HESI RN
Adult Health 2 HESI Quizlet
1. Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room?
- A. Tie the knot with a double turn or square knot
- B. Ensure that the restraints are snug against the client's wrists
- C. Ensure that the knot can be quickly released
- D. Move the ties so the restraints are secured to the side rails
Correct answer: C
Rationale: The priority is to ensure that the knot can be quickly released to allow for quick intervention if necessary. Tying the knot with a double turn or square knot (Choice A) may make it more difficult to release quickly in an emergency. Ensuring that the restraints are snug against the client's wrists (Choice B) may compromise circulation and cause discomfort. Moving the ties to secure the restraints to the side rails (Choice D) is not the appropriate action as it can limit the client's movement and access to care.
2. 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.
3. A patient comes to the clinic complaining of frequent, watery stools for the last 2 days. Which action should the nurse take first?
- A. Obtain the baseline weight
- B. Check the patient’s blood pressure
- C. Draw blood for serum electrolyte levels
- D. Ask about any extremity numbness or tingling
Correct answer: B
Rationale: The correct answer is to check the patient’s blood pressure. Given the patient's symptoms of frequent, watery stools, there is a concern for fluid volume deficit. Assessing the blood pressure helps determine the patient's perfusion status, which is crucial in managing fluid volume deficits. While obtaining baseline weight, drawing blood for serum electrolyte levels, and asking about extremity numbness or tingling are important assessments, checking the blood pressure takes precedence as it provides immediate information on the patient's circulatory status.
4. The nurse is teaching the parent of a child newly diagnosed with a latex allergy. Which information by the parents indicates a need for further teaching?
- A. Rubber-free toys, such as wooden building blocks, are good choices for the child.
- B. Only foil balloons will be used for the child's birthday party.
- C. A diet of healthy fruits, such as bananas and kiwis, is best for the child.
- D. An epinephrine auto-injector will be on hand to treat allergic reactions.
Correct answer: C
Rationale: The correct answer is C. Bananas and kiwis are foods that can cross-react with latex allergy, indicating that the parents need further teaching on managing latex allergies. Choices A, B, and D are correct as rubber-free toys, using foil balloons, and having an epinephrine auto-injector are appropriate measures to prevent and manage allergic reactions in a child with a latex allergy.
5. The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has a low serum total protein level. Which assessment finding indicates that the patient’s condition has improved?
- A. Hematocrit 28%
- B. Absence of skin tenting
- C. Decreased peripheral edema
- D. Blood pressure 110/72 mm Hg
Correct answer: C
Rationale: The decrease in peripheral edema indicates an improvement in the patient’s protein status. Edema is caused by low oncotic pressure in individuals with low serum protein levels. Good skin turgor is an indicator of fluid balance, not protein status. A low hematocrit could be caused by poor protein intake. Blood pressure does not provide a useful clinical tool for monitoring protein status.
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