HESI Prep Questions
A client is admitted to the hospital with a diagnosis of severe acute diverticulitis. Which nursing intervention has the highest priority? A. Place the client on NPO status B. Assess the client's temperature C. Obtain a stool specimen D. Administer IV Fluids
Answer: A A client with acute severe diverticulitis is at risk for peritonitis and intestinal obstruction and should be made NPO (A) to reduce risk of intestinal rupture. (B, C, and D) are important but are less of a priority than (A), which is implemented to prevent a severe complication.
A client is diagnosed with an acute small bowel obstruction. Which assessment finding requires the most immediate intervention by the nurse? A. Fever of 102° F B. Blood pressure of 150/90 mm Hg C. Abdominal cramping D. Dry mucous membranes
Answer: A A sudden increase in temperature is an indicator of peritonitis. The nurse should notify the health care provider immediately (A). (B, C, and D) are also findings that require intervention by the nurse, but are of less priority than (A). (B) may indicate a hypertensive condition but is not as acute a condition as peritonitis. (C) is an expected finding in clients with small bowel obstruction and may require medication. (D) indicates probable fluid volume deficit, which requires fluid volume replacement.
Which consideration is most important when the nurse is assigning a room for a client being admitted with progressive systemic sclerosis (scleroderma)? A. Provide a room that can be kept warm B. Make sure that the room can be kept dark C. Keep the client close to the nursing unit D. Select a room that is visible from the nurse's desk
Answer: A Abnormal blood flow in response to cold (Raynaud's phenomenon) is precipitated (A) in clients with scleroderma. (B) is not a significant factor. Stress can also precipitate the severe pain of Raynaud's phenomenon, so a quiet environment is preferred to (C), which is often very noisy. (D) is not necessary.
Based on the clinical manifestations of Cushing's syndrome, which nursing intervention would be appropriate for a client who is newly diagnosed with Cushing's syndrome? A. Monitor blood glucose levels daily. B. Increase intake of fluids high in potassium. C. Encourage adequate rest between activities. D. Offer the client a sodium-enriched menu.
Answer: A Cushing's syndrome results from a hypersecretion of glucocorticoids in the adrenal cortex. Clients with Cushing's syndrome often develop diabetes mellitus. Monitoring of serum glucose levels (A) assesses for increased blood glucose levels so that treatment can begin early. A common finding in Cushing's syndrome is generalized edema. Although potassium is needed, it is generally obtained from food intake, not by offering potassium-enhanced fluids (B). Fatigue is usually not an overwhelming factor in Cushing's syndrome, so an emphasis on the need for rest (C) is not indicated A low-calorie, low-carbohydrate, low-sodium diet is not recommended (D).
A resident in a long-term care facility is diagnosed with hepatitis B. Which intervention should the nurse implement with the staff caring for this client? A. Determine if all employees have had the hepatitis B vaccine series. B. Explain that this type of hepatitis can be transmitted when feeding the client. C. Assure the employees that they cannot contract hepatitis B when providing direct care. D. Tell the employees that wearing gloves and a gown are required when providing care.
Answer: A Hepatitis B vaccine should be administered to all health care providers (A). Hepatitis A (not hepatitis B) can be transmitted by fecal-oral contamination (B). There is a chance that staff could contract hepatitis B if exposed to the client's blood and/or body fluids; therefore, (C) is incorrect. There is no need to wear gloves and gowns except with blood or body fluid contact (D).
During a health fair, a male client with emphysema tells the nurse that he fatigues easily. Assessment reveals marked clubbing of the fingernails and an increased anteroposterior chest diameter. Which instruction is best to provide the client? A. "Pace your activities and schedule rest periods." B. "Increase the amount of oxygen you use at night." C. "Obtain medical evaluation for antibiotic therapy." D. "Reduce your intake of fluids containing caffeine."
Answer: A Manifestations of emphysema include an increase in AP diameter (referred to as a barrel chest), nail bed clubbing, and fatigue. The nurse can provide instructions to promote energy management, such as pacing activities and scheduling rest periods (A). (B) may result in a decreased drive to breathe. The client is not exhibiting any symptoms of infection, so (C) is not necessary. (D) is less beneficial than (A).
