HESI NCLEX Practice Questions

pH = 7.28 pCO2 = 35 HCO3 = 18 The client has _____________

Metabolic acidosis without compensation

The nurse is caring for a client who is 24 hours post procedure for a hemicolectomy with a temporary colostomy placement. The nurses assess the client's stoma, which is dry and dark blue. Which action should the nurse take based on this finding? A. Notify the healthcare provider of the finding B. Document the finding in the client record. C. Replace the pouch system over the stoma. D. Place petrolatum gauze dressing on the stoma.

A. Notify the healthcare provider of the finding This indicates a possible ischemia which is an emergent situation

A client is receiving an infusion of dobutamine hydrochloride. The order reads: Infuse dobutamine IV at 5 mcg/kg/min. 500 mg in 250 mL D5W. The client weighs 65 kg. Calculate the flow rate in mL/hr. _________ mL/hr

9.75 500 mg x 1000 mg = 500000 mcg 500000 mcg/ 250 mL = 2000 mcg/mL 5 mcg x 65 kg x 60 min = 95000 mcg/hr 95000 mcg/hr / 2000 mcg/mL = 9.75 mL/hr

A charge nurse is making assignments for five clients. The nursing team has an RN, a PN, and two UAPs. Which client(s) are appropriate to assign to the RN? (Select all that apply) A. A client from the previous shift with unstable angina. B. A client with a stage 3 pressure ulcer who needs a bed bath. C. A client with an enteral feeding absorbing at 30 mL/h D. A cardiotomy client who is day 2 postoperative and who has chest tubes. E. A client with quadriplegia for whom urinary catheterization is prescribed.

A. A client from the previous shift with unstable angina. D. A cardiotomy client who is day 2 postoperative and who has chest tubes. A involves pain medications that only RNs can give and D involves complicated equipment. B can be given to the UAP. C and E can be given to the PN because of the feeding tube equipment and the need for catheterization.

pH = 7.56 pCO2 = 44 HCO3 = 38 The client has _____________

Metabolic alkalosis without compensation

pH = 7.43 pCO2 = 40 HCO3 = 24 The client has _____________

Normal

The charge nurse is planning client assignments for the shift. The care team includes a registered nurse (RN), a licensed practical nurse (PN), and unlicensed assistive personnel (UAP) on the care team. Which client(s) are appropriate to be assigned to the PN? (Select all that apply) A. A client scheduled for a STAT CAT x-ray after a fall from a stretcher B. A client receiving IV vancomycin through a peripherally inserted catheter (PICC) line. C. A client with sickle cell crisis who was transferred from the ICU to the acute care area and who is receiving hydromorphone via a patient-controlled analgesia (PCA) pump. D. A client with a pressure ulcer who was prescribed negative pressure (wound VAC) care E. A postoperative client who has been prescribed 2 units of packed red blood cells.

A. A client scheduled for a STAT CAT x-ray after a fall from a stretcher D. A client with a pressure ulcer who was prescribed negative pressure (wound VAC) care A practical nurse can do most tasks and work with a lot of equipment such as dressings, suctioning, catheters, administering PO/IM/SC medications, and wound VAC

The nurse is assigned to receive a client in the emergency department with suspected anthrax exposure pre decontamination. Which transmission precautions should be most appropriate for the client? (Select all that apply) A. Airborne B. Contact C. Aplastic D. Droplet E. Standard

A. Airborne B. Contact D. Droplet E. Standard Because it is an unknown exposure you would use all necessary precautions. Aplastic precautions are only used for neutropenic populations.

The emergency department nurse is assessing a client with a vesicular rash as a result of suspected smallpoz exposure. Which transmission precautions should be most appropriate for this client? (Select all that apply) A. Airborne B. Contact C. Aplastic D. Droplet E. Standard

A. Airborne B. Contact D. Droplet E. Standard Must cover all bases until suspicion is concerned. Aplastic precautions are only used for neutropenic populations.

