Hesi wgu medical adult health 1
Total Questions : 51
Showing 25 questions, Sign in for moreWhich instruction should the nurse include in the discharge teaching plan for an adult client with hypernatremia?
Explanation
Choice A rationale
Monitoring daily urine output volume is important for assessing fluid balance, but it does not directly address the issue of hypernatremia. Hypernatremia is characterized by high sodium levels in the blood, and monitoring urine output alone will not help in managing sodium intake or identifying sources of excess sodium.
Choice B rationale
Using salt tablets after strenuous exercise is not recommended for clients with hypernatremia. Salt tablets can increase sodium levels further, exacerbating the condition. Hypernatremia requires careful management of sodium intake, and salt tablets would be counterproductive.
Choice C rationale
Reviewing food labels for sodium content is crucial for clients with hypernatremia. This helps them identify and avoid foods high in sodium, which can contribute to elevated sodium levels in the blood. Educating clients on reading food labels empowers them to make informed dietary choices and manage their condition effectively.
Choice D rationale
Drinking plenty of water whenever thirsty is a general recommendation for maintaining hydration, but it does not specifically address hypernatremia. Clients with hypernatremia need to focus on managing their sodium intake and ensuring they do not consume excessive amounts of sodium.
The healthcare provider prescribes bismuth subsalicylate, metronidazole, tetracycline, and pantoprazole for a client with H. pylori. Prior to administering the H. pylori treatment regimen, the nurse should review the client’s medication list for which medication?
Explanation
Choice A rationale
Ipratropium is a bronchodilator used to treat respiratory conditions such as chronic obstructive pulmonary disease (COPD) and asthma. It does not have significant interactions with the medications prescribed for H. pylori treatment, so it is not a priority to review in this context.
Choice B rationale
Aspirin is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the risk of gastrointestinal bleeding and ulcers, especially when combined with other medications that affect the stomach lining, such as bismuth subsalicylate and tetracycline. Reviewing the client’s use of aspirin is important to prevent potential adverse effects and complications.
Choice C rationale
Famotidine is an H2 receptor antagonist used to reduce stomach acid production. While it is relevant to gastrointestinal health, it does not have significant interactions with the H. pylori treatment regimen. Therefore, it is not a priority to review in this context.
Choice D rationale
Loperamide is an antidiarrheal medication used to manage diarrhea. It does not have significant interactions with the medications prescribed for H. pylori treatment, so it is not a priority to review in this context.
The nurse is admitting a client with possible tuberculosis (TB). The client is placed in a private room with airborne precautions pending diagnostic test results. Which diagnostic test should the nurse review to confirm the diagnosis of TB?
Explanation
Choice A rationale
A chest X-ray or computed tomography (CT) scan can show abnormalities in the lungs that are suggestive of tuberculosis (TB), but they cannot definitively diagnose TB. These imaging tests can reveal changes in the lungs, such as nodules, inflammation, or fluid buildup, which can be caused by TB or other conditions. Therefore, a chest X-ray or CT scan alone is not sufficient to diagnose TB.
Choice B rationale
A hemoccult test on sputum collected from hemoptysis is not a diagnostic test for TB. It is a test for blood in the stool, which can be a symptom of TB but is not specific to TB. Hemoptysis, or coughing up blood, can occur in various conditions, including bronchitis, pneumonia, lung cancer, and TB. The hemoccult test cannot differentiate between these causes, making it an unreliable test for diagnosing TB.
Choice C rationale
A positive purified protein derivative (PPD) skin test indicates exposure to TB but does not confirm active infection. The PPD skin test involves injecting a small amount of tuberculin, a protein derived from Mycobacterium tuberculosis, into the skin. If a person has been exposed to TB, their immune system will react to the tuberculin, causing a raised red bump to appear at the injection site. However, a positive PPD skin test does not necessarily mean that a person has active TB infection. It could also mean that they have been exposed to TB in the past but have successfully fought off the infection. Further testing, such as a sputum culture, is needed to confirm the diagnosis of TB.
