Adult Health Exam 1 (all possible questions with 100% correct answers) 2024 LATEST VERSION
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Course
ADULT HEALTH HESI
Institution
ADULT HEALTH HESI
1. 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 for the last 8 hours. d. There is prolo...
Adult Health Exam 1 (all possible questions with 100%
correct answers)
1. 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 for the last 8 hours. d.
There is prolonged skin tenting over the sternum. correct answers ANS: A The blood pressure
indicates that the patient may be developing hypovolemic shock as a result of intravascular fluid
loss due to the burn injury. This finding will require immediate intervention to prevent the
complications associated with systemic hypoperfusion. The poor oral intake, decreased urine
output, and skin tenting all indicate the need for increasing the patients fluid intake but not as
urgently as the hypotension.
2. A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate
antidiuretic hormone (SIADH). The nurse should notify the health care provider about which
assessment finding? a. Reported weight gain b. Serum hematocrit of 42% c. Serum sodium level
of 120 mg/dL d. Total urinary output of 280 mL during past 8 hours correct answers ANS: C
Hyponatremia is the most important finding to report. SIADH causes water retention and a
decrease in serum sodium level. Hyponatremia can cause confusion and other central nervous
system effects. A critically low value likely needs to be treated. At least 30 mL/hr of urine output
indicates adequate kidney function. The hematocrit level is normal. Weight gain is expected with
SIADH because of water retention.
3. A patient is admitted for hypovolemia associated with multiple draining wounds. Which
assessment would be the most accurate way for the nurse to evaluate fluid balance? a. Skin
turgor b. Daily weight c. Presence of edema d. Hourly urine output correct answers ANS: B
Daily weight is the most easily obtained and accurate means of assessing volume status. Skin
turgor varies considerably with age. Considerable excess fluid volume may be present before
fluid moves into the interstitial space and causes edema. Although very important, hourly urine
outputs do not take account of fluid intake or of fluid loss through insensible loss, sweating, or
loss from the gastrointestinal tract or wounds.
4. 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 answers ANS: A An alert, older patient will be able to self-assess for signs of oral
dryness such as thick oral secretions or dry- appearing mucosa. The thirst mechanism decreases
with age and is not an accurate indicator of volume depletion. Many older patients prefer to
restrict fluids slightly in the evening to improve sleep quality. The patient will not be likely to
notice and act appropriately when changes in level of consciousness occur.
5. A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains
of generalized weakness. It is most appropriate for the nurse to take which action? a. Assess for
facial muscle spasms. b. Ask the patient about loose stools. c. Suggest that the patient avoid
,orange juice with meals. d. Ask the health care provider to order a basic metabolic panel. correct
answers ANS: D Generalized weakness is a manifestation of hypokalemia. After the health care
provider orders the metabolic panel, the nurse should check the potassium level. Facial muscle
spasms might occur with hypocalcemia. Orange juice is high in potassium and would be
advisable to drink if the patient was hypokalemic. Loose stools are associated with
hyperkalemia.
6. Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which
statement by the patient indicates that the teaching about this medication has been effective? a. I
will try to drink at least 8 glasses of water every day. b. I will use a salt substitute to decrease my
sodium intake. c. I will increase my intake of potassium-containing foods. d. I will drink apple
juice instead of orange juice for breakfast correct answers ANS: D Because spironolactone is a
potassium-sparing diuretic, patients should be taught to choose low-potassium foods (e.g., apple
juice) rather than foods that have higher levels of potassium (e.g., citrus fruits). Because the
patient is using spironolactone as a diuretic, the nurse would not encourage the patient to
increase fluid intake. Teach patients to avoid salt substitutes, which are high in potassium.
7. A newly admitted patient is diagnosed with hyponatremia. When making room assignments,
the charge nurse should take which action? a. Assign the patient to a room near the nurses
station. b. Place the patient in a room nearest to the water fountain. c. Place the patient on
telemetry to monitor for peaked T waves. d. Assign the patient to a semi-private room and place
an order for a low-salt diet. correct answers ANS: A The patient should be placed near the nurses
station if confused in order for the staff to closely monitor the patient. To help improve serum
sodium levels, water intake is restricted. Therefore a confused patient should not be placed near a
water fountain. Peaked T waves are a sign of hyperkalemia, not hyponatremia. A confused
patient could be distracting and disruptive for another patient in a semiprivate room. This patient
needs sodium replacement, not restriction.
8. IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe
hypokalemia. Which action should the nurse take? a. Administer the KCl as a rapid IV bolus. b.
Infuse the KCl at a rate of 10 mEq/hour. c. Only give the KCl through a central venous line. d.
Discontinue cardiac monitoring during the infusion. correct answers ANS: B IV KCl is
administered at a maximal rate of 10 mEq/hr. Rapid IV infusion of KCl can cause cardiac arrest.
Although the preferred concentration for KCl is no more than 40 mEq/L, concentrations up to 80
mEq/L may be used for some patients. KCl can cause inflammation of peripheral veins, but it
can be administered by this route. Cardiac monitoring should be continued while patient is
receiving potassium because of the risk for dysrhythmias.