A client with a known cardiac history is admitted to the acute care unit with stable angina. At 7:00 am, the client had stable vital signs and was on 2 L of oxygen via nasal cannula. At 10:00 am, the client reports chest pain of 6 on a scale of 1 to 10, is slightly diaphoretic and pale, has a blood pressure (BP) of 100/52 mmHg, and has a respiratory rate of 24 breaths/min. Which action should the nurse implement first? A. Apply 4 L of oxygen as ordered. B. Administer a fluid bolus of 0.9 normal saline. C. Administer the prescribed opioid for pain control. D. Obtain a full set of vital signs, including temperature.

A. Apply 4 L of oxygen as ordered. When a patient has chest pain, give O2 or increase rate. Blood pressure is low but still acceptable and we would give pain medication after breathing is fixed.

The nurse is caring for a client in shock of unknown etiology and observes the rhythm on the right on the monitor. Which is the nurse's priority intervention? A. Check for a carotid pulse B. Defibrillate the patient with 360 joules of energy C. Administer an intravenous saline bolus D. Give two breaths via Ambu bag

A. Check for a carotid pulse The leads could have become disconnected and caused the distorted signal. It is important to assess the patient first before interventions. If the patient did not have a pulse you would begin CPR and defibrillation.

A practical nurse (PN) is assigned to care for an 82-year-old client who had a total right hip replacement with cement 2 days ago. Which observation(s) should the PN immediately report to the RN? (Select all that apply) A. The client complains of incisional pain, rating it an 8 on a scale of 0-10 B. The client has had a change in orientation to person but not to time or place. C. Swelling and redness have developed in the client's lower left leg. D. The LPN emptied 15 mL of bloody drainage from the Jackson-Pratt drain E. The client's last set of vital signs was temperature 37.9 C (100.2 F), pulse 87, respirations 12, blood pressure 108/74, and O2 saturation 93%

A. The client complains of incisional pain, rating it an 8 on a scale of 0-10 B. The client has had a change in orientation to person but not to time or place. C. Swelling and redness have developed in the client's lower left leg. E. The client's last set of vital signs was temperature 37.9 C (100.2 F), pulse 87, respirations 12, blood pressure 108/74, and O2 saturation 93% A indicates dislocation of the hip. B indicates some sort of imbalance with perfusion, neurostatus or electrolytes. C indicates a DVT. And E indicates an infection or serious illness.

The unlicensed assistive personnel (UAP) reports to the staff nurse that a client who had surgery 4 hours ago has a decrease in blood pressure (BP), from 150/80 to 110/70, in the past hour. The nurse advises the UAP to check the client's dressings for excess drainage and report the findings to the nurse. Which factor is most important to consider when assessing the legal ramifications of this situation? A. The parameters of the state's or province's nurse practice act B. The need to complete an adverse occurrence report C. Hospital protocol regarding the frequency of vital sign assessment every hour postoperatively D. The healthcare provider's prescription for changing the postoperative dressing

A. The parameters of the state's or provinces nurse practice act The nurse asked the UAP to perform a task that is outside of their scope of practice. This is states in the Nurse Practice Act for the state or province.

Four clients arrive in the emergency department after an explosion. In which order should hey be assessed? All options must be included. A. A 70-year-old who is complaining of a pain level of 8/10 from a hand burn B. A 35-year-old with partial and full thickness burns to the anterior and posterior chest C. A 25-year-old with a superficial burn to the right anterior arm and lateral chest D. A 42-year-old with a partial-thickness burn to the anterior lower extremity and confusion

B. A 35-year-old with partial and full thickness burns to the anterior and posterior chest D. A 42-year-old with a partial-thickness burn to the anterior lower extremity and confusion A. A 70-year-old who is complaining of a pain level of 8/10 from a hand burn C. A 25-year-old with a superficial burn to the right anterior arm and lateral chest Physiological injuries are prioritized over mental status, full thickness over partial. Pain level raises A over C.

