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Hesi RN Adult Health

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Total Questions : 57

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Question 1:

A patient's data shows the following: Oxygen saturation is 94% on room air, pain is 4 on a scale of 0 to 10, temperature is 99.6°F (37.6°C) orally, and heart rate is 95 beats/minute.
Which physician orders would the nurse anticipate being prescribed after reporting these findings? Select all that apply.

A. Place client on oxygen 2 to 4 liters and maintain oxygen saturation at or above 95%. B. Stat ventilation/perfusion (V/Q) of chest. C. Stat 2 views chest x-ray. D. Stat Complete blood count (CBC), basic metabolic panel (BMP), and blood cultures. E. Send sputum for culture & sensitivity.

Answer and Explanation

Choice A:

The patient’s oxygen saturation is at 94%, which is just below the normal range of 95-100% for healthy adults breathing room air. Administering oxygen 2 to 4 liters to maintain oxygen saturation at or above 95% is a standard intervention to ensure adequate oxygenation.

Choice B:

A stat ventilation/perfusion (V/Q) scan is typically ordered for suspected pulmonary embolism, which is not indicated by the patient’s current data. The patient’s symptoms do not specifically suggest a V/Q mismatch that would necessitate this diagnostic test.

Choice C:

A chest x-ray is a common diagnostic tool for evaluating the lungs and heart, especially when a patient presents with symptoms that may indicate respiratory or cardiac issues. Given the patient’s temperature and heart rate, which are slightly elevated, a chest x-ray can help identify any potential underlying conditions.

Choice D:

Ordering a CBC, BMP, and blood cultures can help identify the cause of the patient’s fever and tachycardia. These tests provide valuable information about the patient’s immune response, electrolyte balance, kidney function, and whether there is a bacterial infection.

Choice E:

While sending sputum for culture and sensitivity could be helpful if a respiratory infection is suspected, the patient’s data does not strongly indicate a respiratory infection as the primary issue. Therefore, this test may not be the most immediate need.

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Question 2:

A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions. How should the nurse respond?

A. Instruct the client to avoid foods with gluten, such as wheat bread. B. Describe the use of an elimination diet to find trigger foods. C. Advise the client to limit foods that are high in calcium and iron. D. Explain that the need to restrict fluids is the primary limitation.

Answer and Explanation

Choice A:

While some individuals with Crohn's disease may find that avoiding gluten improves their symptoms, this is not a universal recommendation. Gluten restriction is more often indicated for those with celiac disease or gluten sensitivity. It's important to individualize dietary recommendations based on personal triggers and sensitivities.

Choice B:

An elimination diet is a systematic approach to identifying foods that may trigger or worsen Crohn's disease symptoms. It involves removing certain foods from the diet for a period of time, typically 2-4 weeks, and then gradually reintroducing them one at a time to observe any reactions. This process can help individuals pinpoint specific foods that contribute to their symptoms and make informed dietary choices to manage their condition.

Choice C:

There is no evidence to support a general restriction of calcium and iron in individuals with Crohn's disease. In fact, these nutrients are essential for overall health and should be consumed in adequate amounts unless a specific deficiency or intolerance is identified. Restriction of these nutrients could lead to nutritional deficiencies.

Choice D:

Fluid restriction is not a primary dietary limitation for individuals with Crohn's disease. Maintaining adequate hydration is crucial for overall health, especially during flares when fluid loss through diarrhea may be increased. Restricting fluids could potentially lead to dehydration and electrolyte imbalances.

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Question 3:

The nurse is caring for a client who has been admitted with a diagnosis of esophageal cancer.
The client reports a pain level of 8 on a 0 to 10 pain scale, dysphagia, anorexia, anxiety, and a hoarse voice. Which nursing problem is the priority for this client?

A. Chronic pain related to tissue destruction by tumor. B. Anxiety and grieving related to progression of disease. C. Risk for aspiration related to difficulty swallowing. D. Imbalanced nutrition: less than body requirements.