9. A postoperative patient who had surgery for a perforated gastric ulcer has been receiving
nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127
mmol/L). Which prescribed therapy should the nurse question? a. Infuse 5% dextrose in water at
125 mL/hr. b. Administer IV morphine sulfate 4 mg every 2 hours PRN. c. Give IV
metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea. d. Administer 3% saline if
serum sodium decreases to less than 128 mEq/L. correct answers ANS: A Because the patients
gastric suction has been depleting electrolytes, the IV solution should include electrolyte
,replacement. Solutions such as lactated Ringers solution would usually be ordered for this
patient. The other orders are appropriate for a postoperative patient with gastric suction.
10. A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow
for continued mechanical ventilation. How should the nurse interpret the following arterial blood
gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L? a. Metabolic
acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis correct answers
ANS: D The pH indicates that the patient has alkalosis and the low PaCO2 indicates a respiratory
cause. The other responses are incorrect based on the pH and the normal HCO3 .
11. The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep
respirations. Which action should the nurse take? a. Give the prescribed PRN lorazepam
(Ativan). b. Start the prescribed PRN oxygen at 2 to 4 L/min. c. Administer the prescribed
normal saline bolus and insulin. d. Encourage the patient to take deep, slow breaths with guided
imagery correct answers ANS: C The rapid, deep (Kussmaul) respirations indicate a metabolic
acidosis and the need for correction of the acidosis with a saline bolus to prevent hypovolemia
followed by insulin administration to allow glucose to reenter the cells. Oxygen therapy is not
indicated because there is no indication that the increased respiratory rate is related to
hypoxemia. The respiratory pattern is compensatory, and the patient will not be able to slow the
respiratory rate. Lorazepam administration will slow the respiratory rate and increase the level of
acido
12. An older adult patient who is malnourished presents to the emergency department with a
serum protein level of 5.2 g/dL. The nurse would expect which clinical manifestation? a. Pallor
b. Edema c. Confusion d. Restlessness correct answers ANS: B The normal range for total
protein is 6.4 to 8.3 g/dL. Low serum protein levels cause a decrease in plasma oncotic pressure
and allow fluid to remain in interstitial tissues, causing edema. Confusion, restlessness, and
pallor are not associated with low serum protein levels.
13. A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment
ismost important for the nurse to monitor for while the patient is receiving this infusion? a. Lung
sounds b. Urinary output c. Peripheral pulses d. Peripheral edema correct answers ANS: A
Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of
fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are a serious
manifestation of fluid excess. Bounding peripheral pulses, peripheral edema, or changes in urine
output are also important to monitor when administering hypertonic solutions, but they do not
indicate acute respiratory or cardiac decompensation.
14. 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
patients condition has improved? a. Hematocrit 28% b. Absence of skin tenting c. Decreased
peripheral edema d. Blood pressure 110/72 mm correct answers ANS: C
Edema is caused by low oncotic pressure in individuals with low serum protein levels. The
decrease in edema indicates an improvement in the patients protein status. 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.
, 15. A patient who is lethargic and exhibits deep, rapid respirations has the following arterial
blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L.
How should the nurse interpret these results? a. Metabolic acidosis b. Metabolic alkalosis c.
Respiratory acidosis d. Respiratory alkalosis correct answers ANS: A The pH and HCO3
indicate that the patient has a metabolic acidosis. The ABGs are inconsistent with the other
responses.
16. 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 health care 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 answers ANS: A Hypokalemia
increases the risk for digoxin toxicity, which can cause serious dysrhythmias. The nurse will also
need to do more assessment regarding the other medications, but they are not of as much concern
with the potassium level.
17. The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing
action should the nurse include on the care plan? a. Maintain the patient on bed rest. b.
Auscultate lung sounds every 4 hours. c. Monitor for Trousseaus and Chvosteks signs. d.
Encourage fluid intake up to 4000 mL every day correct answers ANS: D To decrease the risk
for renal calculi, the patient should have a fluid intake of 3000 to 4000 mL daily. Ambulation
helps decrease the loss of calcium from bone and is encouraged in patients with hypercalcemia.
Trousseaus and Chvosteks signs are monitored when there is a possibility of hypocalcemia.
There is no indication that the patient needs frequent assessment of lung sounds, although these
would be assessed every shift.
18. When caring for a patient with renal failure on a low phosphate diet, the nurse will inform
unlicensed assistive personnel (UAP) to remove which food from the patients food tray? a.
Grape juice b. Milk carton c. Mixed green salad d. Fried chicken breast correct answers ANS: B
Foods high in phosphate include milk and other dairy products, so these are restricted on low-
phosphate diets. Green, leafy vegetables; high-fat foods; and fruits/juices are not high in
phosphate and are not restricted.
19. A nurse in the outpatient clinic is caring for a patient who has a magnesium level of 1.3
mg/dL. Which assessment would be most important for the nurse to make? a. Daily alcohol
intake b. Intake of dietary protein c. Multivitamin/mineral use d. Use of over-the-counter (OTC)
laxatives correct answers ANS: A Hypomagnesemia is associated with alcoholism. Protein
intake would not have a significant effect on magnesium level. OTC laxatives (such as milk of
magnesia) and use of multivitamin/mineral supplements would tend to increase magnesium
levels
20. 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
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