HESI 2022

A client is prone to hyponatremia. Which factors would the nurse identify that can precipitate hyponatremia? Select all that apply. One, some, or all responses may be correct. a. wound drainage b. diuretic therapy c. GI suction d. parenteral infusion of 0.9% sodium chloride e. inappropriate anti-diuretic hormone (ADH) secretions

a, b, c, e Wound drainage can result in hyponatremia from loss of sodium ions. Most diuretics interfere with sodium reabsorption in the nephrons and have the side effect of hyponatremia. Gastrointestinal fluids are rich in sodium ions, which are lost by GI suction. With the syndrome of inappropriate antidiuretic hormone (SIADH), high levels of the antidiuretic hormone (ADH) are produced, causing the body to retain water instead of excreting it normally in the urine. Parenteral infusion of 0.9% sodium chloride, an isotonic solution, should be compatible with body fluids; if given in excess, it may lead to hypernatremia.

A client with schizophrenia takes ziprasidone. Which conditions in the client may indicate a need to discontinue the medication? Select all that apply. One, some, or all responses may be correct. a. leukoenia b. tachycardia c. hypokalemia d. hypermagnesemia e. prolonged QT interval

a, c, e Ziprasidone is a second-generation antipsychotic medication indicated for schizophrenia. The medication may cause leukopenia, hypokalemia, and hypomagnesemia. This medication may cause a prolonged QT interval, which indicates torsades de pointes. Bradycardia may occur in torsades de pointes but not tachycardia.

Which statements made by the client identify regulatory functions of the kidney? Select all that apply. One, some, or all responses may be correct. a. erhtropoiesis b. acid base balance c. vitamin D activation d. blood pressure control e. fluid and electrolyte balance

b, e Maintaining the acid-base balance of the body by selectively reabsorbing and secreting certain substances from the blood is a regulatory function of the kidneys. The kidneys also perform the regulatory function of electrolyte balance by regulating the reabsorption of certain electrolytes while eliminating others depending on their levels in the serum. The kidneys perform hormonal function by secreting a hormone called erythropoietin that aids in synthesis of red blood cells (erythropoiesis). Activation of vitamin D is a hormonal function of the kidneys. The kidneys perform hormonal function by secreting the hormone renin that assists in blood pressure control.

For which clinical indicator associated with a complication of portal hypertension would the nurse assess the client? a. liver abcess b. intestinal obstruction c. perforation of the duodenum hemorrhage from esophageal varices

c. The increased pressure within the portal circulatory system causes increased pressure in areas of portal systemic collateral circulation (most importantly, in the distal esophagus and proximal stomach). Hemorrhage is a possible complication. Liver abscesses may occur as a complication of intestinal infections, not portal hypertension. Intestinal obstruction may be caused by manipulation of the bowel during surgery, peritonitis, neurological disorders, or organic obstruction, not portal hypertension. Perforation of the duodenum usually is caused by peptic ulcers; it is not a direct result of portal hypertension or cirrhosis.

Oral iron supplements patient education should include...

- should be given on an empty stomach between meals for best absorption - if a child is old enough, the supplements should be offered with citrus fruit juice as vitamin C will increase absorption - milk and products and antacids also decrease absorption of oral iron and should be avoided for 2 hours after administration - iron supplements may cause constipation and dark green, tarry stools - liquid iron can stain teeth and so are administered with a medicine dropper toward the back of the infants cheek

Which statement describes a client's tidal volume? 1 Tidal volume is the volume of air inhaled and exhaled with each breath. 2 Tidal volume is the amount of air remaining in the lungs after forced expiration. 3 Tidal volume is the additional air forcefully inhaled after normal inhalation. 4 Tidal volume is the additional air forcefully exhaled after normal exhalation.

