HESI RN
Adult Health 2 HESI Quizlet Questions
Question 1 of 5
A patient comes to the clinic complaining of frequent, watery stools for the last 2 days. Which action should the nurse take first?
Correct Answer: B
Rationale: The correct answer is to check the patient's blood pressure. Given the patient's symptoms of frequent, watery stools, there is a concern for fluid volume deficit. Assessing the blood pressure helps determine the patient's perfusion status, which is crucial in managing fluid volume deficits. While obtaining baseline weight, drawing blood for serum electrolyte levels, and asking about extremity numbness or tingling are important assessments, checking the blood pressure takes precedence as it provides immediate information on the patient's circulatory status.
Question 2 of 5
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?
Correct Answer: B
Rationale: The correct answer is B: Edema. 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. Pallor is more commonly seen in anemia, confusion and restlessness may be related to other issues like electrolyte imbalances or neurological conditions.
Question 3 of 5
The father of an 11-year-old client reports to the nurse that the client has been wetting the bed since the passing of his mother and is concerned. Which action is most important for the nurse to take?
Correct Answer: D
Rationale: It is common for children to experience bedwetting as a response to severe trauma, such as losing a parent. Referring the father and the client to a psychologist is crucial in this situation to help the child cope with the loss and address any underlying emotional issues. Choice A is incorrect as bedwetting in this context is likely related to the trauma rather than puberty. Choice B is incorrect as nocturnal emissions are not abnormal and do not relate to bedwetting. Choice C is incorrect because the focus should be on addressing the emotional impact of the trauma rather than specifically discussing bedwetting.
Question 4 of 5
An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately?
Correct Answer: C
Rationale: The correct answer is C. The elevated serum sodium level (154 mEq/L) is consistent with the patient's neurologic symptoms of restlessness, agitation, and weakness, indicating a need for immediate action to prevent complications like seizures. The potassium level (3.4 mEq/L) and calcium level (7.8 mg/dL) are slightly off from normal but do not require immediate action. The phosphate level (4.8 mg/dL) is normal and not related to the symptoms presented by the patient.
Question 5 of 5
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?
Correct Answer: D
Rationale: The correct answer is D. Spironolactone is a potassium-sparing diuretic, so patients should choose low-potassium foods. Apple juice is a better choice than orange juice in this case as it is lower in potassium. Option A is incorrect because increasing fluid intake excessively is not necessary. Option B is incorrect as salt substitutes are high in potassium, which should be avoided. Option C is incorrect because patients on spironolactone should avoid increasing their potassium intake.
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