HESI Practice Questions

A client complains of pain. Which question asked by the nurse are most appropriate to assess the nature of the pain? "Can you describe your pain to me?" "Is your pain associated with movements?" "Can you rate your pain on a scale of 0 to 10?" "Do you notice your pain worsening with any activity?"

"Can you describe your pain to me?"

The nurse is educating a client about tips for speaking up to help the client to be more involved in his or her treatment. Which statement made by the client indicates the need for further education? "I should pay attention to the care." "I should make assumptions regarding the treatment." "I should speak up and have questions or concerns." "I should learn about medical tests that are prescribed."

"I should make assumptions regarding the treatment."

Which critical thinking skill does the nurse associate with the concept of maturity? Eagerness to acquire knowledge Being tolerant of different views Trust in own reasoning processes Ability to reflect on own judgments

Ability to reflect on own judgments

A physically ill client is being verbally aggressive to the nursing staff. What is the most appropriate initial nursing response? Accept the client's behavior. Explore the situation with the client. Withdraw from contact with the client. Tell the client the reason for the staff's actions.

Accept the client's behavior.

The registered nurse is teaching a student nurse about making assumptions with an open mind when looking at information about a client. Which critical thinking skill is being referred to? Analysis Inference Evaluation Interpretation

Analysis

What should a nurse recommend to best help a client during the period immediately after a spouse's death? Crisis counseling Family counseling Marital counseling Bereavement counseling

Bereavement counseling

A client who is human immunodeficiency virus (HIV) positive is admitted to a surgical unit after an orthopedic procedure. The nurse should institute appropriate precautions with the awareness that HIV is highly transmissible through what means? Feces Blood Semen Urine Sweat Tears

Blood Semen

How can nurses exhibit the concept of open-mindedness as a part of critical thinking behavior in their teams? By being organized and focused By working with cognitive maturity By seeking the true meaning of any situation By respecting the right of others to have different opinions By becoming sensitive to the possibility of their own prejudices

By respecting the right of others to have different opinions By becoming sensitive to the possibility of their own prejudices

Which intrinsic factors may contribute to falls in older adults? Deconditioning Impaired vision Inappropriate foot wear Improper use of assistive devices Unfamiliar environment of hospital room

Deconditioning Impaired vision

After abdominal surgery a client reports pain. What action should the nurse take first? Reposition the client. Obtain the client's vital signs. Administer the prescribed analgesic. Determine the characteristics of the pain.

Determine the characteristics of the pain.

Which nursing intervention is performed for a middle-aged adult in restorative and continuing care? Establishing independence Focusing on problems related to sense of identity Reorganizing intimate relationships and family structure Determining the coping mechanisms of the client and the family

Determining the coping mechanisms of the client and the family

When caring for a client with venous insufficiency, the nurse would implement which nursing measure? Apply abdominal girdle as needed. Remove compression stockings for client ambulation. Elevate the client's legs above heart level. Keep the upper extremities elevated.

Elevate the client's legs above heart level.

A registered nurse instructs a nursing student to use knowledge and experience to choose proper strategies to use to care for clients. Which critical-thinking skill does the registered nurse refer to? Analysis Evaluation Explanation Interpretation

Explanation

Which critical thinking skill in nursing practice requires the nurse to possess knowledge and experience for choosing care strategies for clients? Analysis Inference Explanation Interpretation

Explanation

Which therapeutic communication technique is useful when the nurse and a client have a conversation and the client begins to repeat the conversation to himself or herself? Focusing Clarifying Paraphrasing Summarizing

Focusing

A client has been admitted with a diagnosis of intractable vomiting and can only tolerate sips of water. The initial blood work shows a sodium level of 122 mEq/L (122 mmol/L) and a potassium level of 3.6 mEq/L (3.6 mmol/L). Based on the lab results and symptoms, what is the client experiencing? Hypernatremia Hyponatremia Hyperkalemia Hypokalemia

Hyponatremia

Which nursing process involves delegation and verbal discussion with the healthcare team? Planning Evaluation Assessment Implementation

Implementation

A nurse explains to an obese client that the rapid weight loss during the first week after initiating a diet is because of fluid loss. The weight of extracellular body fluid is approximately 20% of the total body weight of an average individual. Which component of the extracellular fluid contributes the greatest proportion to this amount? Plasma Interstitial Dense tissue Body secretions

