HESI 101-200

Question 1

When performing postural drainage on a client with Chronic Obstructive
Pulmonary Disease (COPD), which approach should the nurse use?

Answer 1

Explain that the client may be placed in five positions

Question 2

A client presents in the emergency room with right-sided facial asymmetry. The
nurse asks the client to perform a series of movements that require use of the facial muscles. What symptoms suggest that the client has most likely experience a Bell’s palsy rather than a stroke?

Answer 2

Inability to close the affected eye, raise brow, or smile

Question 3

The nurse is teaching a client how to perform colostomy irrigations. When
observing the client’s return demonstration, which action indicated that the client understood the teaching?

Answer 3

Keeps the irrigating container less than 18 inches above the stoma

Question 4

The nurse should teach the client to observe which precaution while taking dronedarone?

Answer 4

Avoid grapefruits and its juice

Question 5

A client who sustained a head injury following an automobile collision is
admitted to the hospital. The nurse include the client’s risk for developing increased intracranial pressure (ICP) in the plan of care. Which signs indicate to the nurse that ICP has increased?

Answer 5

Confusion and papilledema

Question 6

The nurse is caring for a client receiving continuous IV fluids through a single lumen central venous catheter (CVC). Based on the CVC care bundle, which action should be completed daily to reduce the risk for infection?

Answer 6

Confirm the necessity for continued use of the CVC.

Question 7

During an annual physical examination, an older woman’s fasting blood sugar
(FBS) is determined to be 140 mg/dl or 7.8 mmol/L (SI). Which additional finding obtained during a follow-up visit 2 weeks later is most indicative that the client has diabetes mellitus (DM)?

Answer 7

Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI).

Question 8

A new mother tells the nurse that she is unsure if she will be able to transition into
parenthood. What action should the nurse take?

Answer 8

Determine if she can ask for support from family, friend, or the baby’s father.

Question 9

A client who was admitted yesterday with severe dehydration is complaining of pain a 24 gauge IV with normal saline is infusing at a rate of 150 ml/hour. Which intervention should the nurse implement first?

Answer 9

Stop the normal saline infusion.

Question 10

An elderly female is admitted because of a change in her level of sensorium.
During the evening shift, the client attempts to get out bed and falls, breaking her left hip. Buck’s skin traction is applied to the left leg while waiting for surgery. Which intervention is most important for the nurse to include in this client’s plan care?

Answer 10

Ensure proper alignment of the leg in traction.

Question 11

An Unna boot is applied to a client with a venous stasis ulcer. One week later,
when the Unna boot is removed during a follow-up appointment, the nurse observes that the ulcer site contains bright red tissue. What action should the nurse take in response to this finding?

Answer 11

Document the ongoing wound healing.

Question 12

At the end of a preoperative teaching session on pain management techniques, a
client starts to cry and states, “I just know I can’t handle all the pain.” What is the priority nursing diagnosis for this client?

Answer 12

Anxiety

Question 13

The nurse note a visible prolapse of the umbilical cord after a client experiences
spontaneous rupture of the membranes during labor. What intervention should the nurse implement immediately?

Answer 13

Elevate the presenting part off the cord.

Question 14

A client who had a right hip replacement 3 day ago is pale has diminished breath
sound over the left lower lung fields, a temperature of 100.2 F, and an oxygen saturation rate of 90%. The client is scheduled to be transferred to a skilled nursing facility (SNF) tomorrow for rehabilitative critical pathway. Based on the client’s symptoms, what recommendation should the nurse give the healthcare provider?

Answer 14

Reassess readiness for SNF transfer.

Question 15

A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin (Glucophage) 500 mg PO twice daily. What information should the nurse include in this client’s teaching plan? (Select all that apply.)

Answer 15

Recognize signs and symptoms of hypoglycemia.
Report persist polyuria to the healthcare provider.
Take Glucophage with the morning and evening meal.

