Adult Health HESI Review
Place the steps of the infection cycle in the order in which an infection would occur: - Portal of entry - Reservoir - Infectious agent - Susceptible host - Means of transmission - Portal of exit
1. Portal of exit 2. Infectious agent 3. Means of transmission 4. Reservoir 5. Portal of entry 6. Susceptible host
A client with multiple sclerosis and muscle spasms receives a prescription for baclofen (Kemstro) 30 mg PO daily. The medication is supplied from the pharmacy in 20 mg scored tablets. How many tablets should the nurse administer?
1.5 tablets
The healthcare provider prescribes a continuous feeding of half strength Osmolite® 240 mL to be infused every 4 hours for a client with a gastrostomy tube (GT). The nurse should program the enteral pump to deliver how many mL/hr?
60 mL/hr
A nurse displays a need for further education when stating which of the following in regards to the use of restraints? a. "Placing soft wrist restraints is a harmless intervention" b. "Alternatives to restraints should be attempted before use" c. "Restraints should be placed if a patient's actions interrupt therapy" d. "A restraint must be ordered by a healthcare practitioner"
a. "Placing soft wrist restraints is a harmless intervention" ** Restraint are NEVER harmless -- should not be used
A new nurse is caring for a patient who is undergoing chemotherapy for cancer. The patient is becoming malnourished because nothing tastes good. Which recommendation by the nurse will be most appropriate for this patient? a. "Rinse your mouth several times a day to hydrate your taste buds" b. "Avoid adding spices or lemon juice to food to prevent nausea" c. "Blend foods together in interesting flavor combinations" d. "Eat soft foods that are easy to chew and swallow"
a. "Rinse your mouth several times a day to hydrate your taste buds" **Stroke/aspiration: soft mechanical feeding
A client is receiving DSW 1,000 mL at 75 mL/hr. Nurse hangs the bag of IV fluids at 0300. At what time, based on the 24-hour clock, should the infusion be completed? a. 1620 b. 1630 c. 420 d. 430
a. 1620
Amoxicillin 500 mg PO every 8 hours is prescribed for a client with an infection. The drug is available in a suspension of 125 mg/5mL. How many mL should the nurse administer with each dose? a. 20 mL b. 4 mL c. 100 mL d. 10 mL
a. 20 mL
The standing orders for a patient include acetaminophen 650 mg every 4 hours PRN for headache. After assessing the patient, the nurse identifies the need for headache relief and determines that the patient has not had acetaminophen in the past 4 hours. Which action will the nurse take next? a. Administer the acetaminophen b. Notify the health care provider to obtain a verbal order c. Direct the nursing assistant personnel to give the acetaminophen d. Perform a pain assessment only after administering the acetaminophen
a. Administer the acetaminophen
A client with pneumonia has a decrease in oxygen saturation from 94% to 80% while ambulating. Based on these findings, which intervention should the nurse implement first? a. Assist the ambulating client back to the bed b. Encourage the client to ambulate to resolve pneumonia c. Obtain a prescription for portable oxygen while ambulating d. Move the oximetry probe from the finger to the earlobe
a. Assist the ambulating client back to the bed THEN reassess → possibility for emboli
The nurse plans to obtain health assessment information from a primary source. Which option is a primary source for the completion of the health assessment? a. Client b. Healthcare provider c. A family member d. Previous medical records
a. Client
While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do? a. Consider cultural differences during this assessment b. Ask the patient to make eye contact to determine her effect c. Continue with the interview and document at the patient is depressed d. Notify the healthcare provider to recommend a psychological evaluation
a. Consider cultural differences during this assessment
A nurse is describing the therapeutic effects of imagery. Which information should the nurse include in the teaching session? Select all that apply. a. Controls pain b. Decreases nightmares c. Improves social anxiety disorders d. Helps with irritable bowel syndrome e. Replaces relapses in alcohol treatment
a. Controls pain b. Decreases nightmares d. Helps with irritable bowel syndrome **Social anxiety disorders are different than anxiety disorders ** IBS - linked to anxiety, imagery calms
The nurse is reviewing a patient's database for significant changes and discovers that the patient has not voided in over 8 hours. The patient's kidney function lab results are abnormal, and the patient's oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review? a. Diagnosis b. Planning c. Implementation d. Evaluation
a. Diagnosis
A patient continues to report post-surgical incision pain at a level of a 9 out of 10 after pain medicine is given. The next dose of pain medicine is not due for another hour. What should the critical thinking nurse do first? a. Explore other options for pain relief b. Discuss the surgical procedure and reason for the pain c. Explain to the patient that nothing else has been ordered d. Offer to notify the healthcare provider after morning rounds are completed