Choice D rationale
A sputum culture positive for Mycobacterium tuberculosis is the definitive diagnostic test for TB. It involves collecting a sample of sputum, which is the mucus coughed up from the lungs, and culturing it in a laboratory to see if Mycobacterium tuberculosis, the bacteria that causes TB, grows. This test is highly specific for TB, meaning that a positive result is almost always indicative of TB infection. It is also sensitive, meaning that it can detect TB infection even when there are few bacteria present.
The nurse is preparing a teaching plan for a group of well-educated clients who were found to be HIV positive within the last year. The nurse should explain that the human immunodeficiency virus (HIV) acts in which way to suppress the immune system?
Explanation
Choice A rationale
An increase in B-lymphocytes and IgM is not how HIV suppresses the immune system. B-lymphocytes are responsible for producing antibodies, and IgM is a type of antibody. HIV primarily affects T-lymphocytes, specifically helper T-cells (CD4 cells), rather than B-lymphocytes.
Choice B rationale
The destruction of helper T-cells and CD4 cells is the primary mechanism by which HIV suppresses the immune system. HIV targets and infects these cells, leading to their depletion. Helper T-cells play a crucial role in coordinating the immune response, and their loss results in a weakened immune system, making the body more susceptible to infections and diseases.
Choice C rationale
A deficiency of cytotoxic T cells is not the primary mechanism by which HIV suppresses the immune system. Cytotoxic T cells (CD8 cells) are involved in directly killing infected cells, but the main impact of HIV is on helper T-cells (CD4 cells), which are essential for orchestrating the immune response.
Choice D rationale
The proliferation of suppressor T-cells is not how HIV suppresses the immune system. Suppressor T-cells (regulatory T cells) help regulate and control the immune response, but HIV primarily affects helper T-cells (CD4 cells), leading to their destruction and a weakened immune system.
Which technique should the nurse use when assessing for early signs of rheumatoid arthritis?
Explanation
Choice A rationale
Palpating large joints for nodules is not the most effective technique for assessing early signs of rheumatoid arthritis (RA). Nodules typically appear in more advanced stages of RA and are not an early sign.
Choice B rationale
Observing the skin for lesions is not specific to RA. While skin lesions can be associated with other conditions, they are not a primary indicator of early RA1.
Choice C rationale
Observing the client’s fingers is crucial for detecting early signs of RA. Early RA often presents with swelling, tenderness, and stiffness in the small joints of the fingers.
Choice D rationale
Palpating the lymph nodes is not relevant for early RA assessment. Lymph node enlargement is not a typical early sign of RA1.
A client presents to the emergency department with muscle aches, headache, fever, and describes a recent loss of taste and smell. The nurse obtains a nasal swab for COVID-19 testing. Which action is most important for the nurse to take?
Explanation
Choice A rationale
Isolating the client from others is the most important action to prevent the spread of COVID-19. This includes isolating the client from other clients, family, and healthcare workers not wearing proper PPE2.
Choice B rationale
Reporting the COVID-19 result to the local health department is important but not the immediate priority. Isolation takes precedence to prevent transmission.
Choice C rationale
Teaching the client to wear a mask, hand wash, and social distance is essential but secondary to immediate isolation.
Choice D rationale
Counseling family members to monitor for symptoms is important but not the immediate priority. Isolation of the client is the first step.
Which information should the nurse include when giving discharge instructions to a client following a left eye cataract extraction with a lens implant?
Explanation
Choice A rationale
Observing pupil response of the right eye is not relevant to the care of the left eye post-cataract extraction.
Choice B rationale
Sleeping flat in a supine position is not recommended as it can increase intraocular pressure. Elevating the head is advised.
Choice C rationale
Turning, coughing, and deep breathing every 2 hours is not specific to cataract surgery and can increase intraocular pressure.
Choice D rationale
Administering a stool softener is important to prevent straining during bowel movements, which can increase intraocular pressure and affect healing.
Following discharge teaching, a client with a duodenal ulcer tells the nurse of plans to eat plenty of dairy products to help coat and protect the duodenal ulcer. Which is the best follow-up action by the nurse?
Explanation
Choice A rationale
Reviewing with the client the need to avoid foods rich in milk and cream is crucial. Dairy products can increase gastric acid secretion, which can exacerbate duodenal ulcers.