Interstitial

A nurse has provided discharge instructions to a client who received a prescription for a walker to use for assistance with ambulation. The nurse determines that the teaching has been effective when the client does what? Picks up the walker and carries it for short distances Uses the walker only when someone else is present Moves the walker no more than 12 inches (30.5 cm) in front of the client during use States that a walker will be purchased on the way home from the hospital

Moves the walker no more than 12 inches (30.5 cm) in front of the client during use

A client asks about the purpose of a pulse oximeter. The nurse explains that it is used to measure what? Respiratory rate Amount of oxygen in the blood Percentage of hemoglobin-carrying oxygen Amount of carbon dioxide in the blood

Percentage of hemoglobin-carrying oxygen

What is the most important factor relative to a therapeutic nurse-client relationship when a nurse is caring for a client who is terminally ill? Knowledge of the grieving process Personal feelings about terminal illness Recognition of the family's ability to cope Previous experience with terminally ill clients

Personal feelings about terminal illness

In the orientation phase, a nurse and a client meet and get to know each other. Which actions should the nurse follow in this phase? Prioritizing the client's problems Clarifying the client's and nurse's roles Evaluating goal achievement with the client Taking action to meet goals set with the client Encouraging and helping the client with self-exploration

Prioritizing the client's problems Clarifying the client's and nurse's roles

To prevent septic shock in the hospitalized client, what should the nurse do? Maintain the client in a normothermic state. Administer blood products to replace fluid losses. Use aseptic technique during all invasive procedures. Keep the critically ill client immobilized to reduce metabolic demands.

Use aseptic technique during all invasive procedures.

Which nursing activities are examples of primary prevention? Preventing disabilities Correcting dietary deficiencies Establishing goals for rehabilitation Assisting with immunization programs Facilitating a program about smoking cessation

Assisting with immunization programs Facilitating a program about smoking cessation

A nurse provides teaching for a client who is scheduled for a cholecystectomy. In the initial postoperative period, the nurse explains that the most important part of the treatment plan is what? Early ambulation Coughing and deep breathing Wearing antiembolic elastic stockings Maintenance of a nasogastric tube

Coughing and deep breathing

What nursing actions best promote communication when obtaining a nursing history? Establishing eye contact Paraphrasing the client's message Asking "why" and "how" questions Using broad, open-ended statements Reassuring the client that there is no cause for alarm Asking questions that can be answered with a "yes" or "no"

Establishing eye contact Paraphrasing the client's message Using broad, open-ended statements

A nurse provides crutch-walking instructions to a client who has a left-leg cast. The nurse should explain that weight must be placed where? In the axillae On the hands On the right side On the side that the client prefers

On the hands

The nurse provides a client with left-sided weakness with instructions on how to safely use a cane. The nurse should demonstrate proper use of the cane by holding it where? On alternating sides On the right side On the side of the weakness On the side of the client's choice

On the right side

Which concept refers to respecting the rights of others? Maturity Systematicity Inquisitiveness Open-mindedness

Open-mindedness

Which nurse collaborates directly with the client to establish and implement a basic plan of care after admission? Primary nurse Nurse clinician Nurse coordinator Clinical nurse specialist

Primary nurse

A client who has reached the stage of acceptance in the grieving process appears peaceful but demonstrates a lack of involvement with the environment. How should the nurse address this behavior? Ignore the client's behavior when possible. Accept the behavior the client is exhibiting. Explore the reality of the situation with the client. Encourage participation within the client's environment.

Accept the behavior the client is exhibiting.

When caring for a client who is receiving enteral feedings, the nurse should take which measure to prevent aspiration? Elevate the head of the bed between 30 and 45 degrees. Decrease flow rate at night. Check for residual daily. Irrigate regularly with warm tap water.

Elevate the head of the bed between 30 and 45 degrees.

