HESI UCA1 D444 Adult I OA 1.
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1. Which technique should the nurse use when assessing for early signs of rheumatoid arthritis?
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Observe the client's fingers
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Observe the skin for lesions
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Palpate large joints for nodules
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Palpate the lymph nodes
Explanation
Explanation
Correct Answer: (A) Observe the client's fingers
Rheumatoid arthritis characteristically begins in the small joints of the hands and feet, particularly the proximal interphalangeal and metacarpophalangeal joints of the fingers. Early signs include symmetric swelling, warmth, and tenderness of the finger joints. Observing the fingers for these early inflammatory changes is the most appropriate assessment technique for detecting early rheumatoid arthritis.
Why the other options are incorrect:
B. Observe the skin for lesions — Skin changes such as rheumatoid nodules can occur in rheumatoid arthritis, but these are typically seen in more advanced disease rather than early stages. Skin lesion observation is not the primary early assessment technique.
C. Palpate large joints for nodules — Rheumatoid arthritis typically begins in small joints, not large ones. Large joint involvement such as the knees and hips occurs in later stages of the disease. Palpating large joints is not the most appropriate technique for early detection.
D. Palpate the lymph nodes — Lymphadenopathy can occur as a systemic manifestation of rheumatoid arthritis, but it is not a primary early sign and is not used as the initial assessment technique for identifying early joint disease.
Correct Answer: (A) Observe the client's fingers
Rheumatoid arthritis characteristically begins in the small joints of the hands and feet, particularly the proximal interphalangeal and metacarpophalangeal joints of the fingers. Early signs include symmetric swelling, warmth, and tenderness of the finger joints. Observing the fingers for these early inflammatory changes is the most appropriate assessment technique for detecting early rheumatoid arthritis.
Why the other options are incorrect:
B. Observe the skin for lesions — Skin changes such as rheumatoid nodules can occur in rheumatoid arthritis, but these are typically seen in more advanced disease rather than early stages. Skin lesion observation is not the primary early assessment technique.
C. Palpate large joints for nodules — Rheumatoid arthritis typically begins in small joints, not large ones. Large joint involvement such as the knees and hips occurs in later stages of the disease. Palpating large joints is not the most appropriate technique for early detection.
D. Palpate the lymph nodes — Lymphadenopathy can occur as a systemic manifestation of rheumatoid arthritis, but it is not a primary early sign and is not used as the initial assessment technique for identifying early joint disease.
2. An adolescent boy is admitted to the emergency department (ED) following a bee sting. He arrives with a body rash and 30 minutes later he becomes short of breath. The nurse obtains vital signs with a heart rate of 130 beats/minute, respiratory rate 40 breaths/minute, and blood pressure of 90/52 mm Hg. The client is exhibiting clinical manifestations of which type of immune reaction?
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Cell mediated hypersensitivity
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IgE response hypersensitivity
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Autoimmune response
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Type II hypersensitivity
Explanation
Explanation
Correct Answer: (B) IgE response hypersensitivity
This presentation is a classic anaphylactic reaction, which is a Type I IgE-mediated hypersensitivity response. Upon initial exposure to the bee venom antigen, IgE antibodies are produced and bind to mast cells. On re-exposure, the antigen cross-links the IgE antibodies, triggering massive release of histamine and other mediators. This causes the characteristic triad of urticaria (body rash), bronchospasm (shortness of breath, tachypnea), and cardiovascular collapse (tachycardia, hypotension) seen in this client.
Why the other options are incorrect:
A. Cell mediated hypersensitivity — Type IV cell-mediated hypersensitivity involves T-lymphocytes rather than antibodies and occurs over 24 to 72 hours after exposure, such as in contact dermatitis or tuberculin skin test reactions. The rapid onset within 30 minutes rules this out.
C. Autoimmune response — Autoimmune reactions occur when the immune system attacks the body's own tissues. This reaction is triggered by an external allergen (bee sting), not by self-antigens, making it an allergic hypersensitivity rather than an autoimmune process.
D. Type II hypersensitivity — Type II hypersensitivity involves IgG or IgM antibodies directed against antigens on cell surfaces, as seen in hemolytic transfusion reactions or Rh incompatibility. The clinical picture here — rapid onset after a sting with systemic anaphylaxis — is characteristic of Type I IgE-mediated hypersensitivity, not Type II.