Choice B rationale
Suggesting frequent small meals can help reduce discomfort but does not address the issue of dairy products exacerbating the ulcer.
Choice C rationale
Switching to decaffeinated coffee and tea is beneficial but not as critical as avoiding dairy products.
Choice D rationale
Reinforcing teaching by asking the client to list dairy foods does not address the need to avoid these foods.
Which approach is best for the nurse to use when directing a client with Huntington’s disease to the hospital cafeteria?
Explanation
Choice A rationale
Providing step-by-step verbal directions may not be effective for clients with Huntington’s disease due to their cognitive impairments, which can include forgetfulness, impaired judgment, and difficulty concentrating.
Choice B rationale
Escorting the client to the cafeteria is the best approach as it ensures the client reaches the destination safely. Clients with Huntington’s disease often have unsteady gait and involuntary movements, making it difficult for them to navigate independently.
Choice C rationale
Orienting the client to the color-coding system may not be effective due to the cognitive impairments associated with Huntington’s disease, such as difficulty concentrating and impaired judgment.
Choice D rationale
Using the hospital map to show the client where the cafeteria is located is not practical for clients with Huntington’s disease due to their cognitive impairments, which can include forgetfulness and difficulty concentrating.
A client who was admitted yesterday with bilateral pneumonia has congested breath sounds, an oxygen saturation of 94%, a weak cough effort, and is using accessory muscles to breathe. Which intervention should the nurse implement first?
Explanation
Choice A rationale
Suctioning to clear secretions from the airway is the first intervention to implement. The client’s weak cough effort and use of accessory muscles to breathe suggest the presence of retained respiratory secretions, which can impair breathing and lead to further respiratory compromise.
Choice B rationale
Offering a prescribed PRN analgesic is important for overall comfort but is not the most immediate intervention needed to address the client’s respiratory distress.
Choice C rationale
Obtaining arterial blood gases may provide valuable information but is not the most immediate intervention needed to address the client’s respiratory distress.
Choice D rationale
Administering a prescribed antipyretic is not the most immediate intervention needed to address the client’s respiratory distress.
A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath and a productive cough with thickened, tenacious mucus. The client reports difficulty walking up a flight of stairs without experiencing breathlessness. Which action is most important for the nurse to instruct the client about self-care?
Explanation
Choice A rationale
Teaching anxiety reduction methods for feelings of suffocation is important but not the most immediate action needed to address the client’s respiratory symptoms.
Choice B rationale
Increasing the daily intake of oral fluids to liquefy secretions is the most important action for the nurse to instruct the client about self-care. This helps to thin the mucus, making it easier to expectorate and improving breathing.
Choice C rationale
Calling the clinic if undesirable side effects of medications occur is important but not the most immediate action needed to address the client’s respiratory symptoms.
Choice D rationale
Avoiding crowded enclosed areas to reduce pathogen exposure is important but not the most immediate action needed to address the client’s respiratory symptoms.
A client who has had a laryngectomy and tracheostomy frequently expectorates copious amounts of purulent secretions. When changing the ties of the tracheostomy tube, which action is most important for the nurse to take?
Explanation
Choice A rationale
Securing tracheostomy ties by making knots close to the tube can cause irritation and pressure on the skin.
Choice B rationale
Removing ties to secure a disposable, soft foam collar with hook and loop fastener is not the most important action when changing the ties of the tracheostomy tube.
Choice C rationale
Leaving the old ties in place until the new ones are secure is the most important action to prevent accidental dislodgement of the tracheostomy tube.
Choice D rationale
Placing knots of the ties laterally to prevent irritation and pressure is important but not the most critical action when changing the ties of the tracheostomy tube.
The nurse is planning care for a client with a direct (sliding) hiatal hernia. Nursing actions should be planned to meet which goal?
Explanation
Choice A rationale
Promoting effective swallowing is important for patients with dysphagia, but it is not the primary goal for a client with a sliding hiatal hernia. The main concern with a sliding hiatal hernia is the prevention of gastroesophageal reflux, which can lead to complications such as esophagitis and Barrett’s esophagus.
Choice B rationale
Maintaining intact oral mucosa is crucial for patients with conditions affecting the mouth, such as oral mucositis or infections. However, it is not the primary goal for a client with a sliding hiatal hernia. The focus should be on preventing reflux and managing symptoms.
