HESI Practice

A home care nurse is collecting data regarding the environmental safety for the client receiving home oxygen therapy. The nurse determines that the client needs instructions regarding safe use of oxygen if which observation is made? a. Gas stove is lit in a room 30ft from where the oxygen is used b. Oxygen concentrator is placed against a wall c. Oxygen tank is secured in holder d. A "no smoking" sign is in the window near the door of the client's home

B. Oxygen concentrator is placed against a wall

A client is receiving meperidine hydrochloride (Demerol). The nurse monitors which of the following to determine medication effectiveness? a. Blood pressure b. Pain level c. Urinary output d. Level of conciousness

B. Pain level

A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath and is visibly anxious. The nurse immediately assesses the client for: a. Dyspnea, diaphoresis, and cough b. Fever, dizziness, and crackles c. Abnormal heart sounds and radiation of pain to the left arm d. Bilateral wheezing and use of accessory muscles of respiration

A. Dyspnea, diaphoresis, and cough

"The nurse is caring for a client with pneumonia who is to receive oxygen via nasal cannula. To provide a safe and effective delivery of the oxygen, the nurse avoids which of the following?" a. Secured the oxygen tubing to the client's bottom sheet b. Keeps the humidification jar filled with distilled water c. Observes the client's nares frequently for skin breakdown d. Checks the oxygen flow rate and physician's order every shift

A. Secured the oxygen tubing to the client's bottom sheet

A nurse has taught a family how to communicate more effectively with a hearing-impaired client. The nurse determines that the family has incorporated the suggestions if which behavior by the family was observed by the nurse? a. Using appropriate hand motions with communication b. Shouting at the client to enhance hearing c. Speaking while standing behind the client d. Eating and drinking while talking to the client

A. Using appropriate hand motions with communication

The client who has been receiving intravenous (IV) aminophylline (Theophylline) has been prescribed an immediate-release oral form of the medication. The IV medication is to be discontinued. The nurse should administer the first dose of the oral medication: a. Immediately upon discontinuing the IV form b. In 4-6 hours after discontinuing the IV form c. Just before the next meal d. Just after the next meal

B. In 4-6 hours after discontinuing the IV form

A client is being discharged from the hospital and will receive oxygen therapy at home. The nurse is teaching the client and family about oxygen safety measures. Which statement by the client indicates the need for further teaching? a. I realize that I should check the oxygen level of the portable tank on a consistent basis b. It is alright to burn my scented candles as long as they are a few feet away from my oxygen tank c. I will not sit in front of my wood-burning fireplace with my oxygen on d. I will call the physician if I experience any shortness of breath

B. It is alright to burn my scented candles as long as they are a few feet away from my oxygen tank

"A postpartum nurse has instructed a new mother on how to bathe her newborn infant. The nurse demonstrates the procedure to the mother, and on the following day, asks the mother to perform the procedure. Which observation by the nurse indicates that the mother is performing the procedure correctly?" a. The mother cleans the ears and then moves to the eyes and the face b. The mother begins to wash the newborn infant by starting with the eyes and face c. The mother washes the arms, chest, and back followed by the neck, arms, and face d. The mother washes the entire newborn infant's body and then washed the eyes, face, and scalp

B. The mother begins to wash the newborn infant by starting with the eyes and face

A nurse teaches a preoperative client about the nasogastric (NG) tube that will be inserted in preparation for surgery. The nurse determines that the client understands when the tube will be removed in the postoperative period when the client states: a. "When my gastrointestinal (GI) system is healed." b. "When I can tolerate food without vomiting." c. "When my bowels begin to function again and I begin to pass gas." d. "When the doctor says so."

C. "When my bowels begin to function again and I begin to pass gas."

A client with skeletal traction applied to the right leg complains to the nurse of severe right leg pain in spite of being medicated with a prescribed analgesic. Which action should the nurse take? a. Remove some of the traction weights b. Provide pin care c. Call the physician d. Find out when the next dose of the prescribed analgesic can be given

C. Call the physician

A nurse is getting a postoperative client out of bed for the first time since surgery. The nurse raises the head of the bed and the client complains of dizziness. Which of the following actions should the nurse take first? a. Check the oxygen saturation level b. Check the blood pressure c. Lower the head of the bed slowly until the dizziness is relieved d. Have the client take some deep breaths