Correct Answer: (B) IgE response hypersensitivity
This presentation is a classic anaphylactic reaction, which is a Type I IgE-mediated hypersensitivity response. Upon initial exposure to the bee venom antigen, IgE antibodies are produced and bind to mast cells. On re-exposure, the antigen cross-links the IgE antibodies, triggering massive release of histamine and other mediators. This causes the characteristic triad of urticaria (body rash), bronchospasm (shortness of breath, tachypnea), and cardiovascular collapse (tachycardia, hypotension) seen in this client.
Why the other options are incorrect:
A. Cell mediated hypersensitivity — Type IV cell-mediated hypersensitivity involves T-lymphocytes rather than antibodies and occurs over 24 to 72 hours after exposure, such as in contact dermatitis or tuberculin skin test reactions. The rapid onset within 30 minutes rules this out.
C. Autoimmune response — Autoimmune reactions occur when the immune system attacks the body's own tissues. This reaction is triggered by an external allergen (bee sting), not by self-antigens, making it an allergic hypersensitivity rather than an autoimmune process.
D. Type II hypersensitivity — Type II hypersensitivity involves IgG or IgM antibodies directed against antigens on cell surfaces, as seen in hemolytic transfusion reactions or Rh incompatibility. The clinical picture here — rapid onset after a sting with systemic anaphylaxis — is characteristic of Type I IgE-mediated hypersensitivity, not Type II.
3. The nurse is planning care for a client with a direct (sliding) hiatal hernia. Nursing actions should be planned to meet which goal?
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Prevent esophageal reflux
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Promote effective swallowing
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Maintain intact oral mucosa
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Increase intestinal peristalsis
Explanation
Explanation
Correct Answer: (A) Prevent esophageal reflux
A sliding hiatal hernia occurs when the gastroesophageal junction and a portion of the stomach slide up through the diaphragmatic hiatus into the thoracic cavity. This disrupts the lower esophageal sphincter mechanism, allowing gastric acid to reflux into the esophagus. The primary nursing goal is to prevent esophageal reflux through positioning strategies such as elevating the head of the bed, dietary modifications, avoidance of tight clothing, and administration of prescribed antacids or proton pump inhibitors.
Why Other Options are Incorrect:
B. Promote effective swallowing — Swallowing difficulties are more associated with esophageal strictures, motility disorders, or large paraesophageal hernias. While some discomfort with swallowing may occur, promoting swallowing is not the primary care goal for a sliding hiatal hernia.
C. Maintain intact oral mucosa — Oral mucosa integrity is a concern in conditions such as stomatitis, oral infections, or chemotherapy side effects. It is not a relevant care goal for hiatal hernia management.
D. Increase intestinal peristalsis — Intestinal peristalsis is a concern in conditions such as ileus or constipation. A sliding hiatal hernia affects the upper gastrointestinal tract and the gastroesophageal junction, not intestinal motility.
Correct Answer: (A) Prevent esophageal reflux
A sliding hiatal hernia occurs when the gastroesophageal junction and a portion of the stomach slide up through the diaphragmatic hiatus into the thoracic cavity. This disrupts the lower esophageal sphincter mechanism, allowing gastric acid to reflux into the esophagus. The primary nursing goal is to prevent esophageal reflux through positioning strategies such as elevating the head of the bed, dietary modifications, avoidance of tight clothing, and administration of prescribed antacids or proton pump inhibitors.
Why Other Options are Incorrect:
B. Promote effective swallowing — Swallowing difficulties are more associated with esophageal strictures, motility disorders, or large paraesophageal hernias. While some discomfort with swallowing may occur, promoting swallowing is not the primary care goal for a sliding hiatal hernia.
C. Maintain intact oral mucosa — Oral mucosa integrity is a concern in conditions such as stomatitis, oral infections, or chemotherapy side effects. It is not a relevant care goal for hiatal hernia management.
D. Increase intestinal peristalsis — Intestinal peristalsis is a concern in conditions such as ileus or constipation. A sliding hiatal hernia affects the upper gastrointestinal tract and the gastroesophageal junction, not intestinal motility.