Choice C rationale
Preventing esophageal reflux is the primary goal for a client with a sliding hiatal hernia. This condition occurs when the stomach slides up into the chest through the diaphragm, leading to gastroesophageal reflux disease (GERD). Nursing actions should aim to reduce reflux symptoms by advising the client to eat smaller meals, avoid lying down after eating, and elevate the head of the bed.
Choice D rationale
Increasing intestinal peristalsis is important for patients with conditions like constipation or ileus. However, it is not the primary goal for a client with a sliding hiatal hernia. The focus should be on preventing reflux and managing symptoms.
A client with chronic cirrhosis has esophageal varices. It is most important for the nurse to monitor the client for the onset of which problem?
Explanation
Choice A rationale
Hematemesis, or vomiting blood, is a critical sign of bleeding esophageal varices, which can be life-threatening. Clients with chronic cirrhosis and esophageal varices are at high risk for variceal bleeding due to increased portal hypertension. Monitoring for hematemesis is essential to provide timely intervention and prevent complications.
Choice B rationale
Anorexia, or loss of appetite, is a common symptom in clients with chronic liver disease, but it is not the most critical problem to monitor in clients with esophageal varices. The primary concern is the risk of variceal bleeding.
Choice C rationale
Clay-colored stool indicates a lack of bile in the stool, which can occur in liver disease. However, it is not the most critical problem to monitor in clients with esophageal varices. The primary concern is the risk of variceal bleeding.
Choice D rationale
Brown, foamy urine can be a sign of liver dysfunction, but it is not the most critical problem to monitor in clients with esophageal varices. The primary concern is the risk of variceal bleeding.
A client with open-angle glaucoma asks the nurse how long the prescribed eye drops will need to be used. Which response made by the nurse is accurate?
Explanation
Choice A rationale
For long-term control of normal eye pressure is the accurate response. Open-angle glaucoma is a chronic condition that requires ongoing treatment to maintain normal intraocular pressure and prevent further damage to the optic nerve. Eye drops are typically used for life to manage the condition.
Choice B rationale
Until a smaller angle can be restored is not accurate because open-angle glaucoma does not involve a change in the angle of the anterior chamber. The goal of treatment is to lower intraocular pressure, not to restore the angle.
Choice C rationale
For long-term control of pain and swelling is not accurate because open-angle glaucoma primarily involves increased intraocular pressure and optic nerve damage, not pain and swelling. The goal of treatment is to lower intraocular pressure.
Choice D rationale
Until the excess pressure is reduced is not accurate because open-angle glaucoma requires ongoing treatment to maintain normal intraocular pressure. Stopping treatment once pressure is reduced can lead to a recurrence of elevated pressure and further damage.
A teenage client is admitted to the emergency department following a bee sting. The client arrives with a body rash and 30 of 40 breaths per minute and a blood pressure of 90/52 mm Hg. The client is exhibiting clinical manifestations of which type of immune reaction?
Explanation
Choice A rationale
Autoimmune response is not the correct type of immune reaction for a bee sting. Autoimmune responses involve the body’s immune system attacking its own tissues, which is not the case with bee stings.
Choice B rationale
IgE response hypersensitivity is the correct type of immune reaction for a bee sting. Bee stings can trigger an IgE-mediated hypersensitivity reaction, leading to symptoms such as rash, difficulty breathing, and low blood pressure. This type of reaction is also known as anaphylaxis.
Choice C rationale
Cell-mediated hypersensitivity is not the correct type of immune reaction for a bee sting. Cell-mediated hypersensitivity involves T cells and is typically associated with conditions like contact dermatitis, not bee stings.
Choice D rationale
Type II hypersensitivity is not the correct type of immune reaction for a bee sting. Type II hypersensitivity involves antibody-mediated destruction of cells, which is not the case with bee stings.
Before administering a newly prescribed dose of terbinafine HCL to a client with a fungal toenail infection, which assessment finding is most important for the nurse to address?