Question 16

The nurse is developing an educational program for older clients who are being discharged with new antihypertensive medications. The nurse should ensure that the educational materials include which characteristics? Select all that apply

Answer 16

Contains a list with definitions of unfamiliar terms
Uses common words with few syllables
Uses pictures to help illustrate complex ideas

Question 17

During the admission assessment, the nurse auscultates heart sounds for a client with no history of cardiovascular disease. Where should the nurse listen when assessing the client’s point of maximal impulse (PMI)

Answer 17

This is a picture. Please reference the document

Question 18

An older male adult resident of long-term care facility is hospitalized for a cardiac catheterization that occurred yesterday. Since the procedure was conducted, the client has become increasingly disoriented. The night shift nurse reports that he attempted to remove the sandbag from his femoral artery multiple times during the night. What actions should the nurse take? (Select all that apply.)

Answer 18

Notify the healthcare provider of the client’s change in mental status.
Include q2 hour’s reorientation in the client’s plan of care.

Question 19

An older male comes to the clinic with a family member. When the nurse
attempts to take the client’s health history, he does not respond to questions in a clear manner. What action should the nurse implement first?

Answer 19

Assess the surroundings for noise and distractions

Question 20

The nurse caring for a client with acute renal fluid (ARF) has noted that the client
has voided 800 ml of urine in 4 hours. Based on this assessment, what should the nurse anticipate that client will need?

Answer 20

Large amounts of fluid and electrolyte replacement.

Question 21

Which intervention should the nurse include in the plan of care for a child with tetanus?

Answer 21

Minimize the amount of stimuli in the room

Question 22

Suicide precautions are initiated for a child admitted to the mental health unit
following an intentional narcotic overdose. After a visitor leaves, the nurse finds a package of cigarettes in the client’s room. Which intervention is most important for the nurse to implement?

Answer 22

Remove cigarettes for the client’s room

Question 23

A family member of a frail elderly adult asks the nurse about eligibility
requirements for hospice care. What information should the nurse provide? (Select all that apply.)

Answer 23

A client must be willing to accept palliative care, not curative care.
The healthcare provider must project that the client has 6 months or less to live.

Question 24

A client with atrial fibrillation receives a new prescription for dabigatran. What
instruction should the nurse include in this client’s teaching plan?

Answer 24

Avoid use of nonsteroidal ant-inflammatory drugs (NSAID).

Question 25

A nurse with 10 years experience working in the emergency room is reassigned to the perinatal unit to work an 8 hour shift. Which client is best to assign to this nurse?

Answer 25

A mother with an infected episiotomy

Question 26

An infant who is admitted for surgical repair of a ventricular septal defect (VSD) is irritable and diaphoretic with jugular vein distention. Which prescription should the nurse administer first?

Answer 26

Digoxin.

Question 27

The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN?

Answer 27

Supervise a newly hired graduate nurse during an admission assessment.

Question 28

While teaching a young male adult to use an inhaler for his newly diagnosed asthma, the client stares into the distance and appears to be concentrating on something other than the lesson the nurse is presenting. What action should the nurse take?

Answer 28

Ask the client what he is thinking about at his time.

Question 29

After several hours of non-productive coughing, a client presents to the emergency room complaining of chest tightness and shortness of breath. History includes end stage chronic obstructive pulmonary disease (COPD) and diabetes mellitus. While completing the pulmonary assessment, the nurse hears wheezing and poor air movement bilaterally. Which actions should the nurse implement? (Select all that apply.)

Answer 29

Administer PRN nebulizer treatment. Obtain 12 lead electrocardiogram. Monitor continuous oxygen saturation.

Question 30

The nurse caring for a 3 mont old boy one day after a pylorotomy notices that the infant is restless, is exhibiting facial grimaces, and is drawing his knees to his chest. What action should the nurse take?

Answer 30

Administer a prescribes analgesia for pain

Question 31

A 4 year old with acute lymphocytic leukemia (ALL) is receiving a chemotherapy (CT) protocol that included methotrexate (Mexate, Trexal, MIX), an antimetabolite. Which information should the nurse provide the parents about caring for their child?