A client has been diagnosed with type 1 diabetes mellitus. When providing instructions on sharps disposal, the nurse should instruct the client to place the syringes in what? Bubble wrap/packaging wrap A garbage bag in the trash can A cardboard box with a firmly secured lid A plastic liquid detergent bottle with a screw-top lid

A plastic liquid detergent bottle with a screw-top lid

A hospitalized client is scheduled to have a sigmoidoscopy. The nurse anticipates that preprocedure prescriptions will include what? Providing instructions about restraints used during the procedure Administering a Fleet enema 1 hour before the procedure Encouraging increased intake of clear fluids Administering morphine 30 minutes before the procedure

Administering a Fleet enema 1 hour before the procedure

A nurse is taking care of a client who is extremely confused and experiencing bowel incontinence. What measures can the nurse take to prevent skin breakdown in this client? Instruct the client to call for help with elimination needs; answer the client's call light immediately to prevent incontinence. Place a waterproof pad under the client to prevent incontinence and soiling the linens. Check the client's buttocks at least every 2 hours; clean the client immediately after discovering incontinence. Offer toileting to the client every 2 hours to prevent incontinence.

Check the client's buttocks at least every 2 hours; clean the client immediately after discovering incontinence.

What safety factor should the nurse teach parents about using a crib for an infant? Ensure the crib has a drop-side rail. Place soft toys and soft pillows inside the crib. Attach toys with hanging strings over the crib. Check the slats are less than 6 cm (2.4 in) apart.

Check the slats are less than 6 cm (2.4 in) apart.

Which findings in the older client are associated with a urinary tract infection (UTI)? Fever Urgency Confusion Incontinence Slight rise in temperature

Confusion Incontinence Slight rise in temperature

Which critical thinking skill refers to the use of knowledge and experience to choose effective client care strategies? Evaluation Explanation Interpretation Self-regulation

Explanation

The nurse listens to and validates the feelings expressed by a confused older adult. Which elements does the nurse convey in this situation? Recalling Respecting Reassuring Reinforcing Understanding

Respecting Reassuring Understanding

A nurse is teaching a client how to use the call bell/call light system. Which level of Maslow's hierarchy of needs does this nursing action address? Safety Self-esteem Physiological Interpersonal

Safety

When assessing a client's fluid and electrolyte status, the nurse recalls that the regulator of extracellular osmolarity is what? Sodium Potassium Chloride Calcium

Sodium

A family has undergone the emotional transition of accepting a new generation of members into the family system. Which changes in the family's status are required to proceed developmentally? . Taking on parental roles Adjusting to a reduction in family size Development of intimate peer relationships Adjusting the marital system to make space for children Realigning relationships to in-laws and grandchildren

Taking on parental roles Adjusting the marital system to make space for children

A nurse is caring for a client on bed rest. How can the nurse help prevent a pulmonary embolus? Limit the client's fluid intake. Teach the client how to exercise the legs. Encourage use of the incentive spirometer. Maintain the knee gatch position at an angle.

Teach the client how to exercise the legs.

What should the nurse teach the parents of an infant about the use of car seats? The infant should ride in a front-facing car safety seat. The infant should ride in a car safety seat until one year of age. The infant should be restrained properly in a federally approved car safety seat. The infant should always ride in a car seat restrained to the front seat of the car.

The infant should be restrained properly in a federally approved car safety seat.

A client with a history of ulcerative colitis is admitted to the hospital because of severe rectal bleeding. The client engages in angry outbursts and places excessive demands on the staff. One day an unlicensed healthcare worker tells the nurse, "I've had it. I am not putting up with that behavior. I'm not going in there again." What is the best response by the nurse? "You need to try to be patient. The client is going through a lot right now." "I'll talk with the client. Maybe I can figure out the best way for us to handle this." "Just ignore it and get on with your work. I'll assign someone else to take a turn." "The client's frightened and taking it out on the staff. Let's think of approaches we can take."

"The client's frightened and taking it out on the staff. Let's think of approaches we can take."

A client is admitted voluntarily to a psychiatric unit. Later, the client develops severe pain in the right lower quadrant and is diagnosed as having acute appendicitis. How should the nurse prepare the client for the appendectomy? Have two nurses witness the client signing the operative consent form. Ensure that the primary healthcare provider and the psychiatrist sign for the surgery because it is an emergency procedure. Ask the client to sign the operative consent form after the client has been informed of the procedure and required care. Inform the client's next of kin that it will be necessary for one of them to sign the consent form because the client is on a psychiatric unit.

Ask the client to sign the operative consent form after the client has been informed of the procedure and required care.

