HESI PRACTICE QUESTIONS AND ANSWERS
1. A client with skin grafts covering full thickness burns on both arms and legs as scheduled for a dressing change.
... [Show More] The client is nervous and requests that the dressing change be skipped this time. What action is most important for the nurse to take?
Encourage the client to express any anxieties.
2. second a male client with angina pectoris is being discharged from the hospital. What instruction should the nurse plan to include in his discharge teaching?
Avoid isometric exercises but walk regularly.
3. A client is admitted to the mental health unit after attempting suicide by taking a handful of medications. In developing a plan of care for this client which goal has the highest priority
signs of no self-harm contract
4. A female client with cancer tells the home care nurse that she has a good appetite but experiences nausea whenever she smells food cooking. What action should the nurse implement.
Encourage family members to cook meals outdoors and bring the cook food inside.
5. Second when entering a client room to administer and oh 900 Ivy antibiotic, the nurse finds the client is engaged in sexual activity with the visitor. Which action should the nurse implement?
Leave the room and close the door quietly.
6. the nurses conducting intake interviews of children at a city clinic. Which child is most susceptible to contracting lead poisoning?
a 2-year-old child who plays on aging outdoor playground equipment.
7. Which instruction is most important for the nurse to provide a client who receives a new prescription for risendronate sodium to treat osteoporosis?
Remain upright after taking the medication.
8. second client who is newly diagnosed with type 2 diabetes mellitus receives a prescription for metformin 500 milligrams PO twice daily. One information should the nurse include in the client's teaching plan. (Select all that apply).
Take metformin with the morning and evening meal.
use sliding scale insulin for finger stick glucose elevations. recognize signs and symptoms of hypoglycemia.
9. the nurse assesses an older adult who is newly admitted to the long-term care facility. The client has dry, flaky skin and long thickened fingernails. The client has a medical history of a stroke which resulted in left sided paralysis and dysphasia. In planning care for the client, which task should the nurse delegate to the uap?
Ambulate in the hallway.
10. What nursing intervention is particularly indicated for the second stage of Labor?
assisting the client to push effectively so that expulsion of the fetus can be achieved.
11. An older female client living in a low-income apartment complex tells a home health nurse that she is concerned about her 81-year-old neighbor, a widow whose son recently assumed her financial affairs. Lately, her neighbor has become reclusive, but is occasionally seen walking outside wearing only a robe and slippers. What response should the nurse offer?
Turn the client to talk to the health care provider before reporting suspicion of neglect to the authorities.
provide the number for adult Protective Services so the client can report any suspicion of elder abuse.
12. in preparing a nursing care plan for a client admitted with a diagnosis of Guillain-Barre syndrome, which nursing problem has the highest priority.
Ineffective breathing pattern related to ascending paralysis.
13. The mother of a school age child calls the school nurse to ask winter daughter can return to school after treatment for a pediculosis capitus.
after the treatment kills all the live lice
14. a client with major depression who is taking fluoxetine caused the psychiatric clinic reporting being more agitated, irritable and anxious than usual. Which intervention should the nurse implement?
Instruct the client to seek medical attention immediately.
15. After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wishes to see the body before it is taken to the Funeral Home. Which intervention should the nurse take to prepare the body before the family member enters the room? Select all that apply.
Place a small pillow under the head.
remove resuscitation equipment from the room. Gently close the eyes
16. second after successful resuscitation, a client given propanol law and transferred to intensive coronary care unit. On admission, magnesium sulfate 4 grams Ivy and 250 milliliters of G5W at 1 gram per hour period which assessment finding requires immediate intervention by the nurse?
Respiratory rate of 10 breast per minute and pulse oximetry of 90%
17. the nurse is developing a teaching plan for a client with acute gastritis caused by drinking contaminated water. The nurse should emphasize the need to report the onset of which problem?
Bloody emesis
18. a client with multiple sclerosis is experiencing scotomas (blind spots), second which are limiting peripheral vision. What intervention should the nurse include in the client's plan of care?
alternate and eye patch from eye to eye every two hours.