Answer 31

Use sunblock or protective clothing when outdoors

Question 32

Two days after admissions male client remembers that he is allergic to eggs, and informs the nurse of the allergy. What actions should the nurse implement (Select all that apply)

Answer 32

Notify the food services department of the allergy Enter the allergy information in the clients record Add egg allergy to the clients allergy arm band

Question 33

The rapid response teams detect return of spontaneous circulation (ROSC) after 2 mins of continuous chest compressions. The client has a weak, fast pulse and no respiratory effort, so the healthcare provider performs a successful oral, intubation. What action should the nurse implement?

Answer 33

Reform bilateral chest auscultation

Question 34

After administering an antipyretic medication. Which intervention should the nurse implement?

Answer 34

Encouraging liberal fluid intake

Question 35

A client with hyperthyroidism is being treated with radioactive iodine (I-131). Which explanation should be included in preparing this client for this treatment?

Answer 35

Describe radioactive iodine as a tasteless, odorless medication administered by the healthcare provider

Question 36

After a colon resection for colon cancer, a male client is moaning while being transferred to the Post-anesthesia Care Unit (PACU). Which intervention should the nurse implement first?

Answer 36

Determine client's pulse, blood pressure and respirations

Question 37

The nurse is caring for a groups of clients with the help of licensed practical nurse (LPN) and an unexperienced unlicensed assistive personal (UAP). Which procedures can the nurse delegate to the UAP? ( select all that apply)

Answer 37

Take postoperative vital signs for a client who has an epidural following knew arthroplasty Collect a sputum specimen for a client with a fever of unknown origin Ambulate a client who has a femoral-popliteal bypass graft yesterday

Question 38

A male client with cirrhosis has ascites and reports feeling short of breath. The clients is in semi Fowler position with his arms at his side. What action should the nurse implement.

Answer 38

Raise the bed to a Fowler's position and support his arms with a pillow

Question 39

A client with a history of chronic pain requests a non-opiod analgesic. The client is alert but has difficult describing the exact nature and location of the pain to the nurse. What action should the nurse implement next?

Answer 39

Administer the analgesic as requested

Question 40

A client with chronic health problem has difficult ambulating short distance due to generalized weakness, but is able to bear weight on both legs. To assist with ambulation and provide the greatest stability, what assistive device is best for this client?

Answer 40

Crutches with a 4 point gait

Question 41

The nurse uses parkland formula (4ml x kg x total body surface area = 24 hours fluid replacement ) to calculate the 24-hours IV fluid replacement for a client with 40 % burns who weights 76 kg. How many ml should the client receive ?

Answer 41

12160 (4ml x 67 kg x 40 (bsa) = 12, 160 ml)

Question 42

A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure?

Answer 42

Observe aspiration site

Question 43

An 18 year old female client is seen at the health department for treatment of condylomata acuminate (perineal warts) caused by the human papillomavirus (HPV). Which intervention should the nurse implement?

Answer 43

Reinforce the importance of annual papnicolaou (pap) smears

Question 44

A client admitted to the psychiatric unit diagnosed with major depression want to sleep during the day, refuses to take a bath, and refuses to eat. Which nursing intervention should the nurse implement first?

Answer 44

Establish a structured routine for the client to follow

Question 45

A client with history of bilateral adrenalectomy is admitted with a week, irregular pulse, and hypotension. Which assessment finding warrant immediate intervention by the nurse?

Answer 45

Ventricular arrhythmias

Question 46

The mother of a 7 month old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The mother reports no evidence of watery stools. Which nursing intervention should the nurse implement?

Answer 46

Instruct the mother to change the child's diaper more often

Question 47

A resident of a long-term care facility, who has moderate dementia, is having difficulty in the dinning room. The client becomes frustrated when dropping utensils on the floor and then refused to eat. What action should the nurse implement?

Answer 47

Encourage the client to eat finger foods

Question 48

A client is receiving mesalamine 800 mg PO TID. Which assessment is most important for the nurse to assess the effectiveness of the medication?

Answer 48

Bowel patterns

Question 49

While in the medical records department, the nurse observes several old medical records with names visible in waste container. What action should the nurse implement?