C. Lower the head of the bed slowly until the dizziness is relieved

"A nurse is assisting with transferring a client from the operating room table to a stretcher. To provide safety to the client, the nurse:" a. Moves the client rapidly from the table to the stretcher b. Uncovers the client completely before transferring to the stretcher c. Secures the client with safety belts after transferring to the stretcher d. Instructs the client to move self from the table to the stretcher

C. Secures the client with safety belts after transferring to the stretcher

A nurse is assessing the environmental safety for a client receiving home oxygen therapy. The nurse determines that which observation is within the principles of safe oxygen use? a. Scented candle is burning in the client's room b. Oxygen concentrator is places against the wall c. Oxygen tank is lying on its side on the floor next to the client d. A "No Smoking" sign is placed in the front window of the client's home

D. A "No Smoking" sign is placed in the front window of the client's home

A client with heart failure is receiving furosemide (Lasix) and digoxin (Lanoxin) daily. When the nurse enters the room to administer the morning doses, the client complains of anorexia, nausea, and yellow vision. The nurse should do which of the following first? a. Administering the medications b. Give the digoxin only c. Check the morning serum potassium level d. Check the morning serum digoxin level

D. Check the morning serum digoxin level

"A nurse is planning a discharge teaching plan for a client with a spinal cord injury. To provide for a safe environment regarding home care, which of the following would be the priority in the discharge teaching plan?" a. What the physician has indicated needs to be taught b. Follow-up laboratory and diagnostic tests that need to be done c. Assisting the client to deal with long-term care placement d. Including the client's significant others in the teaching session

D. Including the client's significant others in the teaching session

A home care nurse is providing instructions to the spouse of a client with Alzheimer's disease who will be taking donepezil hydrochloride (Aricept). Which of the following instructions would the nurse provide to the spouse regarding the administration of the medication? a. To administer the medication in the morning with the breakfast meal b. To administer the medication on an empty stomach 1 hour prior to the noontime meal c. To administer the medication at 5PM with dinner and an antacid d. To administer the medication in the evening before bedtime with a snack

D. To administer the medication in the evening before bedtime with a snack

A nurse is monitoring a client with a spinal cord injury for signs of spinal shock. Which of the following is indicative of this complication of a spinal cord injury? a. hypertension b. tachycardia c. profuse diaphoresis d. areflexia below the level of injury

D. areflexia below the level of injury

A nurse reviewing the record of a client with Ménière's disease prepares dietary instructions for the client. Which of the following dietary prescriptions would the nurse expect to be prescribed for the client? a. Low-cholesterol diet b. Low-sodium diet c. Low-carbohydrate diet d. Low-fat diet

B. Low-sodium diet

A nurse is preparing to assist the client from the bed to a chair using a hydraulic lift. The nurse would do which of the following to move the client safely with this device? a. Have 3 people available to assist b. Position the client in the center of the sling c. Have the client grasp the chains attaching the sling to the lift d. Lower the client rapidly once positioned over the chair

B. Position the client in the center of the sling

A client is being transferred to the nursing unit from the postanesthesia care unit following spinal fusion with rod insertion. The nurse prepares to transfer the client from the stretcher to the bed by using: a. A bath blanket and the assistance of three people b. A bath blanket and the assistance of four people c. A transfer board and the assistance of two people d. A transfer board and the assistance of four people

D. A transfer board and the assistance of four people

A nurse demonstrates to a mother how to correctly take an axillary temperature to determine if the child has a fever. Which action by the mother would indicate a need for further teaching? a. She selects a thermometer with a slender tip b. She holds the thermometer in the axilla for one minute c. She records the actual temperature reading and route d. She places the thermometer in the center of the axilla

B. She holds the thermometer in the axilla for one minute

"A client receives meperidine (Demerol) by the intramuscular (IM) route. Thirty minutes after receiving the medication, the client develops signs of an allergy to the medication. The client's temperature is 101° F, and the skin is warm and flushed with a notable rash on the chest and back. The nurse further assesses the client, contacts the physician, and begins to document on an incident report. The nurse most accurately documents which of the following?" a. The client had an allergy to the meperidine b. The physician was notified because the client developed a rash after receiving meperidine c. Thirty minutes after receiving meperidine, the temperature is 101F, skin is warm and flushed, and a rash is noted on the chest and back; the physician was notified d. The client apparently is allergic to meperidine as noted by a temperature of 101F, warm and flushed skin, and a rask on the chest and back

C. Thirty minutes after receiving meperidine, the temperature is 101F, skin is warm and flushed, and a rash is noted on the chest and back; the physician was notified