HESI RN
Adult Health 2 HESI Quizlet
1. A patient has a parenteral nutrition infusion of 25% dextrose. A student nurse asks the nurse why a peripherally inserted central catheter was inserted. Which response by the nurse is most appropriate?
- A. There is a decreased risk for infection when 25% dextrose is infused through a central line.
- B. The prescribed infusion can be given much more rapidly when the patient has a central line.
- C. The 25% dextrose is hypertonic and will be more rapidly diluted when given through a central line.
- D. The required blood glucose monitoring is more accurate when samples are obtained from a central line.
Correct answer: C
Rationale: The 25% dextrose solution is hypertonic. Shrinkage of red blood cells can occur when solutions with dextrose concentrations greater than 10% are administered IV. Blood glucose testing is not more accurate when samples are obtained from a central line. The infection risk is higher with a central catheter than with peripheral IV lines. Hypertonic or concentrated IV solutions are not given rapidly.
2. A client with bladder cancer had surgical placement of a ureteroileostomy (ileal conduit) yesterday. Which postoperative assessment finding should the nurse report to the healthcare provider immediately?
- A. red and edematous stoma appearance
- B. liquid brown drainage from stoma
- C. stoma output of 40ml in the last hour
- D. mucous strings floating in the drainage
Correct answer: C
Rationale: Stoma output of only 40ml in the last hour may indicate a problem, such as dehydration or blockage, and should be reported immediately. A red and edematous stoma appearance could be due to inflammation, which is expected in the early postoperative period. Liquid brown drainage from the stoma is a normal finding. Mucous strings floating in the drainage are also a common occurrence postoperatively and do not typically require immediate reporting.
3. The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give to this patient related to fluid intake?
- A. Increase fluids if your mouth feels dry.
- B. More fluids are needed if you feel thirsty.
- C. Drink more fluids in the late evening hours.
- D. If you feel lethargic or confused, you need more to drink.
Correct answer: A
Rationale: The correct answer is A. An alert, older patient can self-assess for signs of dehydration like dry mouth. This instruction is appropriate as it encourages the patient to respond to early signs of dehydration. Choice B is incorrect because the thirst mechanism decreases with age and feeling thirsty may not accurately indicate the need for fluids. Choice C is incorrect as many older patients prefer to limit evening fluid intake to enhance sleep quality. Choice D is incorrect because an older adult who is lethargic or confused may not be able to accurately assess their need for fluids.
4. The nurse is caring for a patient who has a central venous access device (CVAD). Which action by the nurse is appropriate?
- A. Avoid using friction when cleaning around the CVAD insertion site.
- B. Use the push-pause method to flush the CVAD after giving medications.
- C. Obtain an order from the healthcare provider to change the CVAD dressing.
- D. Position the patient’s face away from the CVAD during injection cap changes.
Correct answer: B
Rationale: The correct answer is B because using the push-pause method to flush the CVAD after giving medications helps remove debris from the CVAD lumen and decreases the risk for clotting. Choice A is incorrect because friction should be used when cleaning the CVAD insertion site to decrease infection risk. Choice C is incorrect because obtaining an order from the healthcare provider to change the CVAD dressing is not necessary; the dressing should be changed when damp, loose, or visibly soiled. Choice D is incorrect because the patient should face away from the CVAD during cap changes to minimize the risk of contamination.
5. The nurse requests a meal tray for a client who follows Mormon beliefs and who is on a clear liquid diet following abdominal surgery. Which menu items should the nurse request for this client? (Select all that apply)
- A. apple juice
- B. black coffee
- C. orange juice
- D. hot chocolate
Correct answer: A
Rationale: The correct answer is A: apple juice. Clear liquids like apple juice and orange juice are suitable for a client following a clear liquid diet and Mormon beliefs. Options B and D, black coffee and hot chocolate, contain caffeine, which may not align with the client's religious dietary restrictions. Therefore, these options should be avoided for this client.
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