A client with burn injuries has lost a significant amount of body fluid. An IV of lactated ringer's solution is infusing at 200 mL/hr, and the client's urine output for the past 8 hours is 400 mL. Which sign or symptom is the top priority in early distributive shock? A. A change in BP from 118/60 to 102/68 B. A change in level of consciousness from awake to restless C. A decrease in O2 saturation from 98% to 93% D. A decrease in urine output over 8 hours from 400 to 240 mL

B. A change in level of consciousness from awake to restless Changes in LOC are generally early signs of something going wrong. The other answers are later signs.

A 72-year-old client returned from surgery 6 hours ago. The client received hydromorphone 2 mg IV 30 minutes ago for pain rating 8/10. The Family member requests her father be checked immediately. On arrival to the room, the nurse finds the client difficult to arouse, with a respiration rate of 6. Which is the priority nursing action? A. Elevate the head of the bed. B. Administer naloxone 0.4 mg IV C. Assess breath sounds. D. Check vital signs and pulse oximetry

B. Administer naloxone 0.4 mg IV The patient had too much opioids and needs to have naloxone immediately. Taking time for assessments can lead to more problems.

The newly licensed nurse overhears two nurses talking in the elevator about a client who will lose her leg because of negligence of the staff. Which action by the newly licensed nurse should be implemented first? A. Monitor the nurses closely for further occurrences B. Advise them to cease their communication C. Inform the nurse manager of the conversation D. Submit an occurrence or variance report

B. Advise them to cease their communication This is a HIPPA violation and needs to be addressed presently. The new nurse should tell them to talk privately or not at all about the case. If they continue the conversation the nurse should inform the nurse manager of the conversation. There is no event taken place with a patient or to a patient so a report is not necessary.

The nurse admits a client with suspected early DIC. Which symptoms may indicate early organ ischemia? (Select all that apply) A. Slight gingival bleeding B. Alterations in mental status C. Petechial hemorrhage to chest D. Slight decrease to urine output E. Bluish discoloration of fingertips

B. Alterations in mental status D. Slight decrease to urine output E. Bluish discoloration of fingertips These are the early signs. A and C are later signs of DIC.

The complete blood count (CBC) results for a client receiving chemotherapy are hemoglobin 85 mmol/L (8.5 g/dL); hematocrit, 32%; WBC count 6.5 x 10 9/L (6500 cells per mm3). Which meal choice is best for this client? A. Grilled chicken, rice, fresh fruit salad, milk B. Broiled steak, whole wheat rolls, spinach salad, coffee C. Smoked ham, mashed potatoes, applesauce, iced tea D. Tuna noodle casserole, garden salad, lemonade

B. Broiled steak, whole wheat rolls, spinach salad, coffee Patients on chemo should be given meals that have lots of iron.

The nurse finds a client slumped in a chair. Place the nurse's actions in order of priority from first to last for this client. A. Activate the code team and obtain defibrillator B. Determine unresponsiveness C. Assess the cardiac rhythm using the quick look paddles D. Assess for a carotid pulse E. Open airway and give two rescue breaths by bag-valve mask F. Move the client to a flat position in bed or on the floor G. Begin compressions

B. Determine unresponsiveness A. Activate the code team and obtain defibrillator D. Assess for a carotid pulse F. Move the client to a flat position in bed or on the floor G. Begin compressions E. Open airway and give two rescue breaths by bag-valve mask C. Assess the cardiac rhythm using the quick look paddles

A client is admitted with a 2-day history of cough, fever, and fatigue. The medical history is positive for type 1 diabetes and recent upper respiratory infection (URI). Vita signs are heart rate 109 beats per minute, blood pressure 102/58 mm Hg, respiratory rate 24 breaths/min, temperature 104 F (40 C) , and SpO2 92% on 2 L oxygen via nasal cannula. Which prescription has the highest priority in this client's care? A. Initiate large-bore IV access B. Draw two sets of blood cultures C. Administer the ordered IV antibiotics D. Draw serum lactate and glucose levels

B. Draw two sets of blood cultures The cultures are needed in order for the antibiotics to be administered for the infection. The diabetes part is a distractor for the infection.