Answer 49

Contact the medical records department supervisor

Question 50

A 16 year old adolescent with meningococcal meningitis is receiving a continuous IV infusion of penicillin G, which is prescribed as 20 million units in a total volume of 2 liters of normal saline every 24 hours. The pharmacy delivers 10 million units/ liters of normal saline. How many ml/hr should the nurse program the infusion pump?

Answer 50

83

Question 51

While visiting a female client who has heart failure (HF) and osteoarthritis, the home health nurse determines that the client is having more difficulty getting in and out of the bed than she did previously. What action should the nurse implement first?

Answer 51

Submit a referral for an evaluation by a physical therapist

Question 52

A client has an intravenous fluid infusing in the right forearm. To determine the client's distal pulse rate most accurately, which action should the nurse implement?

Answer 52

Palpate at the radial pulse site with the pads of two or three fingers

Question 53

A child is admitted to the pediatric unit diagnosed with sickle cell crisis. When the nurse walks into the room, the unlicensed assertive personnel (UAP) is encouraging the child to stay in bed in the supine position. Which action should the nurse implement?

Answer 53

Reposition the client with the head of the bed elevated

Question 54

A preschool-aged boy is admitted to the pediatric unit following successful resuscitation from a near-drowning incident. While providing care to hold, the nurse begins talking with his preadolescent brother who rescued the child from the swimming pool and intimated resuscitation. The nurse notices the older boy becomes withdrawn when asked about what happened. What action should the nurse take?

Answer 54

Ask the older brother how he felt during the incident

Question 55

After six days on a mechanical ventilator, a male client is extubated and placed on 40% oxygen via face mask. He is awake and cooperative, but complaint of a severe sore throat. While sipping water to swallow a medication, the client begins coughing, as if strangled. What intervention is most important for the nurse to implement?

Answer 55

Hold oral intake until swallow evaluation is done

Question 56

The nurse is interacting with a female client who is diagnosed with postpartum depression. Which finding should the nurse document as an objective sign of depression? (select all that apply)

Answer 56

Interacts with a flat affect Avoids eye contact Has a disheveled appearance

Question 57

A client in the post-anesthesia care unit (PACU) has an either on the Aldrete post anesthesia scoring system. What intervention should the nurse implement?

Answer 57

Transfer the client to the surgical floor

Question 58

In caring for the body of a client who just died, which tasks can be delegated to the unlicensed assertive personnel (UAP)? (select all that apply)

Answer 58

Place personal religious artifacts on the body Attach identifying name tags to the body Follow cultural beliefs in preparing the body

Question 59

An adult male reports the last time he received penicillin he developed a severe maculopapular rash al over his chest. What information should the nurse provide the client about future antibiotic prescriptions?

Answer 59

Be alert for possible cross-sensitive to cephalosporin agents

Question 60

A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement?

Answer 60

The client's need for pain medication should be determined

Question 61

A client with cirrhosis of the liver is admitted which complications related to end stage liver disease. Which intervention should the nurse implement? (select all that apply)

Answer 61

Monitor abdominal girth Report serum albumin and globulin levels Note the signs of swelling and edema

Question 62

During discharge teaching, the nurse discusses the parameters for weight monitoring with a client who was recently diagnosed with heart failure (HF). Which information is most important for the client to acknowledge?

Answer 62

Report weight gain of 2 pounds in 24 hours

Question 63

Which problem, noted in the client's history, is important for the nurse to be aware of prior to administration of a newly prescribed selective serotonin repute inhibitor (SSRI)?

Answer 63

Aural migraine headaches

Question 64

When implementing a disaster intervention plan, which intervention should the nurse implement first?

Answer 64

Identify a command center where activities are coordinated

Question 65

The nurse is evaluating a client's symptoms, and formulates the nursing diagnosis, "high risk for injury due to possible urinary tract infection." which symptoms indicate the need for this diagnosis?

Answer 65

Fever and dysuria

Question 66

A client is admitted with metastatic carcinoma of the liver, ascites, and bilateral 4 + pitting edema of both lower extremities. When the client complains that the anti embolic stockings are too constricting, which intervention should the nurse implement?