Explanation
Choice A rationale
Reported history of alcoholism is the most important assessment finding to address before administering terbinafine HCL. Terbinafine is metabolized by the liver, and clients with a history of alcoholism may have impaired liver function, increasing the risk of hepatotoxicity. Monitoring liver function and assessing for signs of liver damage are crucial before starting treatment.
Choice B rationale
Toenails appear thick and yellow is a common symptom of fungal toenail infection, but it is not the most critical assessment finding to address before administering terbinafine HCL. The focus should be on assessing liver function.
Choice C rationale
Employed as a construction worker is not the most critical assessment finding to address before administering terbinafine HCL. While occupational exposure to fungi may be relevant, the primary concern is liver function.
Choice D rationale
White blood cell count of 8,500/mm³ (8.5 x 10⁹/L) is within the normal range and is not the most critical assessment finding to address before administering terbinafine HCL. The primary concern is liver function.
A client diagnosed with chronic obstructive pulmonary disease (COPD) is given a new prescription for tiotropium via an inhalation device. Which statement indicates the client understands the instructions for using this medication?
Explanation
Choice A rationale
Tiotropium is a long-acting bronchodilator used daily to manage chronic obstructive pulmonary disease (COPD). It helps to relax the muscles around the airways, making it easier to breathe. This medication is not intended for immediate relief of acute symptoms but for long-term control of COPD1.
Choice B rationale
Using another inhaler in between uses of tiotropium is not necessary unless prescribed by a healthcare provider. Tiotropium is meant to be used daily, and other inhalers may be prescribed for different purposes, such as rescue inhalers for sudden symptoms.
Choice C rationale
While tiotropium can help improve breathing and reduce symptoms over time, it is not specifically indicated to reduce the thickness of sputum. Other medications or treatments may be needed to address sputum consistency.
Choice D rationale
Tiotropium is not a rescue inhaler and should not be used for sudden shortness of breath. Rescue inhalers, such as albuterol, are designed for immediate relief of acute symptoms.
When performing postural drainage on a client with chronic obstructive pulmonary disease (COPD), which approach should the nurse use?
Explanation
Choice A rationale
Postural drainage involves placing the client in various positions to facilitate the drainage of secretions from different parts of the lungs. Typically, the client may be placed in five positions: head down, prone, right and left lateral, and sitting upright.
Choice B rationale
Performing postural drainage immediately after meals is not recommended as it can cause nausea, vomiting, and aspiration. It is best to perform the procedure before meals.
Choice C rationale
Obtaining an arterial blood gas (ABG) prior to the procedure is not a standard requirement for postural drainage. ABGs are typically obtained to assess the client’s respiratory status but are not necessary for the procedure itself.
Choice D rationale
Instructing the client to breathe shallow and fast is not appropriate for postural drainage. The client should be encouraged to breathe slowly and deeply to help keep the airways open and facilitate the drainage of secretions.
The nurse is performing a routine dressing change for a client with a stage 3 pressure injury that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?
Explanation
Choice A rationale
Increasing the frequency of dressing changes may not be necessary and could potentially disrupt the healing process. The type of dressing used is more important for managing the wound.
Choice B rationale
Leaving the dressing off until consulting with the healthcare provider is not recommended as it can expose the wound to infection and delay healing.
Choice C rationale
Applying a hydrocolloidal gel dressing is appropriate for a stage 3 pressure injury with significant granulation. Hydrocolloidal dressings provide a moist environment that promotes healing and protects the wound from contamination.
Choice D rationale
Replacing the gauze with a transparent dressing may not provide the necessary moisture and protection for a stage 3 pressure injury. Hydrocolloidal dressings are more suitable for this type of wound.
A client with newly diagnosed Crohn’s disease asks the nurse about dietary restrictions. How should the nurse respond?
Explanation
Choice A rationale
Restricting fluids is not a primary limitation for clients with Crohn’s disease. Adequate hydration is important for overall health and managing symptoms.
Choice B rationale
Limiting foods high in calcium and iron is not typically recommended for Crohn’s disease. These nutrients are important for maintaining bone health and preventing anemia, which can be concerns for individuals with Crohn’s disease.
Choice C rationale
An elimination diet can help identify trigger foods that may exacerbate symptoms of Crohn’s disease. This approach involves removing certain foods from the diet and gradually reintroducing them to determine which foods cause symptoms.