a. Explore other options for pain relief
A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every 4 hours as needed. Which action should the nurse implement? a. Give an around-the-clock schedule for administration of analgesics b. Administer analgesic medication as needed when the pain is severe c. Provide medication to keep the client sedated and unaware of stimuli d. Offer a medication-free period so that the client can do daily activities
a. Give an around-the-clock schedule for administration of analgesics
The nurse is caring for a patient who is recovering from a traumatic brain injury and frequently becomes disoriented to everything except location. Which nursing intervention will the nurse add to the care plan to reduce confusion? a. Keep a day-by-day calendar at the patient's bedside. b. Place a patient observer in the patient's room for safety c. Assess a patient's level of consciousness and document every 4 hours d. Prepare to discharge once the patient is awake, alert, and oriented
a. Keep a day-by-day calendar at the patient's bedside Reorient patient to name, date/time, etc. !!
A patient asks the nurse for a non-medical approach to excessive worry and work stress. Which therapy should the nurse recommend? a. Meditation b. Acupuncture c. Ayurvedic herbs d. Chiropractic care
a. Meditation
A nurse is preparing to give medications through a nasogastric feeding tube. Which nursing action should prevent complications during administration? a. Mix each medication individually b. Use sterile gloves for the procedure c. Monitor vital signs before giving medications d. Mix all medications together to facilitate administration
a. Mix each medication individually
The Unlicensed Assistive Personnel (UAP) notifies the nurse that the blood pressure on a patient is 160/90. What is the appropriate nursing intervention? Select all that apply. a. Obtain a repeat blood pressure reading b. Obtain a HR and pulse measurement c. Do nothing, the BP is within normal limits d. Ask the UAP if they have received proper training on BP measurements e. Take a coffee break, you deserve it!
a. Obtain a repeat blood pressure reading b. Obtain a HR and pulse measurement d. Ask the UAP if they have received proper training on BP measurements
A nurse is developing a care plan for a patient prescribed bed rest as a result of a pelvic fracture. Which goal statement is realistic for the nurse to assign to this patient? a. Patient will increase activity level this shift b. Patient will turn side to back to side with assistance every 2 hours c. Patient will use the walker correctly to ambulate to the bathroom as needed d. Patient will use a sliding board correctly to transfer to the bedside commode as needed
a. Patient will increase activity level this shift ** Usually don't turn with pelvic fractures -- could displace it ** Sliding board: complicated, patient won't be able to do on own, requires more than one person
A Native American patient is asking for a spiritual healer. Which person should the nurse try to contact for the patient? a. Shaman b. Vitalist c. Ayurvedic d. Curanderismo
a. Shaman
The nurse is caring for a patient with conductive hearing loss resulting from prolonged cerumen impaction. Which intervention by the nurse is most important in establishing effective communication with the patient? a. Speaking with hands, face, and expressions b. Using a loud voice, enunciating every syllable c. Having direct conversations with the patient in the affected ear d. Repeating the phrase again, if the patient does not understand what the nurse said
a. Speaking with hands, face, and expressions
A patient is diagnosed with influenza and is placed on droplet precautions. The nurse understands the need for which of the following PPE before entering the room of the patient? a. Surgical mask b. N95 c. Gloves and gowns d. Goggles
a. Surgical mask - N95: Airborne (TB, measles, etc.) - Gloves: everyone - Gowns: bodily fluid - Goggles: possible splashes
The nurse witnesses the signature of a client who has signed an informed consent. Which statement best explains this nursing responsibility? a. The client voluntarily signed the form b. The client fully understands the procedure c. The client agrees with the procedure to be done d. The client authorizes continued treatment
a. The client voluntarily signed the form
A patient is recovering from surgery 1 day ago, and complains about abdominal pain at the surgical site. His vital signs are within normal limits. The nurse should consider which of the following interventions? a. Wait for an hour and if the patient still has pain, administer the prescribed pain medication b. Administer the prescribed pain medication c. Give half of the prescribed pain medication to avoid addiction d. Get him OOB so the pain will subside
b. Administer the prescribed pain medication ** DO NOT withhold pain meds!