A client with a history of uterine fibroids had a cesarean delivery 12 hours earlier and delivered healthy twins. At shift change, the nurse assesses the client and notes shortness of breath, cool extremities, and oozing of blood from the incision site. Based on the client's presentation, which nursing action has the highest priority? A. Assess the client's temperature B. Notify the healthcare provider C. Clean the blood from the incision site D. Draw labs for PT, PTT, CBC, and fibrinogen

B. Notify the healthcare provider The oozing blood indicates a DIC which is a emergency situation requiring immediate HCP intervention.

After the change-of-shift report, the nurse reviews assignments. WHich client should the nurse assess first? A. The elderly client receiving palliative care for heart failure who complains of constipation and nervousness B. The adult client who is 48 hours postoperative for a colectomy and who is reported to be having nausea and vomiting C. the middle-aged client with chronic renal failure whose urinary catheter has been draining 95 mL for 8 hours D. The client who is 2 days postoperative for a thoracotomy and who has chest tubes, is on oxygen at 3 L/min, and has a respiratory of 12 breaths/min

B. The adult client who is 48 hours postoperative for a colectomy and who is reported to be having nausea and vomiting Nausea and vomiting after the surgery is normal but should go away within a few hours. Since this is 48 hours after it is concerning because it indicates a possible ileus forming.

An awake, alert client with impending pulmonary edema is brought to the emergency department. The client provides the nurse with a copy of a living will that states that "no invasive" medical procedures should be used to "keep her alive". The healthcare team is questioning whether the client should be intubated. WHich information should guid the team's decision? A. The living will removes the obligation to the client in any medical decision making. B. The client is awake and alter, which makes the living will irrelevant and nonbinding C. Lifesaving measures do not have to be explained to the client because of the signed living will. D. The family shoul dbe contacted to determine who has durable power of attorney for health care for the client.

B. The client is awake and alter, which makes the living will irrelevant and nonbinding Because they are awake and alert they are bale to make medical decisions and the living will is not active. If they were not awake and alert then the healthcare team would use the living will to decide.

A client has not had a bowel movement in 2 days and reports this information to the nurse. Which intervention should the nurse implement first? A. Instruct the caregiver to offer a glass of warm prune juice at mealtimes. B. Notify the HCP and request a prescription for a stool softener C. Assess the client's medical record to determine his normal bowel pattern. D. Instruct the caregiver to increase the client's fluids to five 8 ounce glasses per day.

C. Assess the client's medical record to determine his normal bowel pattern. Bowel movements vary per person. Some people go multiple times a day and others go a few times a week. The answer is an assessment, not an intervention.

The nurse is preparing for change of shift. Which action by the nurse is characteristic of ineffective handoff communication? A. The nurse states to the nurse coming on duty: "The client is anxious about pain after surgery. Review the information I provided about how to use an incentive spirometer" B. The nurse refers to the electronic medical record (EMR) to review the client's medication administration record C. During rounds, the nurse talks about the problem the UAP created by not performing a fingerstick glucose test on the client D. Before giving report, the nurse performs rounds on assigned clients so that there is less likelihood of interruption during handoff.

C. During rounds, the nurse talks about the problem the UAP created by not performing a fingerstick glucose test on the client This is gossip and is inappropriate to discuss in handoff or at all within the unit.