A 63-year-old client with type 2 diabetes mellitus is admitted for treatment of an ulcer on the heel of the left foot that has not healed with wound care. The nurse observes that the entire left foot is darker in color than the right foot. Which additional symptom should the nurse expect to find? A. Pedal pulses will be weak or absent in the left foot. B. The client will state that the left foot is usually warm. C. Flexion and extension of the left foot will be limited. D. Capillary refill of the client's left toes will be brisk.
Answer: A Symptoms associated with decreased blood supply are weak or absent pedal and tibial pulses (A). The client with diabetes experiences vascular scarring as a result of atherosclerotic changes in the peripheral vessels. This results in compromised perfusion to the dependent extremities, which further delays wound healing in the affected foot. Although flexion and extension may be limited (C), depending on the degree of damage, this is not always the case. (B and D) are signs of adequate perfusion of the foot, which would not be expected in this client.
A client with hypertension has been receiving ramipril (Altace), 5 mg PO, daily for 2 weeks and is scheduled to receive a dose at 0900. At 0830, the client's blood pressure is 120/70 mm Hg. Which action should the nurse take? A. Administer the prescribed dose at the scheduled time. B. Hold the dose and contact the health care provider. C. Hold the dose and recheck the blood pressure in 1 hour. D. Check the health care provider's prescription to clarify dose.
Answer: A The client's blood pressure is within normal limits, indicating that the ramipril, an antihypertensive, is having the desired effect and should be administered (A). (B and C) would be appropriate if the client's blood pressure was excessively low (<100 mm Hg systolic) or if the client were exhibiting signs of hypotension such as dizziness. This prescribed dose is within the normal dosage range, as defined by the manufacturer; therefore, (D) is not necessary.
The nurse is preparing a teaching plan for a group of healthy adults. Which individual is most likely to maintain optimum health? A. A teacher whose blood glucose levels average 126 mg/dL daily with oral antidiabetic drugs B. An accountant whose blood pressure averages 140/96 mm Hg and who says he does not have time to exercise C. A stock broker whose total serum cholesterol level dropped to 290 mg/dL with diet modifications D. A recovering IV heroin user who contracted hepatitis more than 10 years ago
Answer: A The diabetic teacher (A) has assumed responsibility for self-care, so among those listed, is the most likely to maintain optimum health. (B) has expressed a lack of interest in health promotion. (C) continues to demonstrate a high-risk cholesterol level despite a reported attempt at dietary modifications. Previous IV drug use and a history of hepatitis (D) make this individual a health risk despite the fact that the individual is in recovery.
Seconal, 0.1 g PRN at bedtime, is prescribed for rest. The scored tablets are labeled grain 1.5 per tablet. How many tablets should the nurse plan to administer? A. 1/2 tablet B. 1 tablet C. 1 1/2 tablets D. 2 tablets
Answer: B 15 gr = 1 g. Converting the prescribed dose of 0.1 g to grains requires multiplying 0.1 × 15 = 1.5 grains. The tablets come in 1.5 grains; therefore, the nurse should plan to administer one tablet (B). (A, C, and D) are incorrect.
A hospitalized client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He begins to cough and produces a moderate amount of white sputum. Which action should the nurse take first? A. Auscultate the client's breath sounds. B. Turn off the continuous feeding pump. C. Check placement of the nasogastric tube. D. Measure the amount of residual feeding.
Answer: B A productive cough may indicate that the feeding has been aspirated. The nurse should first stop the feeding (B) to prevent further aspiration. (A, C, and D) should all be performed before restarting the tube feeding if no evidence of aspiration is present and the tube is in place.
An older male client comes to the outpatient clinic complaining of pain in his left calf. The nurse notices a reddened area on the calf of his right leg that is warm to the touch, and the nurse suspects that the client may have thrombophlebitis. Which additional assessment is most important for the nurse to perform? A. Measure the client's calf circumference. B. Auscultate the client's breath sounds. C. Observe for ecchymosis and petechiae. D. Obtain the client's blood pressure.
