HESI RN
Adult Health 1 HESI Questions
Question 1 of 5
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?
Correct Answer: A
Rationale: The patient's pH is below the normal range (7.35-7.45), and the HCO3 is also below the normal range (22-26 mEq/L), indicating an acidic environment, which is consistent with metabolic acidosis. The ABGs provided do not support respiratory acidosis or alkalosis, as the PaCO2 is within the normal range (35-45 mm Hg) despite the patient's deep, rapid respirations. Therefore, the correct interpretation is metabolic acidosis.
Question 2 of 5
The nurse is caring for a patient who has a central venous access device (CVAD). Which action by the nurse is appropriate?
Correct Answer: B
Rationale: The correct answer is B because using the push-pause method to flush the CVAD after giving medications helps remove debris from the CVAD lumen and decreases the risk for clotting. Choice A is incorrect because friction should be used when cleaning the CVAD insertion site to decrease infection risk. Choice C is incorrect because obtaining an order from the healthcare provider to change the CVAD dressing is not necessary; the dressing should be changed when damp, loose, or visibly soiled. Choice D is incorrect because the patient should face away from the CVAD during cap changes to minimize the risk of contamination.
Question 3 of 5
The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be a priority for the nurse to report to the health care provider?
Correct Answer: C
Rationale: The priority assessment finding for the nurse to report to the healthcare provider is a gradually decreasing level of consciousness (LOC). This change in LOC could indicate fluid and electrolyte disturbances, which require immediate attention to prevent complications. While the other options such as an elevated temperature, serum sodium level, and weight gain are important to note and report, they do not indicate an urgent need for intervention compared to changes in LOC which could signify serious issues that need prompt evaluation and management.
Question 4 of 5
A patient with renal failure has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion. The patient arrives for outpatient hemodialysis and is unresponsive to questions and has decreased deep tendon reflexes. Which action should the dialysis nurse take first?
Correct Answer: A
Rationale: The health care provider should be notified immediately. The patient has a history and manifestations consistent with hypermagnesemia. The nurse should check the chart for a recent serum magnesium level and make sure that blood is sent to the laboratory for immediate electrolyte and chemistry determinations. Dialysis should correct the high magnesium levels. The patient needs teaching about the risks of taking magnesium-containing antacids. Monitoring of potassium levels also is important for patients with renal failure, but the patient's current symptoms are not consistent with hyperkalemia.
Question 5 of 5
Which task can the registered nurse (RN) caring for a critically ill patient with multiple IV lines delegate to an experienced licensed practical/vocational nurse (LPN/LVN)?
Correct Answer: B
Rationale: An experienced LPN/LVN can monitor IV sites for signs of infection because it falls within their education, experience, and scope of practice. Administering IV antibiotics through an implantable port, adjusting infusion rates, and removing central catheters are tasks that require RN level education and scope of practice. These activities involve a higher level of assessment, critical thinking, and potential complications that are typically within the RN's domain.