A patient visiting with family members in the waiting area tells the nurse "I don't feel good, especially in the stomach." What should the nurse do ? a. Request that the family leave, so the patient can rest b. Ask the patient to return to the room, so the nurse can inspect the abdomen c. Ask the patient when the last bowel movement was and to lie down on the sofa d. Tell the patient that the dinner tray will be ready in 15 minutes and that may help the stomach feel better
b. Ask the patient to return to the room, so the nurse can inspect the abdomen
On admission, a client presents a signed living will that includes a Do-Not-Resuscitate (DNR) prescription. When the client stops breathing, the nurse performs cardiopulmonary resuscitation (CPR) and successfully revives the client. What legal issues could be brought against the nurse? a. Assault b. Battery c. Malpractice d. False imprisonment
b. Battery Assault vs. battery: Assault = threat - "I'm going to kick your ass" → ASSAULT Battery = physical action - "I'm going to get a bat and do it" → BATTERY
The patient database reveals that a patient has decreased oral intake, decreased oxygen saturation when ambulating, reports of shortness of breath when getting out of bed, and a productive cough. Which elements will the nurse identify as defining characteristics for the diagnostic label of activity intolerance? a. Increase oral intake and decreased oxygen saturation when ambulating b. Decreased oxygen saturation when ambulating and reports of shortness of breath when getting out of bed c. Reports of shortness of breath when getting out of bed and a productive cough d. Productive cough and decreased oral intake
b. Decreased oxygen saturation when ambulating and reports of shortness of breath when getting out of bed
An elderly male client who suffered a cerebral vascular accident is receiving tube feedings via a gastrostomy tube. The nurse knows that the best position for this client during the administration of the feedings is: a. Prone b. Fowler's c. Sims' d. Supine
b. Fowler's - Prone: on stomach - Fowler's: sitting up - Sims': on stomach w/ leg bent, used for enemas - Supine: on back
Three days following surgery, male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that the stoma is much bigger than he expected. What is the best response by the nurse? a. Reassure the client that he will become accustomed to the stoma appearance in time b. Instruct the client that the stoma will become smaller when the initial swelling diminishes c. Offer to contact a member of the local ostomy support group to help him with his concerns d. Encourage the client to handle the stoma equipment to gain confidence with the procedure
b. Instruct the client that the stoma will become smaller when the initial swelling diminishes
A nurse provides immunization to children and adults through the public health department. Which type of health care is the nurse providing? a. Primary care b. Preventive care c. Restorative care d. Continuing care
b. Preventive care
The nurse is digitally removing a fecal impaction for a client. The nurse should stop the procedure and take corrective action if which client reaction is noted? a. Temperature increases from 98.8º to 99.0 ºF b. Pulse rate decreases from 78 to 40 beats/min c. Respiratory rate increases from 16 to 24 breaths/min d. Blood pressure increases from 110/84 to 118/88 mm/Hg
b. Pulse rate decreases from 78 to 40 beats/min Heart racing/tachycardia → vagal response→ parasympathetic response slows HR, stimulated by coughing really hard
The nurse is caring for a patient who is having difficulty understanding the written and spoken word. Which type of aphasia will the nurse report to the oncoming shift? a. Expressive b. Receptive c. Global d. Motor
b. Receptive
Which assessment question should the nurse ask to best understand how visual alterations are affecting a patient's self-care ability? a. "Have you stopped reading books or switched to books on audiotape?" b. "What do you do to protect yourself from injury at work?" c. "Are you able to prepare a meal or write a check?" d. "How does your vision impairment make you feel?"