1

The nurse understands which medication increases the risk of Reye syndrome in children? 1 Aspirin 2 Naloxone 3 Ibuprofen 4 Acetaminophen

1 Aspirin increases the risk of Reye syndrome in children. Naloxone, ibuprofen, and acetaminophen can be used, but the child should be assessed for renal and liver functioning before prescribing.

A blood transfusion is prescribed for a child with acute lymphocytic leukemia (ALL). Which intervention will the nurse implement during the administration of the blood product? 1 Infuse the blood over no more than 4 hours. 2 Take the vital signs 3 hours after the transfusion. 3 Check the vital signs 15 minutes after starting the transfusion. 4 Have the blood warm at room temperature for 1 hour before administration.

1 Blood should be administered within 4 hours; the risk for bacterial proliferation increases over time and exposure to room temperature. Taking the vital signs 3 hours after the transfusion is too long to wait; the vital signs should be checked every 5 minutes during the absorption of the first 50 mL of blood and then routinely thereafter (every 15 minutes to 1 hour, depending on hospital policy). Vital signs must be checked every 5 minutes during the administration of the first 50 mL of blood to detect a transfusion reaction. Blood should be used within 30 minutes after its arrival from the blood bank; the risk for bacterial proliferation increases over time and exposure to room temperature.

A health care provider prescribes B-complex vitamins. Which information will the nurse teach the client? 1 The vitamins may turn the urine bright yellow. 2 The daily fluid intake should be increased. 3 The vitamins should be taken on an empty stomach. 4 Taking the vitamins with a high-fat meal will increase absorption.

1 Bright yellow urine is an expected, insignificant side effect of vitamin B complex. There is no need to increase oral fluids; the client may consume the usual daily intake of fluid. Taking the vitamins on an empty stomach may precipitate nausea; therefore they should be taken with food. Vitamin B complex is a water-soluble vitamin, and excess amounts are excreted in urine. Taking the vitamins with a fatty meal will not improve absorption.

Which malnourished condition may predispose a client to secondary immunodeficiency? 1 Cachexia 2 Cirrhosis 3 Diabetes mellitus 4 Hodgkin lymphoma

1 Cachexia is a nutrition disorder that may occur because of wasting of muscle mass and weight, resulting in a secondary immunodeficiency disorder. Cirrhosis, diabetes mellitus, and Hodgkin lymphoma also lead to secondary immunodeficiency disorder, but these are not malnutrition disorders.

Which type of hepatitis virus spreads through contaminated food and water? 1 Hepatitis A virus 2 Hepatitis B virus 3 Hepatitis C virus 4 Hepatitis D virus

1 Hepatitis A virus spreads through contaminated food and water. Hepatitis B, C, and D viruses spread through contaminated needles, syringes, and blood products.

Which organism is a common opportunistic infection in a client infected with human immunodeficiency virus (HIV)? 1 Oropharyngeal candidiasis 2 Cryptosporidiosis 3 Toxoplasmosis encephalitis 4 Pneumocystis jiroveci pneumonia

1 Oropharyngeal candidiasis is the most common infection associated with HIV because the immune system can no longer control Candida fungal growth. Pneumocystis jiroveci pneumonia (PCP) is more common in a client infected with acquired immunodeficiency syndrome (AIDS). It causes tachypnea and persistent dry cough. Cryptosporidiosis, an intestinal infection caused by Cryptosporidium organisms, presents in clients with AIDS as does toxoplasmosis encephalitis, which is caused by Toxoplasma gondii and is acquired through contact with contaminated cat feces or by ingesting infected undercooked meat.

Which hormone is released from the posterior pituitary gland? 1 Oxytocin 2 Prolactin 3 Growth hormone 4 Luteinizing hormone

1 Oxytocin is released from the posterior pituitary gland, which acts on the uterus and mammary glands. Prolactin, growth hormone, and luteinizing hormone are produced by the anterior pituitary gland.