4. A client experiences residual effects following an acute attack of Ménière's disease and receives a new prescription for an antihistamine. Which assessment finding indicates that the medication is effective?
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Ambulates easily without vertigo
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Oxygen saturation level of 99% on room air
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Headache pain rated 0 on a 0 to 10 scale
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Blood pressure of 120/80 mm Hg
Explanation
Explanation
Ménière's disease is a disorder of the inner ear characterized by episodes of vertigo, tinnitus, fluctuating hearing loss, and a sensation of ear fullness. Antihistamines such as meclizine are prescribed for their vestibular suppressant and antiemetic properties to reduce vertigo and dizziness. The most direct indicator that the antihistamine is effective is the client's ability to ambulate easily without experiencing vertigo, demonstrating resolution of the primary disabling symptom.
Why the other options are incorrect:
B. Oxygen saturation level of 99% on room air — Oxygen saturation is unrelated to Ménière's disease or the therapeutic effect of antihistamines. This finding reflects pulmonary function, not vestibular function.
C. Headache pain rated 0 on a 0 to 10 scale — While headache can accompany Ménière's attacks, it is not the primary symptom targeted by antihistamine therapy. Vertigo reduction is the expected therapeutic outcome, not headache relief.
D. Blood pressure of 120/80 mm Hg — Blood pressure within normal limits does not indicate the effectiveness of an antihistamine for Ménière's disease. Blood pressure is not a therapeutic target in this condition.
Ménière's disease is a disorder of the inner ear characterized by episodes of vertigo, tinnitus, fluctuating hearing loss, and a sensation of ear fullness. Antihistamines such as meclizine are prescribed for their vestibular suppressant and antiemetic properties to reduce vertigo and dizziness. The most direct indicator that the antihistamine is effective is the client's ability to ambulate easily without experiencing vertigo, demonstrating resolution of the primary disabling symptom.
Why the other options are incorrect:
B. Oxygen saturation level of 99% on room air — Oxygen saturation is unrelated to Ménière's disease or the therapeutic effect of antihistamines. This finding reflects pulmonary function, not vestibular function.
C. Headache pain rated 0 on a 0 to 10 scale — While headache can accompany Ménière's attacks, it is not the primary symptom targeted by antihistamine therapy. Vertigo reduction is the expected therapeutic outcome, not headache relief.
D. Blood pressure of 120/80 mm Hg — Blood pressure within normal limits does not indicate the effectiveness of an antihistamine for Ménière's disease. Blood pressure is not a therapeutic target in this condition.
5. When performing postural drainage on a client with chronic obstructive pulmonary disease (COPD), which approach should the nurse use?
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Obtain an arterial blood gas (ABG) prior to the procedure
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Explain that the client may be placed in five positions
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Perform the drainage immediately after meals
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Instruct the client to breathe shallow and fast
Explanation
Explanation
Postural drainage uses gravity to mobilize secretions from different lung segments into the central airways where they can be coughed or suctioned out. The client is placed in various positions — typically up to five positions — to drain different lobes and segments of the lungs. Explaining this to the client promotes understanding, cooperation, and accurate expectations about the procedure.
Why Other Options are Incorrect:
A. Obtain an arterial blood gas (ABG) prior to the procedure — ABG measurement is not a routine prerequisite for postural drainage. While assessing baseline oxygenation is prudent, a formal ABG is not standardly required before performing this procedure.
C. Perform the drainage immediately after meals — Postural drainage should never be performed immediately after meals. Placing the client in head-down positions after eating significantly increases the risk of aspiration of stomach contents. The procedure should be performed before meals or at least two hours after eating.
D. Instruct the client to breathe shallow and fast — Deep, slow breathing is the correct technique during postural drainage, as it helps mobilize and loosen secretions. Shallow, rapid breathing is ineffective for secretion clearance and could worsen gas exchange in a COPD client.
Postural drainage uses gravity to mobilize secretions from different lung segments into the central airways where they can be coughed or suctioned out. The client is placed in various positions — typically up to five positions — to drain different lobes and segments of the lungs. Explaining this to the client promotes understanding, cooperation, and accurate expectations about the procedure.
Why Other Options are Incorrect:
A. Obtain an arterial blood gas (ABG) prior to the procedure — ABG measurement is not a routine prerequisite for postural drainage. While assessing baseline oxygenation is prudent, a formal ABG is not standardly required before performing this procedure.
