Adult Health 2 HESI Quizlet

Questions 26

HESI RN

HESI RN Test Bank

Adult Health 2 HESI Quizlet Questions

Question 1 of 5

A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse?

Correct Answer: D

Rationale: Crackles throughout both lungs suggest that the patient may be experiencing pulmonary edema, a life-threatening adverse effect of hypertonic solutions. The increased pulse rate and blood pressure and the presence of sediment and blood in the urine should also be reported, but they are not as immediately dangerous as the presence of fluid in the alveoli, which compromises gas exchange and can lead to respiratory failure.

Question 2 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.

Question 3 of 5

IV potassium chloride (KCl) 60 mEq is prescribed for the treatment of a patient with severe hypokalemia. Which action should the nurse take?

Correct Answer: B

Rationale: The correct action for the nurse to take is to infuse the KCl at a rate of 10 mEq/hour. Rapid IV infusion of KCl can lead to cardiac arrest due to its potential for causing hyperkalemia. While KCl can be administered through peripheral veins, central venous lines are not necessary unless specified. It is crucial to continue cardiac monitoring during potassium infusion to promptly identify and manage any potential dysrhythmias that may occur.

Question 4 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 5 of 5

A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider?

Correct Answer: A

Rationale: The correct answer is A - 'The patient is experiencing laryngeal stridor.' Hypocalcemia can cause laryngeal stridor, which may lead to respiratory arrest. Rapid action is required to correct the patient's calcium level to prevent a life-threatening situation. Choices B, C, and D are also symptoms of hypocalcemia, but laryngeal stridor takes precedence due to its potential to quickly progress to a critical condition.

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