HESI RN Adult Health (D444)

Correct Answer B. Obtain IV fluids for infusion per protocol

Explanation:

This client is showing classic signs of hypovolemic shock—cool, pale, moist skin; restlessness (early sign of poor perfusion); and decreased urine output. In the postoperative setting, this is most likely due to fluid or blood loss. The immediate priority is to restore circulating volume to improve perfusion and prevent progression to irreversible shock. Since a saline lock is already in place, the nurse should promptly start IV fluids per the provider’s protocol (often isotonic crystalloids like normal saline or lactated Ringer’s).

Why Other Options Are Incorrect:

A. Measure the urine specific gravity

While useful for assessing hydration status, this is not the priority in a patient who is acutely unstable and showing signs of shock.

C. Prepare for insertion of a central venous catheter

Central access may be useful for long-term fluid or medication administration, but it is not the immediate life-saving intervention—fluids should be started now using the existing IV access.

D. Auscultate the client’s breath sounds

Respiratory assessment is important, but this client is already on oxygen and shows no acute signs of respiratory distress. The more urgent need is to correct the likely cause of shock—volume loss.

Correct Answer A. Fever of 102° F

Explanation:

A high fever in the setting of an acute bowel obstruction may indicate peritonitis or bowel perforation, both of which are life-threatening emergencies requiring immediate medical intervention. Prompt recognition and treatment are critical to prevent septic shock and death.

Why Other Options Are Incorrect:

B. Blood pressure of 150/90 mm Hg

While elevated, this blood pressure is not life-threatening in the acute setting and does not require immediate intervention compared to signs of infection and possible perforation.

C. Abdominal cramping

Cramping is an expected symptom of small bowel obstruction and is not necessarily indicative of a complication that requires urgent action.

D. Dry mucous membranes

This suggests dehydration, which is important to address but is not as urgent as a fever that may signal a surgical emergency.

Correct Answer:

C. High-Fowler's position

Explanation

High-Fowler’s position (sitting upright at 60–90 degrees) helps maximize lung expansion, decreases venous return to the heart, and reduces pulmonary congestion. For clients with pulmonary edema, this position improves oxygenation and makes breathing easier by promoting effective use of accessory muscles and reducing pressure on the diaphragm.

Why Other Options Are Wrong

A. Left lateral position

This may help prevent aspiration but does not relieve dyspnea or improve lung expansion in pulmonary edema.

B. Reverse Trendelenburg

This position slightly elevates the head but is less effective than sitting fully upright in improving ventilation and decreasing pulmonary congestion.

D. Supine

Lying flat worsens pulmonary edema by increasing venous return and further compromising breathing, making this the least appropriate option.

Correct Answer D. Schedule an appointment for the patient to see the doctor

Explanation:

Purulent exudate and erythema at the site suggest a secondary bacterial infection, which requires medical evaluation. Continuing corticosteroid use without addressing the infection can worsen the condition, as steroids suppress local immune response. The safest action is to promptly schedule an appointment so the provider can assess the site and initiate appropriate antibiotic therapy if needed. Early treatment prevents the spread of infection and complications.

Why Other Options Are Incorrect:

A. Advise the patient to apply plastic wrap over the ointment to promote healing

Occlusive dressings such as plastic wrap can trap moisture and heat, creating an ideal environment for bacterial growth, which can worsen the infection.

B. Instruct the patient to continue the ointment until all erythema is relieved

Corticosteroids reduce inflammation but do not treat bacterial infections. Continuing without addressing the infection delays proper care and increases the risk of worsening symptoms.

C. Explain that the patient needs to complete all prescribed doses of the medication

Topical corticosteroids are not given as “courses” in the same way as antibiotics, and completion of therapy is not appropriate when an infection has developed. The medication should be reassessed before further use.

Correct Answer A. The xenograft is taken from nonhuman sources

Explanation:

A xenograft is a temporary biological dressing obtained from a nonhuman source, usually pigskin (porcine) or sometimes bovine. This information is important for a Jewish client because of religious dietary and cultural considerations. Xenografts provide a temporary covering to protect the wound, reduce pain, and promote healing until permanent closure can occur. The nurse must explain the source so the client can make an informed decision in alignment with personal and religious beliefs.

Why Other Options Are Incorrect:

B. Grafting increases the risk for bacterial infection

Grafting, when performed under sterile conditions, does not inherently increase infection risk. In fact, it reduces infection risk by covering exposed tissue.