Answer and Explanation

Choice A:

Chronic pain is a significant concern for this client, but it is not the immediate priority. Pain can be managed with medications and comfort measures, while aspiration can be life-threatening. Tissue destruction by the tumor is likely contributing to the pain, but addressing the risk of aspiration takes precedence. Uncontrolled pain can exacerbate anxiety and make it difficult to focus on other interventions, but ensuring airway safety is paramount.

Choice B:

Anxiety and grieving are expected reactions to a diagnosis of esophageal cancer, and they should be addressed as part of the client's care plan. However, they are not the immediate priority in this case. The progression of the disease is a significant stressor, but attending to the risk of aspiration is essential for the client's safety. Psychological distress can negatively impact coping and quality of life, but addressing physical needs takes precedence.

Choice C:

C is the priority nursing problem because: The client's dysphagia puts them at immediate risk for aspiration, which can lead to pneumonia, respiratory failure, and even death. Addressing the risk of aspiration is essential to ensure the client's safety and prevent life-threatening complications. It's crucial to implement interventions to minimize the risk of aspiration, such as: Elevating the head of the bed during meals and for 30-60 minutes after eating Thickening liquids and pureeing foods Encouraging small, frequent meals Monitoring for signs of aspiration, such as coughing, choking, or difficulty breathing

Choice D:

Imbalanced nutrition is a concern for this client due to dysphagia and anorexia. However, it is not the immediate priority. Nutritional interventions can be implemented once the risk of aspiration is addressed. Difficulty swallowing can lead to inadequate intake and malnutrition, but ensuring airway safety is the primary concern. Anorexia can further contribute to nutritional deficits, but preventing aspiration is the most pressing issue.

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Question 4:

The client with Clostridium difficile in the stool receives a prescription for vancomycin PO. Which action should the nurse take before administering the first dose?

A. Measure oxygen saturation. B. Auscultate bowel sounds. C. Assess body temperature. D. Check serum creatinine.

Answer and Explanation

Choice B:

Auscultating bowel sounds, while a part of general abdominal assessment, is not the most crucial action before administering vancomycin. Vancomycin is not known to have significant effects on bowel motility, and its primary concern is nephrotoxicity.

Choice C:

Assessing body temperature can be helpful in evaluating for infection, but it is not the most specific or sensitive indicator of vancomycin-related adverse effects. Fever can be a sign of various conditions, and it does not directly assess kidney function.

Choice D:

Checking serum creatinine is the most essential action before administering vancomycin because it allows for assessment of kidney function. Vancomycin is primarily excreted by the kidneys, and impaired renal function can lead to elevated drug levels and increased risk of nephrotoxicity. By checking serum creatinine, the nurse can ensure that the patient's kidney function is adequate to safely excrete vancomycin and can adjust the dosage or frequency of administration if necessary.

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Question 5:

The patient is a 51-year-old male with pneumonia.
The patient has a history of hypertension and takes enalapril and a multivitamin daily.
His surgical history includes adenoid removal at age 4 and a surgical repair of a fractured tibia at age 20. Based on the information that the nurse has about the patient, what condition is he likely to have?

A. Dysrhythmia B. Toxicity C. Anemia D. Pneumonia

Answer and Explanation

Choice A:

A: Dysrhythmia There is no information in the question stem to suggest that the patient is experiencing a dysrhythmia. Dysrhythmias are abnormal heart rhythms that can be caused by a variety of factors, including heart disease, electrolyte imbalances, and medications. While it is possible that the patient could develop a dysrhythmia as a complication of pneumonia, there is no evidence to support this in the given information. Additionally, enalapril, which the patient is taking for hypertension, is not typically associated with an increased risk of dysrhythmias. Rationale for

Choice B:

B: Toxicity There is no information in the question stem to suggest that the patient is experiencing toxicity. Toxicity can be caused by a variety of substances, including medications, drugs, and environmental toxins. While it is possible that the patient could develop toxicity as a complication of pneumonia, there is no evidence to support this in the given information. Additionally, the patient's medication regimen of enalapril and a multivitamin is not typically associated with an increased risk of toxicity. Rationale for