Choice D rationale
Avoiding gluten is not necessary for all individuals with Crohn’s disease. While some may benefit from a gluten-free diet, it is not a universal recommendation for managing the condition.
A client has been administered lactulose for several days. Which therapeutic response should the nurse expect for a client with hepatic encephalopathy?
Explanation
Choice A rationale
Lactulose is a synthetic sugar used to treat hepatic encephalopathy by reducing the absorption of ammonia in the intestines. Ammonia is a neurotoxin that can impair mental status in patients with liver dysfunction. By decreasing ammonia levels, lactulose helps improve cognitive function and mental status in patients with hepatic encephalopathy.
Choice B rationale
While lactulose can cause diarrhea as a side effect, the therapeutic goal in hepatic encephalopathy is not to reduce the number of liquid stools but to lower ammonia levels in the blood. The reduction in ammonia levels leads to improved mental status, not necessarily a reduction in liquid stools.
Choice C rationale
The ability to ambulate independently is not a direct therapeutic response to lactulose. The primary goal of lactulose therapy in hepatic encephalopathy is to improve mental status by reducing ammonia levels, not to enhance physical mobility.
Choice D rationale
Lactulose does not have a direct effect on urine output. Its primary mechanism of action is to reduce ammonia absorption in the intestines, thereby improving mental status in patients with hepatic encephalopathy.
A client with a history of chronic obstructive pulmonary disease (COPD) receives a new prescription for an ipratropium inhaler. Which action indicates to the nurse that additional teaching is needed?
Explanation
Choice A rationale
Storing the medication at room temperature is appropriate for ipratropium inhalers. This ensures the medication remains effective and safe for use.
Choice B rationale
Attaching a spacer device to the inhaler is recommended for patients using ipratropium inhalers. A spacer helps deliver the medication more effectively to the lungs and reduces the risk of side effects.
Choice C rationale
Rinsing the mouth after each use of the inhaler is a good practice to prevent oral thrush and other side effects. It is a recommended step in the proper use of inhalers.
Choice D rationale
Priming the inhaler with 7 pumps is excessive. Typically, inhalers need to be primed with 2-4 pumps before first use or if they haven’t been used for a while. Over-priming can waste medication and indicate a need for additional teaching.
A client receives a prescription for ophthalmic ketorolac. Prior to administering the medication, the nurse should review the medical record for which condition?
Explanation
Choice A rationale
Corneal abrasion is a contraindication for the use of ophthalmic ketorolac. Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) that can delay healing and increase the risk of further damage to the cornea.
Choice B rationale
Chemical burns are not a primary contraindication for ophthalmic ketorolac. However, the treatment of chemical burns typically involves other specific interventions, and the use of ketorolac should be carefully considered.
Choice C rationale
Radiation exposure is not a direct contraindication for the use of ophthalmic ketorolac. The medication is used to reduce inflammation and pain, which may be beneficial in managing symptoms related to radiation exposure.
Choice D rationale
A foreign body in the eye is not a primary contraindication for ophthalmic ketorolac. However, the foreign body should be removed, and the eye should be thoroughly examined before administering any medication.
Three days after a cholecystectomy for cholelithiasis, a female client reports having persistent upper abdominal pain that radiates to her back. Based on these findings, the nurse should observe the client for which pathophysiological condition?
Explanation
Choice A rationale
Acute pancreatitis is a potential complication after cholecystectomy. The persistent upper abdominal pain radiating to the back is a classic symptom of acute pancreatitis. This condition can occur due to the migration of gallstones or other factors affecting the pancreas.
Choice B rationale
Biliary duct obstruction can cause upper abdominal pain, but it is less likely to present with pain radiating to the back. This condition typically presents with jaundice and other symptoms.
Choice C rationale
Surgical site infection can cause abdominal pain, but it is usually localized to the surgical site and does not typically radiate to the back. Other signs of infection, such as fever and redness, would also be present.
Choice D rationale
Hepatorenal failure is a severe condition that can occur in patients with liver disease, but it is not commonly associated with pain radiating to the back. It typically presents with symptoms of liver and kidney dysfunction.
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