19. A client with diabetes mellitus tells the nurse that she uses cranberry juice to help prevent urinary tract infections. What instructions should the nurse provide?
Drinking cranberry juice does not prevent infection.
20. the health care provider explains through an interpreter the risks and benefits of a scheduled surgical procedure to a non-English speaking female client. The client gives verbal consent and the health care provider leaves, instructing a nurse to witness the signature on the consent form. The client and the interpreter then speak together in the foreign language for an additional 2 minutes until the interpreter concludes, she says it is OK. what action should the nurse take next?
Ask for a full explanation from the interpreter of the witness discussion.
21. second child with heart failure is taking digitalis. Which signs indicate to the nurse that the child may be experiencing digitalis toxicity.
vomiting
22. the unlicensed assistive personnel reports that a client's blood pressure cannot be measured because the client has casts on both arms and is unable to be turned to the prone position for blood pressure measurement in the legs. What action should the nurse implement?
Demonstrate how to palpate the popliteal pulse with client supine and the knee flexed.
23. an older adult with known known cognitive impairment residing in a long-term care facility suddenly comes disoriented and confused. There are no signs of extremity weakness or other neurological changes. Which intervention should the nurse implement?
Assess the urine for cloudiness.
24. a public health nurse receives funding to initiate a primary prevention program in the community. Which program best fits the nurse’s proposal?
Vitamin supplements for high-risk pregnant women
25. second is caring for newborn who arrives in a nursery following a precipitous birth on the way to the hospital. Drug screen of the mother reveals the presence of cocaine metabolites. The infant has a heart rate of 175 beats per minute, cries continuously, is irritable and is hyper reactive to stimuli. Which intervention is most important for the nurse to include in the infant’s plan of care?
Implement seizure precautions.
26. the nurse is assessing a first day postpartum client. Which finding is most indicative of a postpartum infection?
Moderate amount of foul-smelling lochia
27. have a group of nurses implement a pilot study to evaluate a proposed evidence-based change to providing client care period evaluation indicates successful outcomes and the nurses want to integrate the change throughout the facility. What actions should be taken? Select all that apply.
obtain informed consent from clients who received care. invite data review by the quality improvement department.
proposed clinical practice guidelines to the nursing committee.
arrange in service training through the educational department.
28. the nurse is planning to assess a client's oxygen saturation in Sherman if additional oxygen is needed via nasal cannula. The client has bilateral below the knee amputations and radial pulses that are weak and thready. What action should the nurse take?
Place the oximeter clip on the earlobe to obtain the oxygen saturation reading.
29. second nurses screening students for spinal abnormalities and instructs each student to stand up and then touch his toes. Which finding indicates a student should be referred for scoliosis evaluation?
Asymmetry of the shoulders when standing upright.
30. when caring for a client with diabetes insipidus, it is most important for the nurse to include frequent assessment for which condition and the client's plan of care.
Nausea and vomiting, muscle weakness
31. the nurse is preparing an older client for discharge following cataract extractions. Which instruction should be included in the discharge teaching?
Avoid straining at stool, bending or lifting heavy objects.
32. an adult suffered burns to face and chest resulting from a grease fire. On admission, the client has been intubated and a true leader bolus of normal saline was administered. Currently the normal sailing is running at 250 milliliters per hour period the client's heart rate is 120 beats per minute, blood pressure is 90 / 50, respirations are 12, over the ventilated 12 breaths for total of 24 breaths per minute, and the central venous pressure is 4 millimeters water. Which intervention should the nurse implement?
Second fuse an additional bolus of normal saline
33. the nurse identifies the presence of clear fluid on a surgical dressing of a client who just returned CD unit following lumbar surgery. Which action should the nurse implement immediately?
Test of fluid on addressing for glucose.
34. the nurse offers diet teaching to a female college student who was diagnosed with iron deficiency anemia following her voluntary adoption of a lacto vegetarian diet. What nutrients should the nurse suggest just clean eat to best meet her nutritional needs while allowing her to adhere to her lacto vegetarian diet?