Choice C:

C: Anemia There is no information in the question stem to suggest that the patient is anemic. Anemia is a condition in which there is a decreased number of red blood cells or hemoglobin in the blood. While it is possible that the patient could develop anemia as a complication of pneumonia, there is no evidence to support this in the given information. Additionally, the patient's surgical history of adenoid removal and a fractured tibia is not typically associated with an increased risk of anemia. Rationale for

Choice D:

D: Pneumonia The patient is a 51-year-old male with a diagnosis of pneumonia. Pneumonia is an infection of the lungs that can be caused by bacteria, viruses, or fungi. The patient's symptoms, such as cough, fever, and difficulty breathing, are all consistent with a diagnosis of pneumonia. Additionally, the patient's medical history of hypertension does not rule out pneumonia, and in fact, some studies have shown that hypertension may be a risk factor for developing pneumonia. Therefore, pneumonia is the most likely condition that the patient has based on the information provided.

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Question 6:

Patient Data shows that on Day 1, there were no active processes.
On Day 2, there were small bilateral lower lobes pulmonary infiltrates with the right lower lobe showing increased involvement compared to the left side.
What is the likely diagnosis?

A. Pneumonia B. Tuberculosis C. Bronchitis D. Pulmonary Embolism

Answer and Explanation

Choice A:

Pneumonia is the most likely diagnosis given the rapid development of pulmonary infiltrates within a 24-hour period. Pneumonia is an infection of the lungs that can be caused by bacteria, viruses, or fungi. It typically presents with symptoms such as fever, cough, shortness of breath, and chest pain. The presence of pulmonary infiltrates on imaging studies, such as a chest X-ray, is a key diagnostic feature of pneumonia. The distribution of the infiltrates, involving the lower lobes with a predominance on the right side, is also consistent with pneumonia. This is because the lower lobes are more susceptible to pneumonia due to their anatomy and gravity. The absence of active processes on Day 1 makes other diagnoses less likely. For example, tuberculosis typically develops more slowly over weeks or months, and bronchitis usually does not cause pulmonary infiltrates. Pulmonary embolism can cause pulmonary infiltrates, but it would typically be associated with other symptoms such as sudden onset of shortness of breath, chest pain, and tachycardia.

Choice B:

Tuberculosis is a chronic infection that typically develops slowly over weeks or months. It is less likely to cause rapid development of pulmonary infiltrates as seen in this case. Tuberculosis often involves the upper lobes of the lungs, and it may be associated with other symptoms such as fever, night sweats, and weight loss.

Choice C:

Bronchitis is an inflammation of the bronchi, the large airways that carry air to the lungs. It typically causes a cough, but it does not usually cause pulmonary infiltrates. Bronchitis is often caused by a virus, and it usually resolves on its own within a few weeks.

Choice D:

Pulmonary embolism is a blockage of a pulmonary artery, one of the blood vessels that carries blood to the lungs. It can cause pulmonary infiltrates, but it would typically be associated with other symptoms such as sudden onset of shortness of breath, chest pain, and tachycardia. Pulmonary embolism is often caused by a blood clot that travels from a vein in the leg to the lungs.

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Question 7:

A patient who is newly diagnosed with erosive esophagitis secondary to gastroesophageal reflux disease (GERD) reports to the home health nurse that there has been only a minimal reduction in symptoms after taking lansoprazole PO for one full week.
Which action should the nurse take?

A. Auscultate the patient's bowel sounds and measure the abdominal girth. B. Confirm that the patient is taking the medication one hour after meals. C. Notify the healthcare provider that the patient may need a change in dosage. D. Advise the patient that healing typically takes several weeks to occur.