c. "Are you able to prepare a meal or write a check?" IADLs → cooking, grocery shopping, laundry, etc.
A nurse adds the following diagnosis to a patient care plan: Constipation related to decreased gastrointestinal motility secondary to pain medication administration as evidenced by the patient reporting no bowel movement in 7 days, abdominal distention, and abdominal pain. Which element did the nurse write as the defining characteristic? a. Decreased gastrointestinal motility b. Pain medication c. Abdominal distention d. Constipation
c. Abdominal distention Defining characteristics = signs of diagnosis, something you see
A signed consent form indicated a client should have an electrocardiogram, but an echocardiogram was performed instead. Though the echocardiogram revealed Cause of the client's chest pain, which was subsequently treated, the client filed a lawsuit against the nurse and healthcare provider for performing the incorrect procedure. The court is likely to rule in favor of the plaintiff because these events represent what in fraction? a. An intentional tort because a similar mistake can happen to anyone b. Failure to respect client autonomy to choose based on intentional tort law c. Assault and battery with deliberate intent to deviate from the consent form d. An unintentional tort because the client benefited from having the echocardiogram
c. Assault and battery with deliberate intent to deviate from the consent form
The nurse is caring for a patient whose insurance coverage is Medicare. The nurse should consider which information when planning care for this patient? a. Capitation provides the hospital with a means of recovering variable charges b. The hospital will be paid for the full cost of the patient's hospitalization c. Diagnosis-related groups (DRGs) provide a fixed reimbursement of cost d. Medicare will pay the national average for the patient's condition
c. Diagnosis-related groups (DRGs) provide a fixed reimbursement of cost
A nurse is using the holistic approach to care. Which goal is the priority? a. Integrate spiritual treatments b. Join physical care with a vegan diet c. Incorporate the mind-body-spirit connection d. Use complementary and alternative therapies
c. Incorporate the mind-body-spirit connection
The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 mL/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take? a. Infuse normal saline at a keep vein open rate b. Discontinue the IV and flush the port with heparin c. Infuse 10 percent dextrose and water at 54 mL/hr d. Obtain a stat blood glucose level and notify the healthcare provider
c. Infuse 10 percent dextrose and water at 54 mL/hr
The nurse prescribes strategies and alternatives to attain expected outcome. Which standard of nursing practice is the nurse following? a. Assessment b. Diagnosis c. Planning d. Implementation
c. Planning
A nurse identifies gaps between local and best practices. Which Quality and Safety Education for Nurses (QSEN) competency is the nurse demonstrating? a. Safety b. Patient-centered care c. Quality improvement d. Teamwork and collaboration
c. Quality improvement
A patient is diaphoretic and unable to follow commands. The nurse feels the patient's skin and determines the patient feels very warm. Which is the best method to obtain a temperature for this client? a. Axillary b. Oral c. Rectal d. Forehead
c. Rectal **UNLESS it's contraindicated (immunosuppressed, fissure/tumor)
The nurse assigns a UAP to obtain vital signs from a very anxious client. What instructions should the nurse give the UAP? a. Remain calm with the client and record abnormal results in the chart b. Notify the medication nurse immediately if the pulse or blood pressure is low c. Report the results of the vital signs to the nurse d. Reassure the client that the vital signs are normal
c. Report the results of the vital signs to the nurse
The nurse is gathering data on a patient. Which data will the nurse report as objective data? a. States "doesn't feel good" b. Reports a headache c. Respirations 16 d. Feels nauseated
c. Respirations 16
The nurse is applying for a position with a home care organization that specializes in spinal cord injury. In which type of health care facility does the nurse want to work? a. Secondary acute b. Continuing c. Restorative d. Tertiary
c. Restorative
A nurse is using the critical thinking skill of evaluation. Which action will the nurse take? a. Examine the meaning of data b. Support findings and conclusions c. Review the effectiveness of nursing actions d. Search for links between the data and the nurse's assumptions
c. Review the effectiveness of nursing actions