C. As the burn heals the graft permanently attaches

Xenografts are temporary and do not permanently attach to the wound bed; they are eventually replaced by the client’s own skin or a permanent graft.

D. Grafts are later removed by debriding procedure

Xenografts naturally loosen and are removed once the underlying tissue heals sufficiently or a permanent graft is placed. They do not require an extensive debriding procedure for removal.

Correct Answer:

D. Relieve any kinks or obstruction in the client's Foley tubing

Explanation

A client with a C-5 spinal cord injury is at risk for autonomic dysreflexia, a life-threatening condition triggered by noxious stimuli below the level of injury, most often bladder distension. The client’s symptoms—flushing and headache—are classic warning signs. The nurse’s immediate priority is to remove the trigger, with bladder obstruction being the most common. Relieving kinks or obstructions in the Foley catheter addresses the underlying cause promptly and can resolve the crisis.

Why Other Options Are Wrong

A. Administer a prescribed PRN dose of hydralazine

Antihypertensive medication may be necessary if symptoms persist after the cause is removed. However, giving hydralazine before correcting the trigger does not treat the underlying problem and delays resolution.

B. Assess the client's blood pressures every 15 minutes

Blood pressure should be monitored closely in autonomic dysreflexia, but assessment alone does not resolve the condition. Intervening to relieve the noxious stimulus must come first.

C. Teach the client to recognize the symptoms of dysreflexia

Education is important for long-term management, but during an acute episode, immediate nursing intervention is required to prevent stroke, seizure, or death. Teaching at this point is not the priority.

Correct Answer A. Oral care

Explanation:

Clients with Huntington disease have involuntary choreiform movements that can affect all muscles, including those in the face and mouth. This can increase the risk of aspiration and injury during oral care. Supervision is most important during this task to ensure the client’s airway remains protected, suction equipment is available if needed, and oral structures are not injured. Bathing, foot care, and catheter care pose fewer immediate airway risks and do not require the same level of direct supervision for safety in this client population.

Why Other Options Are Incorrect:

B. Bathing

While the client may require assistance with bathing due to limited mobility, it does not carry the same acute risk of airway compromise as oral care.

C. Foot care

Foot care is important for hygiene and preventing skin breakdown, but it is not an airway or aspiration risk.

D. Catheter care

Catheter care is essential to prevent infection, but it is a lower priority for direct supervision compared to a task with an immediate risk for aspiration.

Correct Answer D. Potassium of 2.5 mEq/L

Explanation:

A potassium level of 2.5 mEq/L is critically low and can cause life-threatening cardiac arrhythmias. In DKA, insulin therapy shifts potassium into the cells, which can worsen hypokalemia. Severe hypokalemia must be corrected before starting or continuing insulin infusion to prevent cardiac arrest. Immediate intervention with potassium replacement is the priority to stabilize the patient before addressing other metabolic issues.

Why Other Options Are Incorrect:

A. Blood pH of 7.3

This value indicates mild acidosis, which is expected in DKA and not as immediately life-threatening as severe hypokalemia. Treatment of the underlying cause will improve pH over time.

B. Glucose of 350 mg/dL

This level is elevated but not as critical as a dangerously low potassium level. Hyperglycemia will be addressed with insulin once potassium is stabilized.

C. White blood cell count of 15,000 mm³

This is a mild elevation that likely reflects the infection (UTI). While it requires treatment, it does not present the immediate cardiac risk that severe hypokalemia does.

Correct Answer B. Magnesium sulfate

Explanation:

This presentation strongly suggests torsades de pointes, a form of polymorphic ventricular tachycardia often associated with prolonged QT interval. In a malnourished alcoholic client, hypomagnesemia is a likely underlying cause. Magnesium sulfate is the drug of choice for terminating torsades de pointes and stabilizing the myocardial membrane, even if serum magnesium levels are normal.

Why Other Options Are Incorrect:

A. Amiodarone (Cordarone)

While amiodarone is used for ventricular arrhythmias, it can further prolong the QT interval and worsen torsades de pointes, making it unsafe in this setting.

C. Lidocaine (Xylocaine)

Lidocaine can be useful in some ventricular arrhythmias, but it is not effective for torsades de pointes and does not address the underlying magnesium deficiency.

D. Procainamide (Pronestyl)

Procainamide prolongs the QT interval, which would exacerbate torsades de pointes. It is contraindicated in this rhythm disturbance.