An 85-year-old client is alert and able to participate in care. The nurse understands that, according to Erikson, a person's adjustment to the period of senescence will depend largely on adjustment to which developmental stage? Industry versus inferiority Identity versus role confusion Generativity versus stagnation Autonomy versus shame/doubt

Generativity versus stagnation

When meeting the unique preoperative teaching needs of an older adult, the nurse plans a teaching program based on which principle about learning? It reduces general anxiety. It is negatively affected by aging. It requires continued reinforcement. It necessitates readiness of the learner.

It requires continued reinforcement.

A client with cystic fibrosis asks why the percussion procedure is being performed. The nurse explains that the primary purpose of percussion is to do what? Relieve bronchial spasms Increase depth of respirations Loosen pulmonary secretions Expel carbon dioxide from the lungs

Loosen pulmonary secretions

While undergoing a soapsuds enema, the client reports abdominal cramping. What action should the nurse take? Immediately stop the infusion. Lower the height of the enema bag. Advance the enema tubing 2 to 3 inches (5 to 7.5 cm). Clamp the tube for 2 minutes and then restart the infusion.

Lower the height of the enema bag.

A client who has been battling cancer of the ovary for 7 years is admitted to the hospital in a debilitated state. The healthcare provider tells the client that she is too frail for surgery or further chemotherapy. When making rounds during the night, the nurse enters the client's room and finds her crying. Which is the most appropriate intervention by the nurse? Sit down quietly next to the bed and allow her to cry. Pull the curtain and leave the room to provide privacy for the client. Explain to the client that her feelings are expected and they will pass with time. Observe the length of time the client cries and document her difficulty accepting her impending death.

Sit down quietly next to the bed and allow her to cry.

The registered nurse teaches a nursing student about the implementation process of nursing. Which example does the registered nurse use while describing indirect care interventions using his or her knowledge? The nurse counseling a client at the time of grief The nurse administering an intravenous infusion to a client The nurse teaching the client about an appropriate nutrition plan The management of the client's environment to prevent infections

The management of the client's environment to prevent infections

A client is hospitalized because of severe depression. The client refuses to eat, stays in bed most of the time, does not talk with family members, and will not leave the room. The nurse attempts to initiate a conversation by asking questions but receives no answers. Finally the nurse tells the client that if there is no response, the nurse will leave and the client will remain alone. How should the nurse's behavior be interpreted? A system of rewards and punishment is being used to motivate the client. Leaving the client alone allows time for the nurse to think of other strategies. This behavior indicates the client's desire for solitude that the nurse is respecting. This threat is considered assault, and the nurse should not have reacted in this manner.

This threat is considered assault, and the nurse should not have reacted in this manner.

What are the goals of care when working with families according to the family health system? To improve family health or well-being To help the family prepare for later transitions To assist in family management of illness conditions To promote positive family behaviors to achieve essential tasks To achieve health outcomes related to the family's areas of concern

To improve family health or well-being To assist in family management of illness conditions To achieve health outcomes related to the family's areas of concern

A post-operative client is discharged to home. Which statement made by the nurse would be beneficial for the client's care in the home? "I will change the dressing every day." "I will recommend a physical therapy referral." "I will provide you with a homecare service referral." "I will not allow any family member to be present during dressing change."

"I will provide you with a homecare service referral."

Which caring intervention helps to provide comfort, dignity, respect, and peace to a client? Listening Spiritual caring Providing presence Relieving pain and suffering

Relieving pain and suffering

Which assessment finding is associated with depression? The client has islands of intact memory. The client has impaired recent and remote memory. The client has impaired recent and immediate memory. The client needs step-by-step instructions for simple tasks.

The client has islands of intact memory.

Which psychosocial health concern involves accepting descriptive statements stated by a confused older client? Reminiscence Reality orientation Validation therapy Therapeutic communication

Validation therapy

A nurse assesses drainage on a surgical dressing and documents the findings. Which documentation is most informative? "Moderate amount of drainage." "No change in drainage since yesterday." "A 10-mm-diameter area of drainage at 1900 hours." "Drainage is doubled in size since last dressing change."

"A 10-mm-diameter area of drainage at 1900 hours."