Answer: B All these techniques provide useful assessment data. The most important is to auscultate the client's breath sounds (B) because the client may have a pulmonary embolus secondary to the thrombophlebitis. (A) may provide data that support the nurse's suspicion of thrombophlebitis. (C) is the least helpful assessment because bruising is not a typical finding associated with thrombophlebitis. (D) is always useful in evaluating the client's response to a problem but is of less immediate priority than breath sound auscultation.
A client diagnosed with chronic kidney disease (CKD) 2 years ago is regularly treated at a community hemodialysis facility. Before his scheduled dialysis treatment, which electrolyte imbalance should the nurse anticipate? A. Hypophosphatemia B. Hypocalcemia C. Hypnonatremia D. Hypokalemia
Answer: B Hypocalcemia (B) develops in CKD because of chronic hyperphosphatemia, not (A). Increased phosphate levels cause the peripheral deposition of calcium and resistance to vitamin D absorption needed for calcium absorption. Prior to dialysis, the nurse would expect to find the client hypernatremic and hyperkalemic, not with (C or D).
Which condition should the nurse anticipate as a potential problem in a female client with a neurogenic bladder? A. Stress Incontinence B. Infection C. Painless gross hematuria D. Peritonitis
Answer: B Infection (B) is the major complication resulting from stasis of urine and subsequent catheterization. (A) is the involuntary loss of urine through an intact urethra as a result of a sudden increase in intraabdominal pressure. (C) is the most common symptom of bladder cancer. (D) is the most common and serious complication of peritoneal dialysis.
A 58-year-old client who has no health problems asks the nurse about receiving the pneumococcal vaccine (Pneumovax). Which statement given by the nurse would offer the client accurate information about this vaccine? A. The vaccine is given annually before the flu season to those older than 50 years. B. The immunization is administered once to older adults or those at risk for illness. C. The vaccine is for all ages and is given primarily to those persons traveling overseas to areas of infection. D. The vaccine will prevent the occurrence of pneumococcal pneumonia for up to 5 years.
Answer: B It is usually recommended that persons older than 65 years and those with a history of chronic illness should receive the vaccine once in their lifetime (B). Some recommend receiving the vaccine at 50 years of age. The influenza vaccine is given once a year, not Pneumovax (A). Although the vaccine might be given to a person traveling overseas, that is not the main rationale for administering the vaccine (C). The vaccine is usually given once in a lifetime (D), but with immunosuppressed clients or clients with a history of pneumonia, revaccination is sometimes required.
Which abnormal laboratory finding indicates that a client with diabetes needs further evaluation for diabetic nephropathy? A. Hypokalemia B. Microalbuminuria C. Elevated serum lipid levels D. Ketonuria
Answer: B Microalbuminuria (B) is the earliest sign of diabetic nephropathy and indicates the need for follow-up evaluation. Hyperkalemia, not (A), is associated with end-stage renal disease caused by diabetic nephropathy. (C) may be elevated in end-stage renal disease. (D) may signal the onset of diabetic ketoacidosis (DKA).
A nurse is assisting an 82-year-old client with ambulation and is concerned that the client may fall. Which area contains the older person's center of gravity? A. Head and neck B. Upper torso C. Bilateral arms D. Feet and legs
Answer: B Stooped posture results in the upper torso (B) becoming the center of gravity for older persons. The center of gravity for adults is the hips. However, as a person grows older, a stooped posture is common because of changes caused by osteoporosis and normal bone degeneration. Furthermore, the knees, hips, and elbows flex. The head and neck (A) and feet and legs (D) are not the center of gravity in the older adult. Although the arms (C) comprise a part of the upper torso, they do not reflect the best and most complete answer.
The nurse assesses a postoperative client whose skin is cool, pale, and moist. The client is very restless and has scant urine output. Oxygen is being administered at 2 L/min, and a saline lock is in place. Which intervention should the nurse implement first? A. Measure the urine specific gravity B. Obtain IV fluids for infusion per protocol C. Prepare for insertion of a central venous catheter D. Auscultate the client's breath sounds
Answer: B The client is at risk for hypovolemic shock because of the postoperative status and is exhibiting early signs of shock. A priority intervention is the initiation of IV fluids (B) to restore tissue perfusion. (A, C, and D) are all important interventions, but are of less priority than (B).