The nurse is creating a plan of care for a patient with glaucoma. Which nursing diagnosis will the nurse include in the care plan to address a safety complication of a sensory deficit? a. Body image disturbance b. Social isolation c. Risk for falls d. Fear
c. Risk for falls
An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgment? a. A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes b. The nurse assigned to care for the client who was at lunch at the time of the fall c. The nurse who transferred the client to the chair when the fall occurred d. The charge nurse who completed rounds 30 minutes before the fall occurred
c. The nurse who transferred the client to the chair when the fall occurred
The charge nurse is reviewing outcome statements written by a novice nurse. The nurse is using the SMART approach. Which patient outcome statement will the charge nurse identify as appropriate to the new nurse? a. The patient will ambulate in hallways b. The nurse will monitor the patient's heart rhythm continuously this shift c. The patient will feed self at all mealtimes today without shortness of breath d. The nurse will administer pain medication every 4 hours to keep the patient free from discomfort
c. The patient will feed self at all mealtimes today without shortness of breath ** Outcome statement: look at verbs SMART approach: Specific, Measureable, Attainable, Relevant, and Timely strategy to develop effective and measurable goals
A nurse is caring for a patient in the hospital. When should the nurse begin discharge planning? a. When the patient is ready b. Close to the time of discharge c. Upon admission to the hospital d. After on order is written/prescribed
c. Upon admission to the hospital
An older-adult patient is newly admitted to a skilled nursing facility with the diagnoses of Alzheimer's dementia, lipidemia, and hypertension, and a history of pulmonary embolism. Medications brought on admission include lisinopril (Zestril, Prinivil), hydrochlorothiazide (Microzide), warfarin (Coumadin), low-dose aspirin, ginkgo biloba, and echinacea. What potential interaction will cause the nurse to notify the patient's HCP? a. Echinacea and warfarin b. Lisinopril and echinacea c. Warfarin and ginkgo biloba d. Lisinopril and hydrochlorothiazide
c. Warfarin and ginkgo biloba - Ginkgo biloba: improve memory, circulate blood better, anticoagulant properties ** Interaction: blood too thinned, increase bleeding **All the "G's" make you bleed (herbal medications, and vitamin E) - Echinacea: helps with immune system, take for cold
A patient recovering from a leg fracture after a fall reports having dull pain in the affected leg and rates it as a 7 on a 0-10 scale. The patient is not able to walk around in the room with crutches because of leg discomfort. Which nursing intervention is priority? a. Assess the patient to walk in the room with crutches b. Obtain a walker for the patient c. Consult physical therapy d. Administer pain medication
d. Administer pain medication
Which intervention is the most important for the nurse to implement for a male client who is experiencing urinary retention? a. Apply a condom catheter b. Apply a skin protectant c. Encourage increased fluid intake d. Assess for bladder distention
d. Assess for bladder distention
A patient's plan of care includes the goal of increasing motility this shift. As a patient is ambulating to the bathroom at the beginning of the shift, the patient falls. Which initial action will the nurse take next to most effectively revise the plan of care? a. Consult physical therapy b. Establish a new plan of care c. Set new priorities for the patient d. Assess the patient
d. Assess the patient
A couple is with their adolescent daughter for a school physical and state that they are worried about all of the safety risks affecting this age. What are the greatest risks for injury for an adolescent? a. Home accidents b. Physiological changes of aging c. Poisoning and child abduction d. Automobile accidents, suicide, and substance abuse
d. Automobile accidents, suicide, and substance abuse
A nurse is teaching a patient about the use of biofeedback. Which goal should the nurse add to the care plan? a. Opens emotional channels b. Uses music to calm the mind c. Holds various postures with breathing d. Controls autonomic physiological functions
d. Controls autonomic physiological functions
A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write? a. Ineffective breathing pattern related to pneumonia b. Risk for infection related to chest x-ray procedure c. Risk for deficient fluid volume the related to dehydration d. Impaired gas exchange related to alveolar-capillary membrane changes
d. Impaired gas exchange related to alveolar-capillary membrane changes ** Never include "pneumonia" or any medical diagnoses in the nursing diagnosis!!