Have combined several legumes and grains such as beans and rice to form complete proteins.
35. A client with metastatic cancer who is taking hydromorphone at home is now receiving the medication intravenously while in the hospital period to evaluate if the client is receiving equal analgesic dose of dilaudid, what assessment should the nurse complete?
Pain scale
36. second client with multiple sclerosis is receiving beta 1B interferon every other day. To assess for possible bone marrow suppression caused by the medication, which serum laboratory tests findings should the nurse monitor?
White blood cell count platelet count
red blood cell count
37. A client is receiving Lactulose for signs of hepatic encephalopathy period to evaluate the client's therapeutic response to this medication, which assessments should the nurse obtain?
38. Level of consciousness an older male client arrives at the clinic complaining that his bladder always feels full. He complains of weak urine flow, frequent dribbling after voiding, and increasing the nocturia with difficulty initiating his urinary stream. Which action should the nurse implement?
Palpate the client super pubic area for distention.
39. A client with type 2 diabetes mellitus is admitted for frequent hypoglycemic episodes and glycosylated hemoglobin A1C of 10%. Insulin glargine 10 units subcutaneously once a day at
bedtime in a sliding scale with insulin aspart every six hours are prescribed. What actions should the nurse include in this client's plan of care? Select all that apply.
Fingerstick glucose assessments every six hours with meals coordinate carbohydrate-controlled meals add consistent times and intervals. have review with the client proper foot care and prevention of injury.
teach subcutaneous injection technique, site rotation, and insulin management.
40. a child with leukemia is receiving amphotericin B lipid complex for a systemic fungal infection. Which assessment findings should the nurse report to the health care provider?
Muscle cramps and a regular pulse
41. after learning that she had terminal pancreatic cancer, a female client becomes very angry and says to the nurse, God has abandoned me. What did I do to deserve this? Based on this response, the nurse decides to include which nursing problem in the client's plan of care?
Ineffective coping
42. second instruction should the nurse provide to a client who is preparing to have a cystoscopy.
Report any allergies to shellfish or Iodine /report any pain for urination, blood in urine, fever.
43. Prior to surgery, written consent must be obtained. What is the nurse’s legal responsibility regarding obtaining written consent?
Determine that the surgical sent form has been signed and is included in the client's record.
44. the nurse is caring for a client with a tracheostomy. Which action should the nurse perform when suctioning the tracheostomy tube?
Insert the suction catheter into the trachea and apply intermittent suction with removal of catheter.
45. after diagnosis and initial treatment of a 3-year-old child with cystic fibrosis, the nurse provides home care instructions to the mother. Which statement by the child's mother indicates that she understands home care treatment to promote pulmonary function?
Chest physiotherapy should be formed twice a day before meals.
46. a nurse is administering diazepam, a benzodiazepine, 10 milligrams IV push PRN, as prescribed to a client with alcohol withdrawal symptoms. Which action should the nurse implement when administering the medication? Select all that apply.
perform ongoing assessment of respiratory status.
modern for changes in level of consciousness administer slowly over at least two minutes. protect medication from exposure to light.
47. second client has had several episodes of clear, watery diarrhea that started yesterday. What action should the nurse implement?
Review the client's current medication list.
48. a postpartal client who is bottle feeding develops breast engorgement. What is the best recommendation for the nurse to provide this client?
Avoid stimulation of the breast and wear a tight bra.
49. second a male client with diabetes mellitus takes NPH regular 70/30 insulin before meals and Azithromycin PO daily, using medications he brought from home. When the nurse delivers his breakfast tray, the client tells the nurse that he took the insulin but forgot to take the daily dose of the antibiotic an hour before breakfast as instructed. What action should the nurse implement?
Instruct the client to eat breakfast and take the antibiotic two hours after eating.
50. A client in the intensive care unit is being mechanically ventilated, he has an indwelling urinary catheter in place, and is exhibiting signs of restlessness. Which action should the nurse take first?
auscultate bilateral breath sounds. [Show Less]