A medical-surgical nurse completes the admission assessment on a client diagnosed with a urinary tract infection. The client's admitting weight is 165 lb (74.8 kg). The vital signs are: temperature 96°F (35.6°C), pulse 110 beats per minute, respirations 20 per minute, and blood pressure 88/56 mm Hg. The client received 3 L of normal saline in the emergency department. The total urine output for the past 2 hours was 20 mL via a urinary drainage system. Which intervention would the nurse recommend to the primary health care provider? 1 Transfer the client to a critical care unit. 2 Discontinue the urinary catheter immediately. 3 Administer another 1 L bolus of sodium chloride. 4 Begin a dopamine hydrochloride drip for renal perfusion.

1 The client has a known infection, is exhibiting signs of sepsis, and is unresponsive to fluid therapy as evidenced by the low blood pressure. The client is showing signs of renal failure. The client is manifesting probable signs of septic shock requiring a higher level of care. This question requires the medical/surgical nurse to synthesize the client's manifestations and make an evaluation of the need for more invasive care than is available on the admitting unit. Giving another fluid is plausible, but this client weighs 75 kg, requiring a maximum of 3 L of fluid to be given before a diagnosis of severe sepsis. The client requires more invasive monitoring than can be done on a medical/surgical unit to determine if more fluid or vasopressors are required. The urinary catheter is necessary to continue monitoring the urine output in this acute client.

The nurse identifies that a client's urinary output is less than 40 mL/h over the past 3 hours. Which action would the nurse take? 1 Assess breath sounds and obtain vital signs. 2 Decrease the intravenous flow rate and increase oral fluids. 3 Insert an indwelling catheter to facilitate emptying of the bladder. 4 Check for dependent edema by assessing the lower extremities

1 The imbalance in intake and output, with a decreasing urinary output, may indicate kidney failure. The retention of excess body fluid can precipitate the development of heart failure. Assessing breath sounds and obtaining the vital signs are necessary when monitoring for these complications. In the presence of hypervolemia, oral and intravenous fluid intake should be decreased. There are no data to support a problem with the excretion of urine; the problem is with insufficient production. The insertion of a urinary retention catheter requires a health care provider's prescription. Checking for dependent edema by assessing the lower extremities is an appropriate assessment after respirations and vital signs are assessed.

Which intervention would the nurse implement for a client with Alzheimer disease who has become agitated and aggressive and is incontinent of urine and feces? 1 Manage the behavior. 2 Prevent further deterioration. 3 Focus on the needs of the spouse. 4 Establish an elimination rewards program

1 The nurse would manage the behavior. The client must be kept from harming self or others and needs a calm, supportive environment that meets needs and maintains dignity.

Which urinary diagnostic test does not require any dietary or activity restrictions for the client before or after the test? 1 Renal scan 2 Renal biopsy 3 Renal arteriogram 4 Concentration test

1 A renal scan does not require any dietary or activity restrictions. A renal biopsy requires bed rest for 24 hours after the procedure. A renal arteriogram requires the client to maintain bed rest with affected leg straight. A concentration test requires the client to fast after a given time in the evening.

A high school student arrives at the local blood drive center to donate blood for the first time. As the site is being prepared for needle insertion, the student becomes agitated, starts to hyperventilate, and complains of dizziness and tingling of the hands. Which would the nurse instruct the student to do? 1 Breathe into cupped hands. 2 Pant using rapid, shallow breaths. 3 Use a rapid deep-breathing pattern. 4 Hold the breath for as long as possible.

1 Breathing into cupped hands allows carbon dioxide to reenter the lungs, which will increase the serum bicarbonate level, relieving the respiratory alkalosis that is occurring as a result of hyperventilation.

Which dietary modifications help improve the nutritional status of a client with acquired immunodeficiency syndrome (AIDS)? 1 Refraining from consuming fatty foods 2 Refraining from consuming frequent meals 3 Refraining from consuming high-calorie foods 4 Refraining from consuming high-protein foods

1 Many clients with AIDS become intolerant to fat due to the disease and the antiretroviral medications. The client should be instructed to refrain from consuming fatty foods. The client should be encouraged to eat small and frequent meals to improve nutritional status. High-calorie and high-protein foods are beneficial to clients with AIDS because they provide energy and build immunity.

