HESI Correct Questions And Answers 2023!!!!

HESI Correct Questions And Answers 2023!!!! Rusty called his son complaining that he wasn't feeling well. He had vomiting and diarrhea the past few days, and was unable to eat or drink very much, despite being thirsty. Upon arrival at Rusty's apartment, his son found him lethargic and disoriented. Data suggest that Rusty is at risk for and could be experiencing which of the following? A. fluid imbalance B. Congestive heart failure C. Urinary retention A. fluid imbalance Recent episodes of vomiting and diarrhea, and the presence of dark amber urine and disorientation, suggest that Rusty is fluid deprived. He may also be experiencing electrolyte disturbances, which often accompany fluid imbalances. Besides mental status assessment, what other assessments are relevant at this time for Rusty? (Select all that apply) A. Heart rate B. Blood pressure C. Skin D. Reflexes E. Urine glucose F. Urine specific gravity G. Respirations A. Heart rate B. Blood pressure C. Skin F. Urine specific gravity G. Respirations Assessment of heart rate is important. With significant fluid volume deficit, which can lead to hypovolemic shock, perfusion of tissues is decreased because less fluid is being circulated. Heart rate (pulse) quickens to increase cardiac output. An increase of 15 beats per minute is considered significant. Although Rusty's usual heart rate is not known, a heart rate of 120 is fast and indicates tachycardia. With fluid volume deficit, the palpated pulse is often weak and 'thready.' Assessment of blood pressure is important. With significant fluid volume deficit, which can lead to hypovolemic shock, perfusion of tissues is decreased because less fluid is being circulated. A compensatory vasoconstriction occurs in response to maintain arterial pressure, and coronary and cerebral perfusion, at least initially. Blood pressure is maintained initially, but decreases with significant, prolonged volume depletion. Hypotension is accompanied by postural dizziness. Currently, Rusty's BP is 98/70. Skin assessment is important. With significant fluid volume deficit, peripheral vasoconstriction occurs to maintain blood pressure and shift circulation to major organs. In response, skin may be pale and cool. Skin turgor may be poor and oral mucous membranes may be dry, as fluid shifts from cells to the vascular compartment (although these assessments are not especially good indicators of interstitial fluid deficit). If done, skin turgor assessment in the older adult is best done over the forehead and sternum, and at the inner thigh. This is because there is decreased skin elasticity with aging. It would be useful to determine the degree of urine concentration. Urine specific gravity (SG) is a gross measurement of urine concentration, and can be determined quickly. Normal kidneys usually excrete less water when fluid volume deficit is present, creating dark amber (concentrated) urine. A specific gravity value greater than 1.025 is high, indicative of urine concentration. Assessment of respirations is important. With significant fluid volume deficit, which can lead to hypovolemic shock, perfusion of tissues is decreased because less fluid is being circulated. Respiratory rate increases in an attempt to provide increased amounts of oxygen to body tissues that are not being adequately perfused with oxygenated blood. Rusty's respiratory rate is 30. Which of the following techniques should be used when checking Rusty's postural vital signs? A. First take blood pressure and pulse while he is supine, then repeat them in the upright position B. First take blood pressure and pulse while he is supine, then repeat them in sitting and standing positions C. First take blood pressure and pulse while he is in the Fowler's position, then repeat them with him recumbent D. First take blood pressure and pulse in his left arm, and then in his right A. First take blood pressure and pulse while he is supine, then repeat them in the upright position Postural vital signs are taken by first taking blood pressure and pulse supine, then in an upright position (preferably sitting on the side of the bed with feet dangling). If Rusty were not lethargic and able to get out of bed and stand, you could also check his standing blood pressure and pulse. If his systolic blood pressure falls 20 mm Hg or more, his diastolic blood pressure falls 10 mm Hg or more, or his pulse increases by 15 or more beats per minute, Rusty has a significant intravascular volume deficit. As fluid deficit worsens, blood pressure becomes low