A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last 2 hours. Which action should the nurse take first? A. Irrigate the nasogastric tube with sterile normal saline. B. Reposition the client on her side. C. Advance the nasogastric tube 5 cm. D. Administer an intravenous antiemetic as prescribed.
Answer: B The immediate priority is to determine if the tube is functioning correctly, which would then relieve the client's nausea. The least invasive intervention, repositioning the client (B), should be attempted first, followed by (A and C), unless either of these interventions is contraindicated. If these measures are unsuccessful, the client may require (D).
When assigning clients on a medical-surgical floor to an RN and a PN, it is best for the charge nurse to assign which client to the PN? A. A young adult with bacterial meningitis with recent seizures B. An older adult client with pneumonia and viral meningitis C. A female client in isolation with meningococcal meningitis D. A male client 1 day postoperative after drainage of a brain abscess
Answer: B The most stable client is (B). (A, C, and D) are all at high risk for increased intracranial pressure and require the expertise of the RN for assessment and management of care.
The nurse teaches a client with type 2 diabetes nutritional strategies to decrease obesity. Which food item(s) chosen by the client indicates understanding of the teaching? (Select all that apply.) A. White Bread B. Salmon C. Broccoli D. Whole Milk E. Banana
Answer: B, C, and E (B, C, and E) provide fresh fruits, lean meats and fish, vegetables, whole grains, and low-fat dairy products. All are recommended by the American Diabetes Association (ADA) and are a part of the My Plate guidelines recommended by the U.S. Department of Agriculture (USDA). Whole milk (D) is high in fat and is not recommended by ADA. White bread is milled, a process that removes the essential nutrients. It should be avoided for weight loss and is a poor choice for the client with diabetes (A).
The nurse is assessing a male client with acute pancreatitis. Which finding requires the most immediate intervention by the nurse? A. The client's amylase level is three times higher than the normal level. B. While the nurse is taking the client's blood pressure, he has a carpal spasm. C. On a 1 to 10 scale, the client tells the nurse that his epigastric pain is at 7. D. The client states that he will continue to drink alcohol after going home.
Answer: C A positive Trousseau sign (B) indicates hypocalcemia and always requires further assessment and intervention, regardless of the cause (40% to 75% of those with acute pancreatitis experience hypocalcemia, which can have serious, systemic effects). A key diagnostic finding of pancreatitis is serum amylase and lipase levels that are two to five times higher than the normal value (A). Severe boring pain is an expected symptom for this diagnosis (C), but dealing with the hypocalcemia is a priority over administering an analgesic. Long-term planning and teaching (D) do not have the same immediate importance as a positive Trousseau sign.
In assessing a client with an arteriovenous (AV) shunt who is scheduled for dialysis today, the nurse notes the absence of a thrill or bruit at the shunt site. What action should the nurse take? A. Advise the client that the shunt is intact and ready for dialysis as scheduled. B. Encourage the client to keep the shunt site elevated above the level of the heart. C. Notify the health care provider of the findings immediately. D. Flush the site at least once with a heparinized saline solution.
Answer: C Absence of a thrill or bruit indicates that the shunt may be obstructed. The nurse should notify the health care provider (C) so that intervention can be initiated to restore function of the shunt. (A) is incorrect. (B) will not resolve the obstruction. An AV shunt is internal and cannot be flushed (D) without access using special needles.
In assessing a client diagnosed with primary aldosteronism, the nurse expects the laboratory test results to indicate a decreased serum level of which substance? A. Sodium B. Phosphate C. Potassium D. Glucose
Answer: C Clients with primary aldosteronism exhibit a profound decline in serum levels of potassium (C); hypokalemia; hypertension is the most prominent and universal sign. The serum sodium level is normal or elevated, depending on the amount of water resorbed with the sodium (A). (B) is influenced by parathyroid hormone (PTH). (D) is not affected by primary aldosteronism.
During report, the nurse learns that a client with tumor lysis syndrome is receiving an IV infusion containing insulin. Which assessment should the nurse complete first? A. Review the client's history for diabetes mellitus. B. Observe the extremity distal to the IV site. C. Monitor the client's serum potassium and blood glucose levels. D. Evaluate the client's oxygen saturation and breath sounds.
