2019 HESI V2 QUESTIONS AND ANSWERS 100% CORRECT
1. The nurse knows that which statement by the mother indicates that the mother understands safety
... [Show More] precautions with her four month-old infant and her 4 year-old child?
A) "I strap the infant car seat on the front seat to face backwards."
B) "I place my infant in the middle of the living room floor on a blanket to play with my 4 year old while I make supper in the kitchen."
C) "My sleeping baby lies so cute in the crib with the little buttocks stuck up in the air while the four year old naps on the sofa."
D) "I have the 4 year-old hold and help feed the four month-old a bottle in the kitchen while I make supper." Correct Answer: D) "I have the 4 year-old hold and help feed the four month-old a bottle in the kitchen while I make supper."
2. Upon completing the admission documents, the nurse learns that the 87 year-old client does not have an advance directive. What action should the nurse take?
A) Record the information on the chart
B) Give information about advance directives
C) Assume that this client wishes a full code
D) Refer this issue to the unit secretary Correct Answer: B) Give information about advance directives
3. A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes after the immunization was given, the client complains of itchy and watery eyes, increasedanxiety, and difficulty breathing. The nurse expects that the first action in the sequence of care for this client will be to
A) Maintain the airway
B) Administer epinephrine 1:1000 as ordered
C) Monitor for hypotension with shock
D) Administer diphenhydramine as ordered Correct Answer: B) Administer epinephrine 1:1000 as ordered
4. Which of these children at the site of a disaster at a child day care center would the triage nurse put in the "treat last" category?
A) An infant with intermittent bulging anterior fontanel between crying episode
B) A toddler with severe deep abrasions over 98% of the body
C) A preschooler with 1 lower leg fracture and the other leg with an upper leg fracture
D) A school-age child with singed eyebrows and hair on the arms Correct Answer: B) A toddler with severe deep abrasions over 98% of the body
5. When admitting a client to an acute care facility, an identification bracelet is sent up with the admission form. In the event these do not match, the nurse's best action is to
A) Change whichever item is incorrect to the correct information
B) Use the bracelet and admission form until a replacement is supplied
C) Notify the admissions office and wait to apply the bracelet
D) Make a corrected identification bracelet for the client Correct Answer: C) Notify the admissions office and wait to apply the bracelet
6. The nurse is having difficulty reading the health care provider's written order that was written right before the shift change. What action should be taken?
A) Leave the order for the oncoming staff to follow-up
B) Contact the charge nurse for an interpretation
C) Ask the pharmacy for assistance in the interpretation
D) Call the provider for clarification Correct Answer: D) Call the provider for clarification
7. An adult client is found to be unresponsive on morning rounds. After checking for responsiveness and calling for help, the next action that should be taken by the nurse is
to:
A) check the carotid pulse
B) deliver 5 abdominal thrusts
C) give 2 rescue breaths
D) open the client's airway Correct Answer: D) open the client's airway
8. A client has an order for 1000 ml of D5W over an 8 hour period. The nurse discovers that 800 ml has been infused after 4 hours. What is the priority nursing
action?
A) Ask the client if there are any breathing problems
B) Have the client void as much as possible
C) Check the vital signs
D) Auscultate the lungs Correct Answer: D) Auscultate the lungs
9. Following change-of-shift report on an orthopedic unit, which client should the nurse see first?
A) 16 year-old who had an open reduction of a fractured wrist 10 hours
ago
B) 20 year-old in skeletal traction for 2 weeks since a motor cycle accident
C) 72 year-old recovering from surgery after a hip replacement 2 hours
ago
D) 75 year-old who is in skin traction prior to planned hip pinning surgery. Correct Answer: C) 72 year-old recovering from surgery after a hip replacement 2 hours
ago
10. A nurse observes a family member administer a rectal suppository by having the client lie on the left side for the administration. The family member pushed the suppository until the finger went up to the second knuckle. After 10
minutes the client was told by the family member to turn to the right side and the client did this. What is the appropriate comment for the nurse to make?
A) Why don't we now have the client turn back to the left side.
B) That was done correctly. Did you have any problems with the insertion?
C) Let's check to see if the suppository is in far enough.
D) Did you feel any stool in the intestinal tract? Correct Answer: B) That was done correctly. Did you have any problems with the insertion?
11. A client with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA) has died. Which type of precautions is the appropriate type to use when performing postmortem care?
A) airborne precautions
B) droplet precautions
C) contact precautions
D) compromised host precautions Correct Answer: C) contact precautions
12. The nurse is reviewing with a client how to collect a clean catch urine specimen. Which sequence is appropriate teaching?
A) Void a little, clean the meatus, then collect specimen
B) clean the meatus, begin voiding, then catch urine stream
C) Clean the meatus, then urinate into container
D) Void continuously and catch some of the urine Correct Answer: B) clean the meatus, begin voiding, then catch urine stream
13. The provider orders Lanoxin (digoxin) 0.125 mg PO and furosomide 40 mg every day. Which of these foods would the nurse reinforce for the client to eat at least daily?
A) spaghetti
B) watermelon
C) chicken
D) tomatoes Correct Answer: B) watermelon
14. A nurse is stuck in the hand by an exposed needle. What immediate action should the nurse take?
A) Look up the policy on needle sticks
B) Contact employee health services
C) Immediately wash the hands with vigor
D) Notify the supervisor and risk management Correct Answer: C) Immediately wash the hands with vigor
15. As the nurse observes the student nurse during the administration of a narcotic analgesic IM injection, the nurse notes that the student begins to give the medication
without first aspirating. What should the nurse do?