and pulse is rapid in all positions. It is important to take note of changes in Rusty's pulse pressure when you monitor his vital signs. What is pulse pressure? A. The diastolic pressure reading B. The difference between the apical pulse rate and the diastolic pressure reading C. The difference between the systolic and diastolic pressure readings D. The difference between the apical and radial pulse rates C. The difference between the systolic and diastolic pressure readings Pulse pressure is defined as the difference between the systolic and diastolic pressure readings. What change occurs in pulse pressure as volume depletion progresses to hypovolemic shock? A. Pulse pressure increases B. Pulse pressure decreases B. Pulse pressure decreases Pulse pressure decreases as the volume of fluid in the vascular compartment continues to decrease. How should a person in hypovolemic shock be positioned? A. Trendelenburg with legs elevated B. Fowler's C. Left side D. Supine with legs elevated D. Supine with legs elevated The supine position with the head slightly elevated and the legs elevated about 30 degrees is the preferred position for patients with fluid volume deficit and hypovolemic shock. This position increases preload and facilitates perfusion of all parts of the body, especially the vital organs. The term used to describe body fluids when they are more concentrated than normal is: A. isotonic B. hypotonic C. hypertonic C. hypertonic Body fluids that are more concentrated than normal are described as hypertonic. When intravascular fluid is hypertonic, fluid is pulled from cells, and cellular dehydration occurs, with shrinking of cells. This is an effort to achieve osmotic balance (homeostasis) by diluting the solute concentration in the intravascular compartment. When body fluids are of normal concentration, they are isotonic. Body fluids that are less concentrated than normal are described as hypotonic. Rusty's urine is amber-colored with a specific gravity (SG) of 1.037, and his urine output is low. Which of the following are responsible for these findings? (Select all that apply) A. An increase in the secretion of antidiuretic hormone (ADH) B. A decrease in the secretion of antidiuretic hormone (ADH) C. An increase in the secretion of aldosterone D. A decrease in the secretion of aldosterone A. An increase in the secretion of antidiuretic hormone (ADH) C. An increase in the secretion of aldosterone When body fluids are detected as more concentrated than normal, the posterior pituitary is stimulated to secrete increased amounts of antidiuretic hormone (ADH, arginine vasopressin or AVP), which causes water to be conserved by the kidneys. Subsequently, more concentrated urine with a high specific gravity (SG) (normal is 1.010-1.025) is eliminated in small amounts. When volume receptors in the kidney detect a low blood volume, the renin-angiotensin system is activated. Aldosterone is secreted in increased amounts from the adrenal cortex, causing sodium and water to be retained. Subsequently, less urine is eliminated. Based on data collected thus far, which of the following apply to Rusty's care? (Select all that apply) A. Ineffective Coping related to lethargic state B. Deficient Knowledge related to lack of information regarding current health problem C. Deficient Fluid Volume related to fluid losses and inadequate fluid intake D. Risk for Infection related to presence of Foley catheter E. Self-Care Deficit Syndrome related to lethargic state C. Deficient Fluid Volume related to fluid losses and inadequate fluid intake D. Risk for Infection related to presence of Foley catheter E. Self-Care Deficit Syndrome related to lethargic state Rusty's assessment data, history, and medical diagnosis support Deficient Fluid Volume as a pertinent problem that applies to Rusty as this time. Addressing this problem with both medical and nursing interventions takes high priority. Rusty is at Risk for Infection because of his indwelling catheter. Nursing measures to maintain perineal hygiene and prevent reflux into the bladder can decrease infection risk. Because of his lethargic and disoriented state, Rusty is dependent on the nursing staff for activities of daily living. Self-Care Deficit Syndrome is a relevant nursing diagnosis. Rusty's urine output is measured as 40 mL over two hours. Which nursing actions are indicated? (Select all that apply) A. Speed up Rusty's IV B. Notify the physician C. Check the specific gravity (SG) of Rusty's urine D. Slow down Rusty's IV E. Check Rusty's blood pressure B. Notify the physician