Answer: C Clients with tumor lysis syndrome may experience hyperkalemia, requiring the addition of insulin to the IV solution to reduce the serum potassium level. It is most important for the nurse to monitor the client's serum potassium and blood glucose levels to ensure that they are not at dangerous levels (C). (A, B, and D) provide valuable assessment data but are of less priority than (C).
Which data would the nurse expect to find when reviewing laboratory values of an 80-year-old man who is in good health overall? A. Complete blood count reveals increased white blood cell (WBC) and decreased red blood cell (RBC) counts. B. Chemistries reveal an increased serum bilirubin level with slightly increased liver enzyme levels. C. Urinalysis reveals slight protein in the urine and bacteriuria, with pyuria. D. Serum electrolytes reveal a decreased sodium level and increased potassium level.
Answer: C In older adults, the protein found in urine slightly rises, probably as a result of kidney changes or subclinical urinary tract infections, and clients frequently experience asymptomatic bacteriuria and pyuria as a result of incomplete bladder emptying (C). Laboratory findings in (A, B, and D) are not considered to be normal findings in an older adult.
When a nurse assesses a client receiving total parenteral nutrition (TPN), which laboratory value is most important for the nurse to monitor regularly? A. Albumin B. Calcium C. Glucose D. Alkaline phosphate
Answer: C TPN solutions contain high concentrations of glucose, so the blood glucose level is often monitored as often as q6h because of the risk for hyperglycemia (C). (A) is monitored periodically because an increase in the albumin level, a serum protein, is generally a desired effect of TPN. (B) may be added to TPN solutions, but calcium imbalances are not generally a risk during TPN administration. (D) may be decreased in the client with malnutrition who receives TPN, but abnormal values, reflecting liver or bone disorders, are not a common complication of TPN administration.
What is the correct location for placement of the hands for manual chest compressions during cardiopulmonary resuscitation (CPR) on the adult client? A. Just above the xiphoid process, on the upper third of the sternum B. Below the xiphoid process, midway between the sternum and the umbilicus C. Just above the xiphoid process, on the lower third of the sternum D. Below the xiphoid process, midway between the sternum and the first rib
Answer: C The correct placement of the hands for chest compressions in CPR is just above the notch where the ribs meet the sternum on the lower part of the sternum (C). (A) is too high. (B) would not compress the heart. (D) would likely cause damage to both structures, possibly causing a puncture of the heart, and would not render effective compressions.
The nurse includes frequent oral care in the plan of care for a client scheduled for an esophagogastrostomy for esophageal cancer. This intervention is included in the client's plan of care to address which nursing diagnosis? A. Fluid volume deficit B. Self-care deficit C. Risk for infection D. Impaired nutrition
Answer: C The primary reason for performing frequent mouth care preoperatively is to reduce the risk of postoperative infection (C) because these clients may be regurgitating retained food particles, blood, or pus from the tumor. Meticulous oral care should be provided several times a day before surgery. Although oral care will be of benefit to the client who may also be experiencing (A, B, or D), these problems are not the primary reason for the provision of frequent oral care.
A home health nurse knows that a 70-year-old male client who is convalescing at home following a hip replacement is at risk for developing pressure ulcers. Which physical characteristic of aging puts the client at risk? A. 16% increase in overall body fat B. Reduced melanin production C. Thinning of the skin, with loss of elasticity D. Calcium loss in the bones
Answer: C Thin nonelastic skin (C) is an important factor in pressure formation. The proportion of body fat to lean mass increases with age (A) and might help decrease ulcer tendency. (B) causes gray hair. (D) can contribute to broken bones, but it is probably not a factor in pressure ulcer formation.
