Hesi for NUR 112 Questions and Answers with Rationales Updated 2024.
A client arrives for a vaccination at an influenza prevention clinic. A nursing
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identifies a current febrile illness with a cough. The nurse should:
a. Give the vaccine
b. Administer aspirin with the vaccine
c. Hold the vaccine and notify the health care provider
d. Reschedule administration of the vaccine for the next month correct answers D!
The appropriate response is to delay the administration of the vaccine until the client is healthy.
Vaccines should not be administered during a febrile illness. Administering an aspirin is a
dependent function of the nurse and requires a health care provider's prescription. Although
holding the vaccine and administering it after the fever and cough are resolved is appropriate,
notifying the health care provider is not necessary.
A daughter of a Chinese speaking client approaches a nurse and asks multiple questions while
maintaining direct eye contact. What culturally related concept does the daughter's behavior
reflect?
a. Prejudice
b. Stereotyping
c. Assimilation
d. Ethnocentrism correct answers C!
Assimilation involves incorporating the behaviors of the dominant culture. Maintaining eye
contact is characteristic of the American culture and not Asian cultures. Prejudice is a negative
belief about another person or group and does not characterize this behavior. Stereotyping is the
perception that all members of a group are alike. Ethnocentrism is the perception that one's
beliefs are better than those of others.
A client has a hiatal hernia. The client is 5 feet 3 inches tall and weighs 160 pounds. When the
nurse discusses prevention of esophageal reflux, what should be included?
a. "Increase your intake of fat with each meal."
b. "Lie down after eating to help your digestion."
c. "Reduce your caloric intake to foster weight reduction."
d. "Drink several glasses of fluid during each of your meals." correct answers C!
Weight reduction decreases intraabdominal pressure, thereby decreasing the tendency to reflux
into the esophagus. Fats decrease emptying of the stomach, extending the period that reflux can
occur; fats should be decreased. Lying down after eating increases the pressure against the
diaphragmatic hernia, increasing symptoms. Drinking several glasses of fluid during each meal
will increase the pressure; fluid should be discouraged with meals.
During an interview, the nurse discovers that the spouse of a debilitated, chronically constipated
client digitally removes stool from the client's rectum. What response to disimpaction is the
nurse attempting to prevent by presenting other strategies to regulate the client's bowel
movements?
a. Increased pulse rate
b. Slowing of the heart
c. Dilation of the bronchioles
d. Coronary Artery Vasodilation correct answers B!
Disimpaction can cause vagal stimulation, which slows the heart. The vagus is the principal
nerve of the parasympathetic portion of the autonomic nervous system, and its axon terminals
release acetylcholine. The response of the viscera to acetylcholine varies, but in general the
organ is in a relaxed state. Increased pulse rate is an action of the sympathetic nervous system
(accelerator nerve) caused by the release of norepinephrine. Stimulation of the sympathetic
nervous system dilates bronchioles in the lungs; the vagus nerve constricts them. There are
parasympathetic fibers to the coronary blood vessels; sympathetic impulses dilate these vessels.
Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiplechoice items. If you are uncertain about a question, eliminate the choices that you believe are
wrong and then call on your knowledge, skills, and abilities to choose from the remaining
responses.
A nurse has just administered an immunization injection to a 2-month-old infant. What
instructions should the nurse give the parent if the infant has a reaction?
a. Give aspirin for pain; if swelling at the injection site develops, call the health care provider.
b. Apply heat to the injection site for the first day after the injection; apply ice if the arm is
inflamed.
c. Give acetaminophen for fever; call the health care provider if the child exhibits marked
drowsiness or seizures.
d. Apply ice to the injection site if soreness develops; call the health care provider if the child
comes down with a fever correct answers C!
Fever is a common reaction to immunizations, and acetaminophen may be given to minimize
discomfort. A central nervous system reaction is rare and requires notification of the health care
provider. Aspirin should not be given to infants and children because it is linked to Reye
syndrome. Infants do not tolerate the application of ice, which will increase discomfort. Fever is
a common reaction to the immunizations; it is not necessary to notify the health care provider.
A nurse inserts a nasogastric tube before an infant is to receive a tube feeding. What action
should the nurse take when the infant begins to cough and gag?
a. Auscultating for breath sounds
b. Removing the tube, then reinserting it
c. Administering the tube feeding slowly
d. Observing the infant for circumoral cyanosis correct answers B!
The infant's response indicates that the tube may be in the trachea rather than the stomach. The
tube should be removed, reinserted, and verified for its placement before the feeding is started.
Auscultating for breath sounds does not provide information about the placement of the tube.
The tube should be removed immediately; it is unsafe to assess the infant for additional signs of
respiratory distress. It is unsafe to administer the feeding until placement in the stomach has been
confirmed.
A 26-year-old homosexual client is diagnosed with acquired immune deficiency syndrome
(AIDS). The primary nurse reports to the nursing team that the client cried when told of the
diagnosis. One of the nursing assistants responds, "I don't feel sorry for him. He made his bed,
and now he can lie in it." To best help the nursing assistant, the nurse manager must first identify
that this comment most likely is a result of the nursing assistant's:
a. Values and beliefs about sexual lifestyles.
b. Anger and mistrust of homosexual males in general.
c. Discomfort with men who are unable to control their emotions.
d. Hostility over having to care for someone with a sexually transmitted infection correct
answers A!
This statement reflects values and beliefs regarding homosexuality as being bad and deserving of
punishment. There is not enough evidence presented to justify drawing the conclusion that the
nursing assistant has anger and mistrust of homosexual males in general or discomfort with men
who are unable to control their emotions. Although there may be hostility over having to care for
someone with a sexually transmitted infection, no information is given to suggest that the
nursing assistant has been assigned to care for this client. [Show Less]