C. Check the specific gravity (SG) of Rusty's urine E. Check Rusty's blood pressure The physician should be notified. Urine output less than 30 mL per hour (oliguria) is insufficient. Oliguria may be a result of poor renal perfusion associated with continuing fluid volume deficit and compensatory fluid conservation, or may be due to acute tubular necrosis from longstanding fluid volume deficit. Medical intervention is indicated. The specific gravity (SG) of Rusty's urine should be checked. The current reading should be compared to earlier readings to determine the effectiveness of therapy in correcting Rusty's fluid volume deficit and dehydration. Specific gravity (SG) of the urine should decrease to normal range with correction of fluid volume deficit. Rusty's current urine specific gravity (SG) is 1.036, still high, and basically unchanged since fluid replacement was started. Blood pressure should be checked and compared to earlier readings. Changes in blood pressure will help determine the effectiveness of therapy in correcting fluid volume deficit and dehydration. Blood pressure should increase with correction of fluid volume deficit. Rusty's current BP is 100/70, basically unchanged since fluid replacement was started. By infusing a bolus of fluid, the physician is attempting to: (Select all that apply) A. increase kidney perfusion B. determine Rusty's volume status C. increase Rusty's urine output D. determine Rusty's kidney function E. determine Rusty's cardiac function A. increase kidney perfusion B. determine Rusty's volume status C. increase Rusty's urine output D. determine Rusty's kidney function Long-standing fluid volume depletion can lead to acute tubular necrosis. Increasing circulating fluid volume can help prevent potential kidney damage by increasing perfusion of this vital organ. Despite IV fluids, Rusty's blood pressure and urine specific gravity (SG) are relatively unchanged, and his urine output is low. Volume status can be determined by evaluating Rusty's response to increased fluids. A rise in blood pressure and an increase in urine output would indicate that fluid volume deficit was responsible for Rusty's low urine output, and that the deficit was now corrected. Assuming normal kidney function, increasing Rusty's circulating fluid volume should increase his urine output. With normal kidney function, infusion of a large amount of fluid (if it substantially corrects fluid deficit) should result in improved renal perfusion and an increase in urine output. Despite IV fluids, Rusty's blood pressure and urine specific gravity (SG) are relatively unchanged, and his urine output is low. Kidney function can be determined by evaluating Rusty's response to increased fluids. If prolonged volume depletion has resulted in acute tubular necrosis, infused fluids will not be eliminated and urine output will continue to be low. Which nursing assessments are essential during Rusty's rapid IV infusion? (Select all that apply) A. Vital signs B. Urine specific gravity (SG) C. Breath sounds D. Neck veins A. Vital signs C. Breath sounds D. Neck veins Vital signs should be closely monitored during Rusty's rapid infusion, to evaluate responsiveness to treatment, and also to detect complications. Even though Rusty's heart condition is currently stable, he is at risk for heart failure and pulmonary edema with this rapid infusion rate. It is possible that his heart might not be able to deal with an increased fluid load. It is important to remain alert for vital sign changes suggestive of heart failure. These primarily include increasing heart rate (tachycardia) and increasing respiratory rate (tachypnea). Even though Rusty's heart condition is currently stable, he is at risk for heart failure and pulmonary edema with this rapid infusion rate. It is possible that his heart might not be able to deal with an increased fluid load. If the left side of the heart becomes inefficient as a pump, backflow of blood from the left side of the heart into the lungs could result in buildup of fluid in the lungs, with onset of dyspnea and cough. Breath sounds should be auscultated for the presence of crackles, which could occur with pulmonary edema. Assessment of neck veins is indicated. Even though Rusty's heart condition is currently stable, he is at risk for heart failure and pulmonary edema with this rapid infusion rate. It is possible that his heart might not be able to deal with an increased fluid load. This could be reflected in jugular venous distention. Jugular neck veins directly reflect right atrial pressure. Distended