APV1 : HESI Medical Health Adult Health
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Free APV1 : HESI Medical Health Adult Health Questions
To assess the quality of an adult client's pain, which approach should the nurse use?
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Observe body language and movement.
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Identify effective pain relief measures.
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Ask the client to describe the pain.
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Provide a numeric pain scale.
Explanation
Correct Answer:
(C) Ask the client to describe the pain. The quality of pain refers to its characteristics, such as sharp, dull, burning, or throbbing, and the most accurate way to assess this subjective aspect is to have the client describe it in their own words, as pain is a highly individualized experience best reported by the client themselves.
Why the other options are incorrect:
Option A is incorrect because observing body language and movement provides information about the client's behavioral response to pain but does not specifically assess the quality or character of the pain. Option B is incorrect because identifying effective pain relief measures pertains to management strategies rather than assessing the quality of the pain itself. Option D is incorrect because a numeric pain scale is used to assess the intensity of pain, not its quality or characteristics.
The nurse is caring for a client after a transurethral resection of the prostate (TURP) who reports bladder spasms. A triple-lumen urinary catheter with continuous bladder irrigation is in place. Which action(s) should the nurse take? Select all that apply.
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Irrigate the catheter manually
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Administer antispasmodics
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Provide Kegel exercises instruction
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Check the catheter for clots
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Guide through relaxation techniques
Explanation
Bladder spasms after TURP are often caused by clots or debris obstructing the catheter, so the nurse should check for clots to ensure proper drainage; administering prescribed antispasmodics helps relieve the spasms directly, and relaxation techniques can help the client cope with discomfort.
Why the other options are incorrect:
A. Irrigate the catheter manually — Manual irrigation is not the first-line action for a client with continuous bladder irrigation already in place; the nurse should first assess for clots and notify the provider if manual irrigation is needed per protocol.
C. Provide Kegel exercises instruction — Kegel exercises are used to strengthen pelvic floor muscles for urinary continence after catheter removal, not as an intervention for acute bladder spasms while the catheter is still in place.
A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions. How should the nurse respond?
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Instruct the client to avoid foods with gluten, such as wheat bread.
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Explain that the need to restrict fluids is the primary limitation.
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Describe the use of an elimination diet to find trigger foods.
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Advise the client to limit foods that are high in calcium and iron.
Explanation
Correct Answer:
C
Why the other options are incorrect:
Option A is incorrect because gluten restriction is specific to celiac disease and is not a standard universal recommendation for all clients with Crohn's disease. Option B is incorrect because fluid restriction is not appropriate for Crohn's disease, as clients are often at risk for dehydration due to diarrhea and should be encouraged to maintain adequate fluid intake. Option D is incorrect because calcium and iron are important nutrients that clients with Crohn's disease often need to maintain or increase, not restrict, due to malabsorption concerns.
The client who is receiving an aminoglycoside for an infection appears dizzy when ambulating. Which laboratory result should the nurse review?
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Peak and trough level.
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Blood urea nitrogen.
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White blood cell count.
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Serum sodium level.
Explanation
Correct Answer:
(A) Peak and trough level. Aminoglycosides have a narrow therapeutic index and are known to cause ototoxicity, which can manifest as dizziness, vertigo, or balance disturbances. Reviewing the peak and trough levels helps the nurse determine whether the drug level is within the therapeutic range or elevated to a toxic level, which would explain the client's dizziness.
Why the other options are incorrect:
Option B is incorrect because while aminoglycosides can also cause nephrotoxicity, BUN alone does not directly explain the dizziness symptom the client is experiencing. Option C is incorrect because white blood cell count reflects infection status and response to treatment, not medication toxicity causing dizziness. Option D is incorrect because serum sodium level is not related to aminoglycoside toxicity or the client's reported symptom.
The healthcare provider (HCP) prescribes interferon beta-1b 0.125 mg every other day for a client with multiple sclerosis. The nurse reconstitutes the single-use vial of powder labeled "Interferon beta-1b 0.3 mg reconstitute with 1.2 mL of sterile water." How many mL should the nurse administer to the client? (Enter the numerical value only. If rounding is required, round to the nearest tenth.)