The registered nurse instructed the nursing student to care for a client who suffers from depression. During a follow up visit, the registered nurse finds that the client's symptoms have not improved. Which activity of the nursing student would the registered nurse relate this to? Modifying the environment Limiting the client's choices of diet and clothing Encouraging fluid intake Discouraging social interaction to avoid the client's distraction from outside environment

Discouraging social interaction to avoid the client's distraction from outside environment

After gastric surgery a client has a nasogastric tube in place. What should the nurse do when caring for this client? Monitor for signs of electrolyte imbalance. Change the tube at least once every 48 hours. Connect the nasogastric tube to high continuous suction. Assess placement by injecting 10 mL of water into the tube.

Monitor for signs of electrolyte imbalance.

Which example in nursing practice would demonstrate Watson's carative factor called forming a human-altruistic value system? Assisting clients with their basic needs Creating a healing environment at all levels Allowing spiritual forces to provide a better understanding Using self-disclosure to promote a therapeutic alliance with the client

Using self-disclosure to promote a therapeutic alliance with the client

What should the nurse consider when obtaining an informed consent from a 17-year-old adolescent? Whether the client is allowed to give consent That the client cannot make informed decisions about healthcare Whether the client is permitted to give voluntary consent when parents are not available That the client probably will be unable to choose between alternatives when asked to consent

Whether the client is allowed to give consent

The nurse manager asks the nurse, "How would you implement clinical decision making in a group of clients?" Which answer provided by the nurse shows effective critical thinking? "I will avoid involving clients as decision-makers and participants in care." "I will discuss complex cases with other members of the healthcare team." "I will identify the nursing diagnoses and collaborative problems of each client." "I will consider the period it takes to care for clients whose problems have higher priority." "I will decide to perform activities individually to resolve more than one client problem at a time."

"I will discuss complex cases with other members of the healthcare team." "I will identify the nursing diagnoses and collaborative problems of each client." "I will consider the period it takes to care for clients whose problems have higher priority."

When the nurse arrives at 8:00 am, a client has a 1000 mL bag of D5W hanging, with 450 mL infused during the prior shift. The IV infusion is to deliver 100 mL per hour. At 11:00 am the healthcare provider changes the prescription for the intravenous solution to 1000 mL 0.9% sodium chloride to be administered at 75 mL per hour and changes the dietary order from nothing by mouth to clear liquids. From 1:00 pm to the end of the 12-hour shift at 8:00 pm, the client has 4 oz (120 mL) of apple juice, a half cup of tea, a half cup of gelatin, and 6 oz (180 mL) of water. How many milliliters should the nurse document as the client's total fluid intake for the 12-hour shift? Record your answer using a whole number. mL

1515

A nurse is changing the dressing of a postoperative client. The nursing assistant informs the nurse that another client has fallen down near the nursing station after losing consciousness. What is the best nursing action in this situation? Attend to the client who lost consciousness. Delegate the dressing change to the nursing assistant. Delegate the care of the unconscious client to the nursing assistant. Complete the dressing as the open wound may increase infection risk.

Attend to the client who lost consciousness.

Which psychophysiologic factors can influence communication between a nurse and a client? Privacy level Emotional status Information exchange Level of caring expressed Growth and development

Emotional status Growth and development

To prevent thrombophlebitis in the immediate postoperative period, which action is most important for a nurse to include in the client's plan of care? Increase fluid intake. Restrict fluids. Encourage early mobility. Elevate the knee gatch of the bed.

Encourage early mobility.

While assessing an older adult, the nurse observes visual impairment in the client. Which technique should the nurse use to communicate? Face the caregiver while speaking Provide bright, diffuse, glare lighting Stand or sit far away from the client while remaining in the client's full view Encourage the older adult to use assistive devices such as glasses

Encourage the older adult to use assistive devices such as glasses

A client is hospitalized for treatment of severe hypertension. Captopril and alprazolam are prescribed. Shortly after admission, the client says, "I don't think any of you know what you are doing. You are just guessing what I need." What does the nurse determine as the probable cause of this behavior? Denial of illness Fear of the health problem Response to cerebral anoxia Reaction to the antihypertensive drug

Fear of the health problem

A nurse is caring for a client who has a Hemovac portable wound suction device after abdominal surgery. What is the reason why the nurse empties the device when it is half full? Emptying the unit is safer when it is half full. Accurate measurement of drainage is facilitated. Negative pressure in the unit lessens as fluid accumulates, interfering with further drainage. Fluid collecting in the unit exerts positive pressure, forcing drainage back up the tubing and into the wound.