C. Perform the drainage immediately after meals — Postural drainage should never be performed immediately after meals. Placing the client in head-down positions after eating significantly increases the risk of aspiration of stomach contents. The procedure should be performed before meals or at least two hours after eating.
D. Instruct the client to breathe shallow and fast — Deep, slow breathing is the correct technique during postural drainage, as it helps mobilize and loosen secretions. Shallow, rapid breathing is ineffective for secretion clearance and could worsen gas exchange in a COPD client.
6. 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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Observe pupil response of the right eye.
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Turn, cough, and deep breathe every 2 hours.
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Sleep flat in a supine position.
Explanation
Explanation
Correct Answer: (A) Administer a stool softener.
Following cataract extraction with a lens implant, it is critical to prevent any sudden increase in intraocular pressure (IOP). Straining during a bowel movement significantly raises IOP, which can disrupt the surgical site and compromise the lens implant. Administering a stool softener prevents constipation and straining, making it the most important discharge instruction to include.
Why the other options are incorrect:
B. Observe pupil response of the right eye — Post-operatively, the nurse should monitor the operative left eye, not the unaffected right eye. Observing the wrong eye provides no clinically useful information regarding surgical recovery.
C. Turn, cough, and deep breathe every 2 hours — This is a standard post-operative instruction for abdominal or thoracic surgeries to prevent pulmonary complications. Coughing, however, dramatically increases intraocular pressure and is actually contraindicated following eye surgery.
D. Sleep flat in a supine position — Clients following cataract surgery are typically instructed to sleep with the head of the bed elevated and to avoid lying on the operative side, not flat. Sleeping flat can increase IOP and increase the risk of complications.
Correct Answer: (A) Administer a stool softener.
Following cataract extraction with a lens implant, it is critical to prevent any sudden increase in intraocular pressure (IOP). Straining during a bowel movement significantly raises IOP, which can disrupt the surgical site and compromise the lens implant. Administering a stool softener prevents constipation and straining, making it the most important discharge instruction to include.
Why the other options are incorrect:
B. Observe pupil response of the right eye — Post-operatively, the nurse should monitor the operative left eye, not the unaffected right eye. Observing the wrong eye provides no clinically useful information regarding surgical recovery.
C. Turn, cough, and deep breathe every 2 hours — This is a standard post-operative instruction for abdominal or thoracic surgeries to prevent pulmonary complications. Coughing, however, dramatically increases intraocular pressure and is actually contraindicated following eye surgery.
D. Sleep flat in a supine position — Clients following cataract surgery are typically instructed to sleep with the head of the bed elevated and to avoid lying on the operative side, not flat. Sleeping flat can increase IOP and increase the risk of complications.
7. A client is recovering from the surgical removal of glass in the right eye. Which intervention should the nurse implement immediately following the procedure?
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Encourage deep breathing and coughing exercises.
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Teach a family member to administer eye drops.
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Provide an eye shield to be worn while sleeping.
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Obtain vital signs every 2 hours during hospitalization.
Explanation
Explanation
Correct Answer: (C) Provide an eye shield to be worn while sleeping.
Immediately following ocular surgery for foreign body removal, protecting the operative eye from accidental trauma is the priority. An eye shield prevents the client from inadvertently rubbing or pressing on the eye during sleep, which could disrupt the surgical site, introduce infection, or cause further injury to the healing tissues.
Why the other options are incorrect:
A. Encourage deep breathing and coughing exercises — Coughing significantly increases intraocular pressure and is contraindicated following eye surgery. This intervention could compromise the surgical repair and is not appropriate in the immediate post-operative period.
B. Teach a family member to administer eye drops — While discharge education about eye drop administration is important, it is not the immediate post-operative priority. Protection of the eye takes precedence first.
D. Obtain vital signs every 2 hours during hospitalization — Routine vital sign monitoring is standard post-operative care but is not specific to the immediate priority of protecting the surgically repaired eye.
Correct Answer: (C) Provide an eye shield to be worn while sleeping.
Immediately following ocular surgery for foreign body removal, protecting the operative eye from accidental trauma is the priority. An eye shield prevents the client from inadvertently rubbing or pressing on the eye during sleep, which could disrupt the surgical site, introduce infection, or cause further injury to the healing tissues.