A) Ask the student: "What did you forget to do?"
B) Stop. Tell me why aspiration is needed.
C) Loudly state: "You forgot to aspirate."
D) Walk up and whisper in the student's ear "Stop. Aspirate. Then inject." Correct Answer: D) Walk up and whisper in the student's ear "Stop. Aspirate. Then inject."
16. A client with Guillain Barre is in a non responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?
A) Comatose, breathing unlabored
B) Glascow Coma Scale 8, respirations regular
C) Appears to be sleeping, vital signs stable
D) Glascow Coma Scale 13, no ventilator required Correct Answer: B) Glascow Coma Scale 8, respirations regular
17. A client enters the emergency department unconscious via ambulance from the client's work place. What document should be given priority to guide the direction of care for this client?
A) The statement of client rights and the client self determination act
B) Orders written by the health care provider
C) A notarized original of advance directives brought in by the partner
D) The clinical pathway protocol of the agency and the emergency
department Correct Answer: C) A notarized original of advance directives brought in by the partner
18. The charge nurse has a health care team that consists of 1 PN, 1 unlicensed assistive personnel (UAP) and 1 PN nursing student. Which assignment should be questioned by the nurse manager?
A) An admission at the change of shifts with atrial fibrillation and heart
failure - PN
B) Client who had a major stroke 6 days ago - PN nursing student
C) A child with burns who has packed cells and albumin IV running -
charge nurse
D) An elderly client who had a myocardial infarction a week ago - UAP Correct Answer: A) An admission at the change of shifts with atrial fibrillation and heart
failure - PN
19. A mother brings her 3 month-old into the clinic, complaining that the
child seems to
be spitting up all the time and has a lot of gas. The nurse expects to find
which of the
following on the initial history and physical assessment?
A) Increased temperature and lethargy
B) Restlessness and increased mucus production
C) Increased sleeping and listlessness
D) Diarrhea and poor skin turgor Correct Answer: B) Restlessness and increased mucus production
20. As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the parents require follow-up and are consistent with the diagnosis?
A) "The child has been listless and has lost weight."
B) "The urine is dark yellow and small in amounts."
C) "Clothes are becoming tighter across her abdomen."
D) "We notice muscle weakness and some unsteadiness." Correct Answer: C) "Clothes are becoming tighter across her abdomen."
21. A 16 year-old enters the emergency department. The triage nurse identifies that this teenager is legally married and signs the consent form for treatment. What would be the appropriate action by the nurse?
A) Ask the teenager to wait until a parent or legal guardian can be
contacted
B) Withhold treatment until telephone consent can be obtained from the
partner
C) Refer the teenager to a community pediatric hospital emergency
department
D) Proceed with the triage process in the same manner as any adult client Correct Answer: D) Proceed with the triage process in the same manner as any adult client
22. A newly admitted elderly client is severely dehydrated. When planning care for this client, which task is appropriate to assign to an unlicensed assistive personnel (UAP)?
A) Converse with the client to determine if the mucous membranes are
impaired
B) Report hourly outputs of less than 30 ml/hr
C) Monitor client's ability for movement in the bed
D) Check skin turgor every 4 hours Correct Answer: B) Report hourly outputs of less than 30 ml/hr
23. The nurse has admitted a 4 year-old with the diagnosis of possible rheumatic fever. Which statement by the parent would cause the nurse to suspect an association with this disease?
A) Our child had chickenpox 6 months ago.
B) Strep throat went through all the children at the day care last month.
C) Both ears were infected over 3 months age.
D) Last week both feet had a fungal skin infection. Correct Answer: B) Strep throat went through all the children at the day care last month.
24. A nurse assigned to a manipulative client for 5 days becomes aware of feelings for a reluctance to interact with the client. The next action by the nurse should be to
A) Discuss the feeling of reluctance with an objective peer or supervisor
B) Limit contacts with the client to avoid reinforcement of the
manipulative behavior
C) Confront the client about the negative effects of behaviors on other
clients and staff
D) Develop a behavior modification plan that will promote more functional
behavior Correct Answer: A) Discuss the feeling of reluctance with an objective peer or supervisor
25. A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse's action
A) May result in charges of unlawful seclusion and restraint
B) Leaves the nurse vulnerable for charges of assault and battery
C) Was appropriate in view of the client's history of violence
D) Was necessary to maintain the therapeutic milieu of the unit Correct Answer: A) May result in charges of unlawful seclusion and restraint
26. A client has been admitted to the Coronary Care Unit with a myocardial infarction. Which nursing diagnosis should have priority?
A) Pain related to ischemia
B) Risk for altered elimination: constipation
C) Risk for complication: dysrhythmias
D) Anxiety related to pain Correct Answer: A) Pain related to ischemia
27. The provisions of the law for the Americans with Disabilities Act require nurse managers to
A) Maintain an environment free from associated hazards
B) Provide reasonable accommodations for disabled individuals
C) Make all necessary accommodations for disabled individuals
D) Consider both mental and physical disabilities Correct Answer: B) Provide reasonable accommodations for disabled individuals
28. A 42 year-old male client refuses to take propranolol hydrochloride (Inderal) as prescribed. Which client statement s from the assessment data is likely to explain his noncompliance?
A) "I have problems with diarrhea." [Show Less]