Answer and Explanation

Choice A:

A: Auscultating bowel sounds and measuring abdominal girth would not provide relevant information for assessing the effectiveness of lansoprazole therapy for erosive esophagitis. These assessments are typically used to evaluate gastrointestinal motility and distention, which are not primary concerns in this case. While bowel sounds can provide some information about gastrointestinal activity, they do not directly correlate with the degree of esophageal inflammation or healing. Similarly, abdominal girth measurements are more useful for monitoring conditions such as ascites or bowel obstruction, which are not related to erosive esophagitis. Rationale for

Choice B:

B: Confirming the timing of medication administration is important for adherence, but it would not be the most appropriate initial action in this scenario. Lansoprazole is typically taken 30-60 minutes before meals to optimize its acid-suppressing effects. However, even if the patient is taking the medication correctly, they may still require a dosage adjustment to achieve adequate symptom control. Rationale for

Choice C:

C: This is the most appropriate action because it directly addresses the possibility that the current dosage of lansoprazole is insufficient to manage the patient's symptoms effectively. The healthcare provider can evaluate the patient's response to therapy and determine if a dosage increase is necessary. In some cases, patients with erosive esophagitis may require twice-daily dosing of lansoprazole or a switch to a different proton pump inhibitor (PPI) to achieve optimal symptom relief and healing. Rationale for

Choice D:

D: While it is true that healing of erosive esophagitis typically takes several weeks, the patient's minimal symptom improvement after one week of treatment suggests that a more proactive approach is warranted. Simply advising the patient to wait for healing to occur could potentially delay necessary adjustments to the treatment regimen, prolonging the patient's discomfort and potentially increasing the risk of complications.

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Question 8:

The patient's Hemoglobin A1C today is 8.29% and was 7.59% three months ago. The reference range is 4 to 5.99%. What is the likely diagnosis?

A. Diabetes Mellitus B. Hypoglycemia C. Hyperglycemia D. Prediabetes

Answer and Explanation

Choice A:

Hemoglobin A1C (HbA1C) is a blood test that reflects a person's average blood glucose levels over the past 2-3 months. It's considered the gold standard for diagnosing and monitoring diabetes. An HbA1C level of 8.29% is significantly elevated above the reference range of 4-5.99%, indicating a high probability of diabetes. The patient's HbA1C has also increased from 7.59% three months ago, suggesting a worsening of glycemic control. Diabetes mellitus is a chronic metabolic disorder characterized by elevated blood glucose levels due to impaired insulin production or action, or both. Common symptoms of diabetes include increased thirst, frequent urination, fatigue, blurred vision, and slow-healing wounds. Early diagnosis and treatment of diabetes are crucial to prevent complications such as heart disease, stroke, kidney disease, nerve damage, and vision loss.

Choice B:

Hypoglycemia refers to abnormally low blood glucose levels, typically below 70 mg/dL. It's often caused by excessive insulin or medication, missed meals, or strenuous exercise. The patient's HbA1C level of 8.29% does not support a diagnosis of hypoglycemia.

Choice C:

Hyperglycemia refers to abnormally high blood glucose levels, typically above 180 mg/dL. It can be caused by diabetes, stress, infection, or certain medications. While the patient's HbA1C level does indicate hyperglycemia, it's specifically the pattern of elevated HbA1C over time that points to a diagnosis of diabetes mellitus, rather than transient hyperglycemia.

Choice D:

Prediabetes is a condition where blood glucose levels are higher than normal, but not high enough to be classified as diabetes. People with prediabetes are at increased risk of developing diabetes. The patient's HbA1C level of 8.29% is above the threshold for prediabetes, which is typically 5.7-6.4%.

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Question 9:

A client receives a prescription for ophthalmic ketorolac.
Prior to administering the medication, the nurse should review the medical record for which condition?

A. Radiation exposure B. Corneal abrasion C. Chemical burn D. Foreign body

Answer and Explanation

Choice A:

Radiation exposure to the eye is a serious condition that requires immediate medical attention. However, it is not a contraindication for ophthalmic ketorolac. In fact, ketorolac may be used to treat pain and inflammation associated with radiation exposure to the eye. Ophthalmic ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) that works by inhibiting the production of prostaglandins, which are substances that cause inflammation and pain. Radiation exposure can damage the cells of the eye, leading to inflammation and pain. Ketorolac can help to reduce these symptoms. However, it is important to note that ketorolac does not address the underlying cause of radiation exposure, and further treatment may be necessary.