Why the other options are incorrect:
A. Encourage deep breathing and coughing exercises — Coughing significantly increases intraocular pressure and is contraindicated following eye surgery. This intervention could compromise the surgical repair and is not appropriate in the immediate post-operative period.
B. Teach a family member to administer eye drops — While discharge education about eye drop administration is important, it is not the immediate post-operative priority. Protection of the eye takes precedence first.
D. Obtain vital signs every 2 hours during hospitalization — Routine vital sign monitoring is standard post-operative care but is not specific to the immediate priority of protecting the surgically repaired eye.
8. The nurse notes that a client has been receiving hydromorphone every six hours for four days. Which assessment is most important for the nurse to complete?
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Auscultate the client's bowel sounds.
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Count the apical and radial rate simultaneously.
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Measure the client's capillary glucose level.
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Observe for edema around the ankles.
Explanation
Explanation
Correct Answer: (A) Auscultate the client's bowel sounds.
Hydromorphone is an opioid analgesic. One of the most common and clinically significant side effects of prolonged opioid use is opioid-induced constipation, which results from slowed gastrointestinal motility. After four days of scheduled dosing, auscultating bowel sounds is the priority assessment to detect decreased or absent peristalsis before it progresses to a serious ileus.
Why the other options are incorrect:
B. Count the apical and radial rate simultaneously — This assesses for a pulse deficit, which is relevant in cardiac dysrhythmias. While opioids can cause bradycardia, this is not the most critical concern after several days of scheduled opioid use.
C. Measure the client's capillary glucose level — Blood glucose monitoring is not a primary concern associated with hydromorphone administration and has no direct pharmacological connection to opioid therapy.
D. Observe for edema around the ankles — Peripheral edema is associated with cardiac or renal conditions and is not a primary adverse effect expected with opioid analgesic therapy.
Correct Answer: (A) Auscultate the client's bowel sounds.
Hydromorphone is an opioid analgesic. One of the most common and clinically significant side effects of prolonged opioid use is opioid-induced constipation, which results from slowed gastrointestinal motility. After four days of scheduled dosing, auscultating bowel sounds is the priority assessment to detect decreased or absent peristalsis before it progresses to a serious ileus.
Why the other options are incorrect:
B. Count the apical and radial rate simultaneously — This assesses for a pulse deficit, which is relevant in cardiac dysrhythmias. While opioids can cause bradycardia, this is not the most critical concern after several days of scheduled opioid use.
C. Measure the client's capillary glucose level — Blood glucose monitoring is not a primary concern associated with hydromorphone administration and has no direct pharmacological connection to opioid therapy.
D. Observe for edema around the ankles — Peripheral edema is associated with cardiac or renal conditions and is not a primary adverse effect expected with opioid analgesic therapy.
9. To assess the quality of an adult client's pain, which approach should the nurse use?
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Identify effective pain relief measures.
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Observe body language and movement.
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Ask the client to describe the pain.
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Provide a numeric pain scale.
Explanation
Explanation
Correct Answer: (C) Ask the client to describe the pain.
Pain quality refers to the character or nature of the pain, such as burning, stabbing, aching, throbbing, or crushing. The most accurate and direct way to assess quality is to ask the client to describe it in their own words, as quality is a subjective experience that cannot be fully captured through observation or numeric ratings alone.
Why the other options are incorrect:
A. Identify effective pain relief measures — This assesses the response to treatment, not the quality of the pain itself. It is relevant to evaluating pain management but does not describe the character of the pain.
B. Observe body language and movement — Behavioral observation can provide supplementary information about pain intensity, particularly in non-verbal clients, but it does not reveal the quality or character of the pain experience.
D. Provide a numeric pain scale — A numeric scale measures pain intensity on a scale from zero to ten. It quantifies how severe the pain is, but it does not capture the qualitative nature or character of the pain being experienced.
Correct Answer: (C) Ask the client to describe the pain.
Pain quality refers to the character or nature of the pain, such as burning, stabbing, aching, throbbing, or crushing. The most accurate and direct way to assess quality is to ask the client to describe it in their own words, as quality is a subjective experience that cannot be fully captured through observation or numeric ratings alone.