A central venous catheter has been inserted via a jugular vein, and a radiograph has confirmed placement of the catheter. A prescription has been received for a medication STAT, but IV fluids have not yet been started. Which action should the nurse take prior to administering the prescribed medication? A. Assess for signs of jugular venous distention B. Obtain the needed intravenous solution C. Flush the line with heparinized solution D. Flush the line with normal saline
Answer: D Medication can be administered via a central line without additional IV fluids. The line should first be flushed with a normal saline solution (D) to ensure patency. Insufficient evidence exists on the effectiveness of flushing catheters with heparin (C). (A) will not affect the decision to administer the medication and is not a priority. Administration of the medication STAT is of greater priority than (B).
The nurse is assessing a client who presents with jaundice. Which assessment finding is most important for the nurse to follow up? A. Urine specific gravity of 1.03 B. Frothy, tea-colored urine C. Clay-colored stools D. Elevated serum amylase and lipase levels
Answer: D Obstructive cholelithiasis and alcoholism are the two major causes of pancreatitis, and elevated serum amylase and lipase levels (D) indicate pancreatic injury. (A) is a normal finding. (B and C) are expected findings related to jaundice.
A 77-year-old female client is admitted to the hospital with confusion and anorexia of several days' duration. She has symptoms of nausea and vomiting and is currently complaining of a headache. The client's pulse rate is 43 beats/min. The nurse is most concerned about the client's history related to which medication? A. Warfarin (Coumadin) B. Ibuprofen (Motrin) C. Nitroglycerin (Nitrostat) D. Digoxin (Lanoxin)
Answer: D Older persons are particularly susceptible to the buildup of cardiac glycosides, such as digoxin (Lanoxin) or digitoxin (medications derived from digitalis) (D), to a toxic level in their systems. Toxicity can cause anorexia, nausea, vomiting, diarrhea, headache, and fatigue. (A, B, and C) are unlikely to result in the symptoms described.
The nurse receives the client's next scheduled bag of TPN labeled with the additive NPH insulin. Which action should the nurse implement? A. Hang the solution at the current rate. B. Refrigerate the solution until needed. C. Prepare the solution with new tubing. D. Return the solution to the
Answer: D Rationale: Only regular insulin is administered by the IV route, so the TPN solution containing NPH insulin should be returned to the pharmacy (D). (A, B, and C) are not indicated because the solution should not be administered.
A client with type 2 diabetes takes metformin (Glucophage) daily. The client is scheduled for major surgery requiring general anesthesia the next day. The nurse anticipates which approach to manage the client's diabetes best while the client is NPO during the perioperative period? A. NPO except for metformin and regular snacks B. NPO except for oral antidiabetic agent C. Novolin N insulin subcutaneously twice daily D. Regular insulin subcutaneously per sliding scale
Answer: D Regular insulin dosing based on the client's blood glucose levels (sliding scale) is the best method to achieve control of the client's blood glucose while the client is NPO and coping with the major stress of surgery (D). (A) increases the risk of vomiting and aspiration. (B and C) provide less precise control of the blood glucose level.
A client with cirrhosis develops increasing pedal edema and ascites. Which dietary modification is most important for the nurse to teach this client? A. Avoid high-carbohydrate foods B. Decrease intake of fat-soluble foods C. Decrease caloric intake D. Restrict salt and fluid intake
Answer: D Salt and fluid restrictions are the first dietary modifications for a client who is retaining fluid as manifested by edema and ascites (D). (A, B, and C) will not affect fluid retention.
The nurse is assessing a 75-year-old client for symptoms of hyperglycemia. Which symptom of hyperglycemia is an older adult most likely to exhibit? A. Polyuria B. Polydipsia C. Weight loss D. Infection
Answer: D Signs and symptoms of hyperglycemia in older adults may include fatigue, infection (D), and evidence of neuropathy (e.g., sensory changes). The nurse needs to remember that classic signs and symptoms of hyperglycemia, such as (A, B, and C) and polyphagia, may be absent in older adults.
An older client is admitted with a diagnosis of bacterial pneumonia. Which symptom should the nurse report to the health care provider after assessing the client? A. Leukocytosis and febrile B. Polycythemia and crackles C. Pharyngitis and sputum production D. Confusion and tachycardia
Answer: D The onset of pneumonia in the older client may be signaled by general deterioration, confusion, increased heart rate, and/or increased respiratory rate (D). (A, B, and C) are often absent in the older client with bacterial pneumonia.
