Adult Health 2 HESI Quizlet

Question 1 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?

A. Reassure the father that it is normal for a pre-teen to wet the bed during times of stress B. Inform the father that nocturnal emissions are abnormal and his son is developmentally delayed C. Inform the father that it is most important to let the son know that bedwetting is normal after trauma D. Refer the father and the client to a psychologist

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 2 of 5

Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room?

A. Tie the knot with a double turn or square knot B. Ensure that the restraints are snug against the client's wrists C. Ensure that the knot can be quickly released D. Move the ties so the restraints are secured to the side rails

Correct Answer: C

Rationale: The priority is to ensure that the knot can be quickly released to allow for quick intervention if necessary. Tying the knot with a double turn or square knot (
Choice
A) may make it more difficult to release quickly in an emergency. Ensuring that the restraints are snug against the client's wrists (
Choice
B) may compromise circulation and cause discomfort. Moving the ties to secure the restraints to the side rails (
Choice
D) is not the appropriate action as it can limit the client's movement and access to care.

Question 3 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?

A. The patient's radial pulse is 105 beats/minute. B. There is sediment and blood in the patient's urine. C. The blood pressure increases from 120/80 to 142/94. D. There are crackles audible throughout both lung fields.

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 4 of 5

A patient is admitted to the emergency department with severe fatigue and confusion. Laboratory studies are done. Which laboratory value will require the most immediate action by the nurse?

A. Arterial blood pH is 7.32. B. Serum calcium is 18 mg/dL. C. Serum potassium is 5.1 mEq/L D. Arterial oxygen saturation is 91%.

Correct Answer: B

Rationale: The correct answer is B. A serum calcium level of 18 mg/dL is significantly elevated, posing a high risk for cardiac dysrhythmias. Immediate action is required to initiate cardiac monitoring and notify the healthcare provider. While the abnormalities in arterial blood pH, serum potassium, and arterial oxygen saturation also need attention, they are not as immediately life-threatening as the critically high serum calcium level.
Therefore, addressing the serum calcium level takes precedence in this scenario.

Question 5 of 5

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 healthcare 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 Answer: A

Rationale: The correct answer is A. Hypokalemia increases the risk for digoxin toxicity, which can lead to serious dysrhythmias.
Therefore, with a low potassium level, the nurse should immediately alert the healthcare provider about the patient being on oral digoxin.

Choices B, C, and D do not pose as much concern with the given potassium level. However, further assessment is still required for these medications.

Nurselytic

HESI RN

HESI RN