Why the other options are incorrect:
A. Identify effective pain relief measures — This assesses the response to treatment, not the quality of the pain itself. It is relevant to evaluating pain management but does not describe the character of the pain.
B. Observe body language and movement — Behavioral observation can provide supplementary information about pain intensity, particularly in non-verbal clients, but it does not reveal the quality or character of the pain experience.
D. Provide a numeric pain scale — A numeric scale measures pain intensity on a scale from zero to ten. It quantifies how severe the pain is, but it does not capture the qualitative nature or character of the pain being experienced.
10. A young adult client who is experiencing a severe asthma attack has been short of breath for three hours. The client's arterial blood gas (ABG) results are a pH of 7.22, PaCO2 55 mm Hg, and a HCO3- 25 mEq/L (25 mmol/L). Which intervention should the nurse implement to address this problem?
Reference Range: pH [7.35 to 7.45], PaCO2 [35 to 45 mm Hg], HCO3- [21 to 28 mEq/L]
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Position the client for maximum comfort
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Administer a PRN dose of albuterol
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Instruct the client to use pursed lip breathing
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Space nursing care to provide rest periods
Explanation
Explanation
Correct Answer: (B) Administer a PRN dose of albuterol
Interpreting the ABG step by step: the pH of 7.22 is below 7.35, confirming acidosis. The PaCO2 of 55 mm Hg is elevated above the normal upper limit of 45 mm Hg, identifying a respiratory cause. The HCO3- of 25 mEq/L is within normal range, ruling out a metabolic component. This pattern is consistent with respiratory acidosis caused by CO2 retention from severe bronchospasm during the asthma attack. The airways are obstructed, preventing adequate ventilation and CO2 elimination. Administering albuterol, a short-acting beta-2 bronchodilator, directly addresses the underlying bronchospasm by relaxing airway smooth muscle, opening the airways, and restoring effective ventilation to allow CO2 to be expelled and pH to normalize.
Why the other options are incorrect:
A. Position the client for maximum comfort — While positioning the client upright or in a high Fowler's position can aid breathing comfort, it does not treat the bronchospasm causing the respiratory acidosis. Positioning is a supportive measure, not a primary intervention for the identified ABG abnormality.
C. Instruct the client to use pursed lip breathing — Pursed lip breathing is a technique used in COPD management to slow exhalation and prevent airway collapse. In an acute severe asthma attack with respiratory acidosis, this technique does not address the bronchospasm and would not be effective or appropriate as the primary intervention.
D. Space nursing care to provide rest periods — While minimizing exertion is a general supportive strategy for clients in respiratory distress, providing rest periods does not treat the acute bronchospasm or the resulting respiratory acidosis. It is not the priority intervention for this ABG finding.
Correct Answer: (B) Administer a PRN dose of albuterol
Interpreting the ABG step by step: the pH of 7.22 is below 7.35, confirming acidosis. The PaCO2 of 55 mm Hg is elevated above the normal upper limit of 45 mm Hg, identifying a respiratory cause. The HCO3- of 25 mEq/L is within normal range, ruling out a metabolic component. This pattern is consistent with respiratory acidosis caused by CO2 retention from severe bronchospasm during the asthma attack. The airways are obstructed, preventing adequate ventilation and CO2 elimination. Administering albuterol, a short-acting beta-2 bronchodilator, directly addresses the underlying bronchospasm by relaxing airway smooth muscle, opening the airways, and restoring effective ventilation to allow CO2 to be expelled and pH to normalize.
Why the other options are incorrect:
A. Position the client for maximum comfort — While positioning the client upright or in a high Fowler's position can aid breathing comfort, it does not treat the bronchospasm causing the respiratory acidosis. Positioning is a supportive measure, not a primary intervention for the identified ABG abnormality.
C. Instruct the client to use pursed lip breathing — Pursed lip breathing is a technique used in COPD management to slow exhalation and prevent airway collapse. In an acute severe asthma attack with respiratory acidosis, this technique does not address the bronchospasm and would not be effective or appropriate as the primary intervention.
D. Space nursing care to provide rest periods — While minimizing exertion is a general supportive strategy for clients in respiratory distress, providing rest periods does not treat the acute bronchospasm or the resulting respiratory acidosis. It is not the priority intervention for this ABG finding.
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