Choice B:

Corneal abrasion is a scratch on the surface of the cornea, the clear outer layer of the eye. It is a common eye injury that can be caused by a variety of factors, such as getting poked in the eye, rubbing the eye too hard, or wearing contact lenses for too long. Ophthalmic ketorolac is contraindicated in patients with corneal abrasions because it can delay healing and increase the risk of infection. This is because ketorolac inhibits the production of prostaglandins, which are involved in the healing process. Prostaglandins also play a role in fighting infection. Therefore, using ketorolac in a patient with a corneal abrasion could potentially lead to a more serious infection.

Choice C:

Chemical burn to the eye is a serious injury that requires immediate medical attention. Ophthalmic ketorolac is not typically used to treat chemical burns to the eye. This is because ketorolac is not effective in reducing inflammation caused by chemical burns. In addition, ketorolac can potentially worsen the injury by delaying healing.

Choice D:

Foreign body in the eye is a common eye injury that can be caused by a variety of objects, such as dust, sand, or metal shavings. Ophthalmic ketorolac is not typically used to treat foreign bodies in the eye. This is because ketorolac will not help to remove the foreign body from the eye. In addition, ketorolac can potentially worsen the injury by delaying healing.

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Question 10:

While changing a client’s postoperative dressing, the nurse observes purulent drainage at the wound.

Before reporting this finding to the healthcare provider, which of the client’s laboratory values should the nurse note?

A. Culture for sensitive organisms. B. C-reactive protein level. C. Blood pH level. D. Serum blood glucose level.

Answer and Explanation

Choice A:

Direct identification of the causative organism: A culture for sensitive organisms is the most direct and definitive way to identify the specific bacteria or other microorganisms that are causing the infection in the wound. This information is crucial for guiding the selection of the most appropriate antibiotic therapy. Tailored antibiotic therapy: By knowing the exact organism responsible, healthcare providers can prescribe antibiotics that are specifically effective against that organism, ensuring optimal treatment and reducing the risk of antibiotic resistance. Informed infection control measures: The results of the culture can also inform appropriate infection control measures to prevent the spread of the infection to other patients or healthcare workers. Monitoring treatment effectiveness: Cultures can also be used to monitor the effectiveness of antibiotic therapy. If the culture results show that the bacteria are no longer present after a course of antibiotics, this indicates that the treatment has been successful.

Choice B:

Non-specific marker of inflammation: C-reactive protein (CRP) is a non-specific marker of inflammation that can be elevated in various conditions, including infections, but also in non-infectious conditions such as autoimmune diseases and trauma. Limited diagnostic value for wound infections: While an elevated CRP level may suggest the presence of an infection, it does not provide information about the specific causative organism, which is essential for guiding antibiotic therapy. Supplementary role: CRP levels can be used in conjunction with other clinical findings and laboratory tests to assess the severity of an infection and monitor the response to treatment, but it should not be relied upon as a sole diagnostic tool for wound infections.

Choice C:

Not directly indicative of wound infection: Blood pH level primarily reflects the acid-base balance of the body and is not directly indicative of a wound infection. Alterations in other conditions: Blood pH can be altered in various conditions, including respiratory and metabolic disorders, and is not specific to wound infections. Limited role in diagnosis: While significant alterations in blood pH may suggest a serious systemic infection, it does not provide information about the location or causative organism of the infection.

Choice D:

Not directly related to wound infection: Serum blood glucose level is primarily used to monitor diabetes and is not directly related to wound infections. Impaired wound healing in diabetes: While elevated blood glucose levels can impair wound healing and increase the risk of infections in diabetic patients, it is not a diagnostic test for wound infections in general. Secondary consideration: Blood glucose levels may be considered as part of the overall assessment of a patient with a wound infection, particularly in those with diabetes, but it is not a primary diagnostic tool.

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Total Questions : 57

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Hesi RN Adult Health

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