In completing a client's perioperative routine, the nurse finds that the consent form has not been signed. The client begins to ask more questions about the surgical procedure. Which action should the nurse take? A. Witness the client's signature on the consent form B. Answer the client's questions about the surgery C. Inform the HCP that the client has questions about the surgery D. Reassure the client that the surgeon will answer any questions before the anesthetic is administered

C. Inform the HCP that the client has questions about the surgery The nurse has to witness the surgery in person but because the client has questions, informed consent is not given. The nurse cannot answer questions about the surgery because that is the HCP's responsibility. If the HCP does not know about questions, they may not answer them before the surgery.

A client who has chronic obstructive pulmonary disease (COPD) is resting in a semi-Fowler's position with oxygen at 2 L/min per nasal cannula. The client develops dyspnea. Which action should the nurse take first? A. Call the HCP B. Obtain a bedside pulse oximeter C. Raise the head of the bed higher D. Assess the clients vital signs

C. Raise the head of the bed higher For COPD you want an SpO2 >90%. Fowler's position can help to open up the chest wall and aid in breathing. B and D are normally done in the same assessment so you can check those off.

Which laboratory result for a preoperative client should prompt the nurse to contact the healthcare provider? A. Platelet count: 151x 10 9/L (151,000/mm3) B. White blood cell (WBC) count: 85 x 10 9/L (8500/mm3) C. Serum potassium level: 2.8 mEq/L (mmol/L) D. Urine specific gravity: 1.031

C. Serum potassium level: 2.8 mEq/L (mmol/L) This is very low and can lead to heart problems. All of the other values are within normal limits.

Which assignment should the nurse delegate to a UAP in an acute care setting? A. Checking blood glucose hourly for a client with a continuous insulin drip. B. Giving PO medications left at the bedside for the client to take after eating C. Taking vital signs for an older client with left humerus and left tibial fractures D. Replacing a client's pressure ulcer dressing that has been soiled by incontinence

C. Taking vital signs for an older client with left humerus and left tibial fractures UAPs can only be delegated to tasks that do not require and assessment or an evaluation. A is wrong because it implies the UAP knows the parameters of blood glucose and how they can change with an insulin drip. UAPs cannot give medications or replace dressings.

A client, who is HIV positive, asks why it is necessary to have a viral load study performed every 3-4 months. Which information should the nurse provide. A. To determine the progression of the disease B. To evaluate the enzyme-linked immunosorbent assay (ELISA) C. To monitor the effectiveness of the treatment D. To track the effectiveness of the vaccine

C. To monitor the effectiveness of the treatment Because of all of the different HIV drugs it is important to find the combination that works the best. The ELISA is used for initial diagnosis of HIV, not monitoring. There is no HIV vaccine. The progression of the disease is evaluated by CD4 T cell counts, not viral load.

A family member of a client who is in a Posey vest restraint (safety reminder device) asks why the restraint was applied. Which response should the nurse make? A. The restraint was prescribed by the healthcare provider. B. There is not enough staff to keep the client safe all the time. C. The other clients are upset when the client wanders at night. D. The client's actions place the client at high risk for self harm.

D. The client's actions place the client at high risk for self harm. Restraints are only used to prevent injury to self or others. They are not used when a client is being inconvenient to the staff or other clients.

The nurse enters the room of a preoperative client to obtain the client's signature on the surgical consent form. Which question is the most important for the nurse to ask the client? A. "When did the surgeon explain the procedure to you?" B. "Is there any member of your family going to be here during your surgery?" C. "Have you been instructed in postoperative activities and restrictions?" D. "Have you received any preoperative pain medication?"

D. "Have you received any preoperative pain medication?" Because pain medications can have a sedative effect, if a patient has already had their pain medications they do not possess the needed mental clarity to provide informed consent for the surgery.

Which situation warrants a variance (incident) report by the nurse? A. A client refuses to take prescribed medication. B. A client's status improves before completion of the course of medication. C. A client has an allergic reaction to a prescribed medication. D. A client received medication prescribed for another client.

D. A client received medication prescribed for another client. This is a huge safety concern and can lead to very negative client outcomes. It is important to report the issue to pharmacy to get the next steps and make changes so it does not happen again.

