy foods
c. upper mid-abdominal pain described as gnawing and burning.
d. Marked loss of weight and appetite over the last 3 or 4 months - (correct Answer) - c. upper mid-
abdominal pain described as gnawing and burning.
The nurse assess a client who is newly diagnosed with hyperthyroidism and observes that the client's
eyeballs are protuberant, causing a wide-eyed appearance and eye discomfort. Based on this finding,
which action should the nurse include in this client's plan of care?
a. Assess for signs of increased intracranial pressure
b. Prepare to administer intravenous levothyroxine
c. Review the client's serum electrolyte values
d. Obtain a prescription for artificial tear drops - (correct Answer) - d. Obtain a prescription for artificial
tear drops
To reduce the risk for pulmonary complication for a client with Amyotrophic Lateral Sclerosis (ALS),
which interventions should the nurse implement? (Select all)
a. Perform chest physiotherapy
, b. Teach the client breathing exercises
c. Initiate passive range of motion exercises
d. Establish a regular bladder routine
e. Encourage use of incentive spriometer - (correct Answer) - a. Perform chest physiotherapy
b. Teach the client breathing exercises
e. Encourage use of incentive spriometer
A client hospitalized with heart failure (HF). Which intervention should the nurse implement to improve
ventilation and reduce venous return?
a. Perform passive range of motion exercises
b. Place the client in high fowler position
c. Administer oxygen per nasal canula
d. Increase the client's activity level - (correct Answer) - b. Place the client in high fowler position
A client who was involved in a motor vehicle collision is admitted with a fractured left femur which is
immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF).
The nurse determines that the client's distal pulses are diminished in the left foot. Which interventions
should the nurse implement? (select all)
a. Verify pedal pulses using a doppler pulse device
b. Evaluate the application of the splint to the left leg.
c. Offer ice chips and oral clear liquids.
d. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure
3. Administer oral antispasmodics and narcotic analgesics - (correct Answer) - a. Verify pedal pulses
using a doppler pulse device
b. Evaluate the application of the splint to the left leg
d. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure
The healthcare provider prescribes diagnostic tests for a client whose chest X-ray indicates pneumonia.
Which diagnostic test should the nurse review for implementation in the most therapeutic treatment of
the pneumonia?
a. Sputum culture and sensitivity