A patient complains about feeling dizzy after moving from the bed to the chair. What is the nurse's priority action? a. Reassuring the patient b. Stabilizing the patient in the chair c. Moving the patient back to the bed right away d. Obtaining a blood pressure
d. Obtaining a blood pressure
The nurse is caring for a patient with expressive aphasia from a traumatic brain injury. Which goal will the nurse include in the plan of care? a. Patient will carry a pen and a pad of paper around for communication b. Patient will recover full use of speech vocabulary in 1 day c. Patient will thicken drinks to prevent aspiration d. Patient will communicate nonverbally
d. Patient will communicate nonverbally
The nurse is performing naso-tacheal suctioning. After suctioning their clients trachea for 15 seconds, large amounts of thick yellow secretions return. What action should the nurse implement next? a. Encourage the client to cough to help loosen secretions b. Advise a client to increase the intake of oral fluids c. Rotate the suction catheter to obtain any remaining secretions d. Re-oxygenate the client before attempting to section again
d. Re-oxygenate the client before attempting to section again
A patient describes practicing a complementary and alternative therapy involving breathwork and yoga. The nurse recommends using energy field therapies. Which techniques did the nurse suggest? a. Prayer and tai chi b. The "zone" and acupressure c. Massage therapy and ayurveda d. Reiki therapy and therapeutic touch
d. Reiki therapy and therapeutic touch Purpose of therapeutic touch: to identify energy obstructions
An older-adult patient has extensive wound care needs after discharge from the hospital. Which facility should the nurse discuss with the patient? a. Hospice b. Respite care c. Assisted living d. Skilled nursing
d. Skilled nursing
A nurse working in a community hospital's emergency department provides care to a patient having chest pain. Which level of care is the nurse providing? a. Continuing care b. Restorative care c. Preventative care d. Tertiary care
d. Tertiary care - Continuing care: available within institutional settings (e.g. nursing centers or nursing homes, group homes, and retirement communities), communities (e.g. adult day care and senior centers), or the home (e.g. home care, home-delivered meals, and hospice). - Restorative care: patients recovering from an acute or chronic illness or disability often require additional services (restorative care) to return to their previous level of function or reach a new level of function limited by their illness or disability. - Preventative care: more disease oriented and focused on reducing and controlling risk factors for disease through activities such as immunization and occupational health programs. - Tertiary care: Hospital emergency departments, urgent care centers, critical care units, and inpatient medical-surgical units provide secondary and tertiary levels of care
Which action by a nurse indicates application of the critical thinking model to make the best clinical decisions ? a. Drawing on past clinical experiences to formulate standardized care plans b. Relying on recall of information from past lectures and textbooks c. Depending on the charge nurse to determine priorities of care d. Using the nursing process
d. Using the nursing process
You have delegated vital signs to assistive personnel (AP). The assistant informs you that the patient has just finished a bowl of hot soup. The nurse's most appropriate advice would be to: a. Take a rectal temperature b. Take the oral temperature as planned c. Advise the patient to drink a glass of cold water d. Wait 30 min and take an oral temperature
d. Wait 30 min and take an oral temperature