Explanation
Correct Answer Is:
0.5 mL. The vial concentration is 0.3 mg per 1.2 mL, which equals 0.25 mg/mL. To administer the prescribed dose of 0.125 mg, the nurse divides 0.125 mg by 0.25 mg/mL, resulting in 0.5 mL to be administered.
A client who has a prescription for benzonatate reports chewing and swallowing the capsules. Which intervention should the nurse take?
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Apply continuous pulse oximetry.
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Notify the healthcare provider.
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Obtain a baseline electrocardiogram.
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Give naloxone intramuscular.
Explanation
Correct Answer:
B
Why the other options are incorrect:
Option A is incorrect because while monitoring may be warranted, continuous pulse oximetry alone is not the priority action following improper administration of this medication. Option C is incorrect because benzonatate does not have known cardiac effects requiring a baseline ECG following chewing of the capsule. Option D is incorrect because naloxone is an opioid antagonist and would not be an appropriate intervention for benzonatate exposure, as this medication is not an opioid.
The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having sex with someone who had many partners. Which response should the nurse provide?
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Instruct the client on the importance of notifying sexual partners.
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Urge the client to have regular STI screening every two years.
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Inform the client that complications will not result from reinfection.
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Provide counseling that most contraceptives protect against infection.
Explanation
Correct Answer:
A
Why the other options are incorrect:
Option B is incorrect because screening every two years is far too infrequent for someone at ongoing risk of STI exposure; more frequent screening is recommended for at-risk individuals. Option C is incorrect because reinfection with syphilis can absolutely lead to complications, and this statement provides false reassurance. Option D is incorrect because most contraceptives, such as birth control pills, do not protect against STIs; only barrier methods like condoms offer some protection.
Which information should the nurse include in preoperative teaching for a client with a retinal tear?
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Instill eye drops to promote pupillary constriction.
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Lift objects that weigh less than 25 pounds (11 kg).
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Avoid reading until the postoperative appointment.
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Wear an eye patch to enhance rapid eye movement.
Explanation
Correct Answer:
C
Why the other options are incorrect:
Option A is incorrect because eye drops used preoperatively for retinal tears typically promote pupillary dilation, not constriction, to allow the surgeon better visualization of the retina. Option B is incorrect because lifting restrictions are more relevant to postoperative care rather than preoperative teaching for this condition. Option D is incorrect because an eye patch is used to limit eye movement and protect the eye, not to enhance rapid eye movement, which would actually be harmful in this situation.
The healthcare provider (HCP) prescribes bismuth subsalicylate, metronidazole, tetracycline, and pantoprazole for a client with a Helicobacter pylori (H. pylori) infection. Prior to administering the H. pylori treatment regimen, the nurse should review the electronic medical record (EMR) for which medication?
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Ipratropium.
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Loperamide.
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Famotidine.
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Aspirin.
Explanation
Correct Answer:
D
Why the other options are incorrect:
Option A is incorrect because ipratropium, an anticholinergic bronchodilator, does not have a significant interaction with the H. pylori treatment regimen. Option B is incorrect because while loperamide could theoretically affect GI motility, it is not the primary medication concern related to this specific drug combination. Option C is incorrect because famotidine, while related to acid suppression, does not pose the same significant interaction risk as aspirin when combined with bismuth subsalicylate.
Which information should the nurse include when giving discharge instructions to a client following a left eye cataract extraction with a lens implant?
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Administer a stool softener.
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Turn, cough, and deep breathe every 2 hours.
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Sleep flat in a supine position.
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Observe pupil response of the right eye.
Explanation
Correct Answer:
A
Why the other options are incorrect:
Option B is incorrect because turning, coughing, and deep breathing exercises can increase intraocular pressure and should generally be avoided following eye surgery. Option C is incorrect because the client should avoid sleeping flat and should instead be instructed to avoid positions or activities that increase intraocular pressure, such as bending or lying face down. Option D is incorrect because monitoring the unaffected eye's pupil response is not a priority discharge instruction compared to preventing complications related to the surgical eye.
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