The nurse is assessing clients at the site of a community disaster. Using the color-code system for triage, which client should the nurse tag with a red code? A. A client with a large head injury that is bleeding, and open chest wound, cyanotic skin, no capillary refill, and agonal respirations B. A client with bruising and swelling of the right forearm, assorted lacerations to the face and neck, dry skin, normal capillary refill, and a respiratory rate of 18 C. A client with scratches and scrapes to the head and face who is limping and helping other clients at the scene D. A client with an open wound to the abdomen, and a deformed right femur, pulse 125, delayed capillary refill, respiration rate 32, who is moaning

D. A client with an open wound to the abdomen, and a deformed right femur, pulse 125, delayed capillary refill, respiration rate 32, who is moaning A has agonal breathing which would give him a black tag. B has stable vital signs and is most likely a yellow tag. C is walking wounded and would get a green tag.

A client who has hyperparathyroidism is scheduled to receive a prescribed dose of oral phosphate. The nurse notes that the client's serum calcium is 12.5 mg/dL. What action should the nurse take? A. Hold the phosphate and notify the HCP B. Review the client's serum parathyroid hormone level C. Give a PRN dose of IV calcium per protocol D. Administer the dose of oral phosphate

D. Administer the dose of oral phosphate A normal calcium level is 5.5-10.5 mg/dL so this value is high. Calcium and phosphate have an inverse reaction so in order to lower the calcium, there needs to be more phosphate. Giving the oral phosphate will be beneficial to lowering the serum calcium level.

What nursing action has the highest priority when admitting a client to a psychiatric unit on an involuntary basis? A. Reassure the client that this admission is only for a limited amount of time. B. Offer the client and family the opportunity to share their feelings about the admission. C. Determine the behaviors that resulted in the need for admission. D. Advise the client about the legal rights of all hospitalized clients.

D. Advise the client about the legal rights of all hospitalized clients. Because they are involuntarily admitted, the nurse should give the client some power back by helping them understand that they still have rights in the facility.

The charge nurse confronts a staff nurse whose behavior has been resentful and negative since a change in unit policy was announced. The staff nurse states, "don't blame me; nobody likes this idea." Which is the charge nurse's priority action? A. Confront the other staff members involved in the change of unit policy. B. Call a unit meeting to review the reasons the change was made. C. Develop a written unit policy for the expression of complaints. D. Encourage the nurse to be accountable for her own behavior.

D. Encourage the nurse to be accountable for her own behavior. Addressing the behavior is the first step. Because she is the only one that appears to have a problem it would not be appropriate to approach other staff or the unit together.

A client in shock develops a mean arterial pressure (MAP) of 60 mm Hg and a heart rate of 110 beats per minute. Which prescribed intervention should the nurse implement first? A. Increase the rate of O2 flow. B. Obtain arterial blood gas results. C. Insert and indwelling urinary catheter. D. Increase the rate of IV fluids.

D. Increase the rate of IV fluids. MAP of 60 is low and requires more organ perfusion. Thus, increasing IV fluids should help to raise the pressure.

The charge nurse is assigning rooms for four new clients. Only one private room is available in the oncology unit. Which client should be placed in the private room? A. The client with ovarian cancer who is receiving chemotherapy B. The client with breast cancer who is receiving external beam radiation C. The client with prostate cancer who has just had a transurethral resection D. The client with cervical cancer who is receiving intracavity radiation.

D. The client with cervical cancer who is receiving intracavity radiation. Internal radiation can be omitted beyond the patients body and caretakers must wear protective gear when interacting with the patient. They should be placed in a single room and have little contact with others.

pH = 7.32 pCO2 = 50 HCO3 = 25 The client has _____________

Respiratory acidosis w/out compensation

pH = 7.33 pCO2 = 50 HCO3 = 29 The client has _____________

Respiratory acidosis with partial compensation