Negative pressure in the unit lessens as fluid accumulates, interfering with further drainage.

The nurse is providing restraint education to a group of nursing students. The nurse should include that it is inappropriate to use a restraint device to do what? Prevent a client from pulling out an intravenous (IV) when there is concern that the client cannot follow instructions or is confused. Prevent an adult client from getting up at night when there is insufficient staffing on the unit. Maintain immobilization of a client's leg to prevent dislodging a skin graft. Keep an older adult client from falling out of bed following a surgical procedure.

Prevent an adult client from getting up at night when there is insufficient staffing on the unit.

The nurse is caring for a client with a temperature of 104.5 degrees Fahrenheit (40.3 degrees Celsius). The nurse applies a cooling blanket and administers an antipyretic medication. The nurse explains that the rationale for these interventions is to do what? Promote equalization of osmotic pressures Prevent hypoxia associated with diaphoresis Promote integrity of intracerebral neurons Reduce brain metabolism and limit hypoxia

Reduce brain metabolism and limit hypoxia

A teenager begins to cry while talking with the nurse about the problem of not being able to make friends. What is the most therapeutic nursing intervention? Sitting quietly with the client Telling the client that crying is not helpful Suggesting that the client play a board game Recommending how the client can change this situation

Sitting quietly with the client

The home healthcare nurse visits a client who lives with her two grandchildren. The client's daughter is a single-parent who is away at work and comes home only on weekends. Which term does the nurse use to define this family form? Nuclear family Extended family Single-parent family Skip-generation family

Skip-generation family

While reviewing the performance of a newly appointed nurse, the chief operational officer finds that the nurse excels at using reflective journaling. What activity of the nurse would lead the chief operational officer to this conclusion? The nurse shares constructive criticism with his or her team members. The nurse meets with colleagues regularly to discuss work experience. The nurse organizes or connects information in a way so the diverse information about a client forms meaningful patterns.

The nurse meets with colleagues regularly to discuss work experience. journaling

What is an example of the critical thinking attitude of independent thinking in nursing practice? To refer to a policy and procedure manual to review steps of a skill To talk with other nurses to share ideas about nursing interventions To recognize when one requires more information for making a decision To explore and learn more about the client for making appropriate clinical judgments

To talk with other nurses to share ideas about nursing interventions

Which principles are appropriate for promoting older adult learning? Emphasize abstract material Use past experiences while teaching Teach by presenting multiple examples at a time Keep the environmental distractions to a minimum Use audio, visual, and tactile cues to enhance learning

Use past experiences while teaching Keep the environmental distractions to a minimum Use audio, visual, and tactile cues to enhance learning

The nurse is questioning a client who reports pain. Which questions asked by the nurse are appropriate? . "Where does it hurt?" "What makes the pain worse?" "How long have you noticed it?" "Have you been treated for pain previously?" "How severe is your pain on a scale of 0 to 10?"

"Where does it hurt?" "What makes the pain worse?" "How long have you noticed it?" "How severe is your pain on a scale of 0 to 10?"

A client with dementia who feels highly anxious and confused believes that the current day is actually different than what it is. Which statement made by the nurse is an example of validation therapy? "No, try to be in your sense of reality." "Yes, today is the day that you just mentioned." "You should try improving your awareness level." "Try to recall your past memories associated with the day."

"Yes, today is the day that you just mentioned."

A nurse is reviewing the laboratory report of a client with kidney problems. When ammonia is excreted by healthy kidneys, what mechanism usually is maintained? Osmotic pressure of the blood Acid-base balance of the body Low bacterial levels in the urine Normal red blood cell production

Acid-base balance of the body

Health promotion efforts for a chronically ill client should include interventions related to primary prevention. What should this include? Encouraging daily physical exercise Performing yearly physical examinations Providing hypertension screening programs Teaching a person with diabetes how to prevent complications

Encouraging daily physical exercise

A nurse educator is presenting information about the nursing process to a class of nursing students. What definition of the nursing process should be included in the presentation? Procedures used to implement client care Sequence of steps used to meet the client's needs Activities employed to identify a client's problem Mechanisms applied to determine nursing goals for the client

Sequence of steps used to meet the client's needs