jugular neck veins reflect inability of the heart to accept and pump the current circulating fluid volume. Rusty's previous specific gravity (SG) was 1.036. Which of the following SG measurements might you expect as Rusty's condition improves? A. SG 1.040 B. SG 1.037 C. SG 1.006 D. SG 1.025 D. SG 1.025 This specific gravity (SG) is reasonable to expect. It reflects a moderate decrease in the concentration of Rusty's urine. From the partial listing of Rusty's other lab values noted below, which are abnormal? (Select all that apply) A. White blood Cell count (WBC) 10,000/mm3 B. Hemoglobin (Hgb) 21 g/dl C. Hematocrit (Hct) 58% D. Blood urea nitrogen (BUN) 16 mg/dl E. Sodium (Na) 154 mEq/L F. Potassium (K) 2.9 mEq/L B. Hemoglobin (Hgb) 21 g/dl C. Hematocrit (Hct) 58% E. Sodium (Na) 154 mEq/L F. Potassium (K) 2.9 mEq/L A hemoglobin (Hgb) of 21 g/dl is high. Artificially high Hgb values occur with dehydration, secondary to hemoconcentration, resulting from a decreased intravascular fluid volume. A hematocrit (Hct) of 58% is high. Artificially high Hct values occur with dehydration, secondary to hemoconcentration, resulting from a decreased intravascular fluid volume. Hct varies based on the percentage of red cells in the total blood volume. A serum sodium (Na) of 154 mEq/L is high (hypernatremia). Fluid losses have exceeded sodium losses, resulting in an increased concentration of sodium. Hypernatremia characterizes dehydration. Variable amounts of sodium are lost with vomit and diarrhea. With correction of fluid volume, sodium level should normalize. A serum potassium (K) of 2.9 mEq/L is low (hypokalemia). Potassium losses have been excessive and not replaced. Large amounts of potassium are lost in vomit and diarrhea. Hypokalemia can cause cardiac dysrhythmias and cardiac arrest. Also, risk for digoxin toxicity is increased when hypokalemia is present. The physician is aware of Rusty's low potassium level. Potassium chloride (KCl) will be added to IV fluids. Rusty's IV orders are changed to 1000 mL dextrose 5% in 0.45% sodium chloride + 20 mEq KCl at 125 mL per hour. Potassium chloride (KCl) is infused diluted in: A. 125 mL B. 1000 mL B. 1000 mL The order as written indicates that potassium chloride (KCl) be infused diluted in 1000 mL of dextrose 5% in 0.45% sodium chloride. IV fluids containing KCl are stocked on your unit. 1000 mL bags of dextrose 5% in 0.45% sodium chloride with 20 mEq KCl are available. Vials of concentrated electrolytes like KCl are not openly stocked on your unit. Medication errors involving high concentrations of electrolytes can be fatal. Although protocols vary, IV infusion concentrations of potassium generally should not exceed 40 mEq per liter of fluid and patients should not receive more than 20 mEq per hour. KCL is always given slowly, diluted in a large volume of fluid. It is never given by IV bolus or by intramuscular or subcutaneous routes. Severe hypocalcemia is characterized by skeletal muscle excitability and twitching. The term used to describe this condition is: A. paresthesia B. tetany C. calcinosis D. tetanus B. tetany Severe hypocalcemia is characterized by tetany. Early symptoms of tetany include numbness and tingling of the nose, ears, fingertips and toes. Without treatment, painful muscles spasms, twitching, and convulsions may occur. With tetany, Chvostek's sign and Trousseau's sign are usually present. To assess for Chvostek's sign, you: A. inflate a blood pressure cuff on Rusty's upper arm and observe for muscle spasm in the hand B. ask Rusty to move his index finger to his nose and observe for tremor and spasm C. tap one side of Rusty's face over the area of the facial nerve and observe for local spasm C. tap one side of Rusty's face over the area of the facial nerve and observe for local spasm This is the appropriate technique to use when checking for Chvostek's sign. Which of the following can be included in a full liquid diet? (Select all that apply) A. Jello B. Clear chicken broth C. Ice cream D. Custard E. Scrambled eggs F. Tea G. Ginger ale A. Jello B. Clear chicken broth C. Ice cream D. Custard F. Tea G. Ginger ale Jello and popsicles, clear chicken broth, ice cream, custard, tea, and ginger ale can be included as part of a full liquid diet, and also a clear liquid diet. Anything that is liquid at room temperature can be included in a full liquid diet. Fruit juices without pulp are considered clear liquids. Other fruit and vegetable juices are considered full liquids. Anything that is liquid at room temperature can be included in a full liquid diet.