Adult Health 1 HESI

Adult Health 1 HESI Related

Review Adult Health 1 HESI related questions and content

A male client with unstable angina needs a cardiac catheterization. So the healthcare provider explains the risks and benefits of the procedure and then leaves to set up for the procedure. When the nurse presents the consent form for signature, the client hesitates and asks how the wires will keep his heart going. Which action should the nurse take?

  • A. Answer the client's specific questions with a short, understandable explanation
  • B. Postpone the procedure until the client understands the risks and benefits
  • C. Call the client's next of kin and ask them to provide verbal consent
  • D. Page the healthcare provider to return and provide additional explanation
Correct Answer: D

Rationale: The correct action for the nurse to take in this situation is to page the healthcare provider to return and provide additional explanation. It is crucial for the client to have a clear understanding of the procedure, including its risks and benefits, before signing the consent form. While the nurse can provide general information, the detailed explanation of how the procedure works and its effects should come from the healthcare provider who will perform the procedure. Postponing the procedure until the client understands is appropriate, but the immediate need is to clarify the client's concerns with the healthcare provider. Calling the client's next of kin for verbal consent is not the correct course of action as the client is present and able to provide consent after receiving adequate information.

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Following a thyroidectomy, a patient complains of "a tingling feeling around my mouth." Which assessment should the nurse complete immediately?

  • A. Presence of the Chvostek's sign
  • B. Abnormal serum potassium level
  • C. Decreased thyroid hormone level
  • D. Bleeding on the patient's dressing
Correct Answer: A

Rationale: The correct assessment the nurse should complete immediately is checking for the presence of the Chvostek's sign. The patient's complaint of tingling around the mouth is indicative of hypocalcemia, which can result from parathyroid injury/removal during thyroidectomy. The Chvostek's sign is a clinical indication of hypocalcemia, where facial muscle twitching occurs when the facial nerve is tapped. Assessing serum potassium levels (choice B) is not the priority in this situation. While thyroid hormone levels (choice C) play a role in overall health, they do not directly relate to the patient's current symptoms. Checking for bleeding on the dressing (choice D) is important but not the immediate priority when addressing potential hypocalcemia.

The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse?

  • A. Blood pressure is 90/40 mm Hg.
  • B. Urine output is 30 mL over the last hour.
  • C. Oral fluid intake is 100 mL over the last 8 hours.
  • D. There is prolonged skin tenting over the sternum.
Correct Answer: A

Rationale: The correct answer is A: "Blood pressure is 90/40 mm Hg." A low blood pressure reading of 90/40 mm Hg indicates that the patient may be developing hypovolemic shock due to intravascular fluid loss from the burn injury. This finding is of utmost concern as it suggests systemic hypoperfusion, requiring immediate intervention to prevent complications. Choices B, C, and D also indicate signs of dehydration and the need to increase fluid intake; however, they are not as urgent as addressing the hypotension and potential shock presented in choice A.

When assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate, which finding should the nurse report to the health care provider immediately?

  • A. The bibasilar breath sounds are decreased.
  • B. The patellar and triceps reflexes are absent.
  • C. The patient has been sleeping most of the day.
  • D. The patient reports feeling 'sick to my stomach.'
Correct Answer: B

Rationale: The correct answer is B because the absence of patellar and triceps reflexes indicates potential magnesium toxicity, requiring immediate intervention. Nausea and lethargy are common side effects of elevated magnesium levels and should be reported, but they are not as critical as the loss of deep tendon reflexes. Decreased breath sounds suggest the need for coughing and deep breathing to prevent atelectasis, which is important but not as urgent as addressing magnesium toxicity.

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.

A postoperative client has three different PRN analgesics prescribed for different levels of pain. The nurse inadvertently administers a dose that is not within the prescribed parameters. What actions should the nurse take first?

  • A. Assess for side effects of the medication.
  • B. Document the client's responses.
  • C. Complete a medication error report.
  • D. Determine if the pain was relieved.
Correct Answer: A

Rationale: This is a medication error, and the first step in addressing it is to assess for any side effects of the medication on the patient. Some analgesics can cause respiratory depression, so it is crucial to monitor for vital sign changes or respiratory distress. Once the patient is stable, the next steps would include contacting the provider, documenting the response, and completing a medication error report. Choices B, C, and D are not the immediate priority when dealing with a medication error. While documenting the client's responses and completing a medication error report are important, assessing for side effects and ensuring patient safety come first.

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