Answer 66

Maintain both lower extremities elevated on pillows

Question 67

A client with muscular dystrophy is concerned about becoming totally dependent and is reluctant to call the nurse to assist with activated of daily living (ADLs). To achieve maximum mobility and independence, which intervention is most important for the nurse to include in the client's plan of care?

Answer 67

Teach family proper range of motion exercises

Question 68

The nurse is teaching a postmenopausal client about osteoporosis prevention. The client reports that she smokes 2 packs of cigarettes a day and takes 750 mg calcium supplements daily. What information should the nurse include when teaching this client about osteoporosis prevention?

Answer 68

Postmenopausal women needs an intake of at least 1,500 mg of calcium daily

Question 69

when evaluating a client's rectal bleeding, which findings should the nurse document?

Answer 69

Color characteristics of each stool

Question 70

The nurse is auscultating a client's lung sounds. Which description should the nurse use to document the is sound?

Answer 70

High pitched or fine crackles

Question 71

An adult male is admitted to the emergency department after falling from a ladder. While waiting to have a CT scan, he requests something for a sever headache. When the nurse offers hims a rep scribed dose of acetaminophen, he asks of something stronger. Which intervention should the nurse implement?

Answer 71

Explain the reason for using only non-narcotics

Question 72

The nurse is managing the care of a client with Cushing's syndrome. Which interventions should the nurse delegate to the unlicensed assertive personnel (UAP)? ( Select all that apply)

Answer 72

Weigh the client and report any weight gain Report any client complaint of pain or discomfort Note and report the client's food and liquid intake during meals and snacks

Question 73

Ten years after a female client was diagnosed with multiple sclerosis (MS), she is admitted to a community palliative care unit. Which intervention is most important for the nurse to include in the client's plan on care?

Answer 73

Medicate as needed for pain and anxiety

Question 74

An increased number of elderly persons are electing to undergo a new surgical procedure which cures glaucoma. What effect is the nurse likely to not as a result of this increases in glaucoma surgeries?

Answer 74

Decrease prevalence of glaucoma in the population

Question 75

The nurse is caring for a client who is entering the second stage of labor. Which action should the nurse implement first?

Answer 75

Convey to the client that birth is imminent

Question 76

To evaluate the effectiveness of male client;s new prescription for ezetimibe, which action should the clinic nurse implement?

Answer 76

Remind the client to keep his appointments to have his cholesterol level checked

Question 77

Diagnostic studies indicate that the elderly client has decreased bone density. In providing client teaching, which area of instruction is most important for the nurse to include?

Answer 77

Fall prevention measures

Question 78

A young adult client is admitted to the emergency room following a motor vehicle collision. The client's head hit the dashboard. Admission assessment include: Blood pressure 85/45 mm hg, temperature 98.6 F, pulse 124 bpm and respirations 22 breaths/min. Based on these data, the nurse formulates the first portion of nursing diagnosis as "risk of injury"what term best expresses the "related to "portion of nursing diagnosis?

Answer 78

Shock

Question 79

An older client who as diagnosed with viral hepatitis A 4 weeks ago returns to the clinic complaint of weakness and fatigue. Which finding is most important for the nurse to report to the healthcare provider?

Answer 79

New onset of purple skin lesions

Question 80

In assessing a client twelves hours following transurethral resection of the prostate (TURP), the nurse observes that the urinary drainage tubing contains a large amount of clear pale pink urine and the continuous bladder irrigation is infusing slowly. What action should the nurse implement?

Answer 80

Ensure that no dependent loops are present in the tubing

Question 81

The healthcare provider prescribes the antibiotics Cefdinir (cephalosporin) 300 mg PO every 12 hours for ancient with post operative wound infections. Which feeds should the nurse encourage this client to eat?

Answer 81

Yogurt and/or buttermilk

Question 82

The charge nurse is making assignments on a psychiatric unit for a practical nurse (PN) and newly license register nurse (RN). Which client should be assigned to the RN?

Answer 82

A young male with schizophrenia who said voices is telling him to kill his psychiatrist

Question 83

A client at 30 weeks gestation is admitted due to preterm labor. A prescription of terbutaline sulfate 8.35mg is given subcutaneously. Based on which findings should the nurse withheld the next dose of this drug?

Answer 83

Maternal pulse rate of 162 beats per min

Question 84

In assessing an older female client with complication associated with chronic obstructive pulmonary disease (COPD), the nurse notices a change in the client's appearance. Her face appears tense and she begs the nurse not to leave her alone. Her pulse rate is 100, and respirations are 26 per min. What is the primary nursing diagnosis?

Answer 84

Anxiety related to fear of suffocation

Question 85

A client with a cervical spinal cord injury (SCI) has crutch field tongs and skeletal traction applied as a method of closed reduction. Which intervention is most important for the nurse to include in the client's plan of care?

Answer 85

Provide daily care of tong insertion sited using saline and antibiotic ointment

Question 86

A client arrives on the surgical floor after major abdominal surgery. What intervention should the nurse perform first?

Answer 86

Determine the client's vital signs

Question 87

A client is admitted to the mergence department with a respiratory rate of 34 breaths per minute and high pitched wheezing on inspiration and expiration, the medical diagnosis is severe exacerbation of asthma. Which assessment finding, obtained 10 min after the admission assessment, should the nurse report immediately to the emergency department healthcare provider?

Answer 87

No wheezing upon auscultation of the chest

Question 88

The nurse is planning a class for a group of clients with diabetes mellitus about blood glucose monitoring. In teaching the class as a whole, the nurse should emphasize the need to check glucose levels in which situation?

Answer 88

During acute illness

Question 89

A 350-bed acute care hospital declares an internal disaster because the mergence generators malfunctioned during a city-wide power failure. The UAPs working on a general medical unit ask the charge nurse what they should do first. What instruction should the charge nurse provide to these UAPs?

Answer 89

Tell all their assigned clients to stay in their rooms

Question 90

The nurse is auscultating a clients heart sounds. Which description should the nurse use to document this sounds?

Answer 90

Murmur

Question 91

The healthcare provider changes a client's medication prescription from IV to PO administration and double the dose. The nurse notes in the drug guide that the prescribed medication, when given orally, has a high first-pass effect and reduce bioavailability. What action should the nurse implement?

Answer 91

Administer the medication via the oral route as prescribed

Question 92

A client refuses to ambulate, reporting abdominal discomfort and bloating caused by "too much gas buildup"the client's abdomen is distended. Which prescribed PRN medication should the nurse administer?

Answer 92

Simethicone (Mylicon)

Question 93

The public health nurse received funding to initiate primary prevention program int he community. Which program best fits the nurse's proposal?

Answer 93

Vitamin supplements for high risk pregnant women

Question 94

When assessing an adult male who presents as the community health clinic with a shivery of hypertension, the nurse notes that he has 2+ pitting edema in both ankles. He also has a history of gastroesophageal reflux disease (GERD) and depression. Which intervention is the most important of the nurse to implement?

Answer 94

Review the client's use of over the counter (OTC) medications

Question 95

An older client is admitted to the intensive care unit with severe abdominal pain, abdominal distention, and absent bowel sounds. The client has a history of smoking 2 packs of cigarettes daily for 50 years and is currently restless and confused. Vital sings are: temperature 96 F, Heart rate 122 beats/min, respiratory rate 36 breaths/min, mean arterial pressure (MAP) 65 mm Hg and Central venous Pressure (CVP) 7 mm Hg. Serum laboratory findings include: hemoglobin 6.5 grams/dl, platelets 60,000 and white blood cell count (WBC) 3,000/mm3. Based enthuse findings this client is at greatest risk for which pathophysiological condition?

Answer 95

Multiple organ dysfunction syndrome (MODS)

Question 96

A man expresses concern to the nurse about the care his mother is receiving whole hospitalized. He believes that her care is not based on any ethical standards and ask what type of care he should expect from a public hospital. What action should the nurse take?

Answer 96

Provide the man and his mother with a copy of the patient's bill of rights

Question 97

A client experiencing withdrawal from the benzodiazepines alprazolam (xanax) is demonstrating severe aviation and tremors. What is the best initial nursing action?

Answer 97

Initiate seizure precautions