Which signs would the nurse expect to observe in a client with small cell carcinoma of the lung who develops syndrome of inappropriate antidiuretic hormone (SIADH)? Select all that apply. One, some, or all responses may be correct. 1 Oliguria 2 Seizures 3 Vomiting 4 Polydipsia 5 Polyphagia

1, 2, 3 Cancerous cells of small cell lung cancer can produce antidiuretic hormone, which causes fluid retention, resulting in increased blood volume and decreased urine volume. Fluid retention associated with SIADH can cause cerebral edema, resulting in confusion and seizures. Fluid retention resulting in hyponatremia causes nausea and vomiting. The client will have nausea and vomiting, resulting in a decreased oral fluid and food intake.

Which nursing actions best promote communication when obtaining a nursing history? Select all that apply. One, some, or all responses may be correct. 1 Establishing eye contact 2 Paraphrasing the client's message 3 Asking "why" and "how" questions 4 Using broad, open-ended statements 5 Reassuring the client that there is no cause for alarm 6 Asking questions that can be answered with a "yes" or "no"

1, 2, 4 Eye contact indicates to the client that the nurse is listening and interested. Paraphrasing is an effective interviewing technique; it indicates to the client that the message was heard and invites the client to elaborate further. Open-ended statements provide a milieu in which people can verbalize their problems rather than be placed in a situation of providing a forced response. Asking "why" and "how" questions can be threatening to the client, who may not have the answer to these questions. False reassurance is detrimental to the nurse-client relationship and does not promote communication. Direct questions do not open or promote communication.

Which instruction on infection prevention would the nurse include when providing discharge education to a client who received a cadaveric renal transplant? Select all that apply. One, some, or all responses may be correct. 1 Avoid eating from buffets. 2 Obtain annual flu vaccinations. 3 Perform regular hand hygiene. 4 Stay away from crowded areas. 5 Report a temperature greater than 100.5°F.

1,2,3,4,5 Clients who receive an organ transplant need to take immunosuppressant medications for the rest of their lives to prevent organ rejection. These medications put the client at increased risk for infection. The nurse would provide infection prevention teaching to the client after renal transplant, which would include instructions to avoid eating from buffets, get an annual flu vaccine, practice regular hand hygiene, and avoid crowded areas. Clients would also be instructed to report a temperature greater than 100.5°F to their health care provider as it could indicate infection or organ rejection and requires treatment.

a normal magnesium level is

1.8-2.6

A client has a blood pressure of 90/50 mm Hg during her first visit to the prenatal clinic. On a subsequent visit, at 34 weeks' gestation, her blood pressure is 120/76 mm Hg. Which would the nurse conclude might have caused the change? 1 The presence of chronic hypertension 2 The possible development of preeclampsia 3 An increased stroke volume during the third trimester 4 An expected increase in blood pressure as pregnancy progresses

2 During the second trimester the blood pressure usually decreases and stays lower for the remainder of the pregnancy; an increase in systolic pressure of 30 mm Hg and diastolic pressure of 15 mm Hg warrants close observation for preeclampsia. The client's baseline blood pressure is low, suggesting that the increase in blood pressure is pregnancy related (i.e., gestational hypertension). Increased stroke volume during the third trimester does not cause an increase in blood pressure. An increase in blood pressure of this amount at 34 weeks' gestation is not expected.

Which teaching would the nurse include for parents of an infant with phenylketonuria (PKU)? 1 Testing for PKU is done immediately after birth. 2 Cognitive impairment occurs if PKU is untreated. 3 Treatment for PKU includes lifelong medications. 4 PKU is transmitted by an autosomal dominant gene.

2 In PKU, the absence of the hepatic enzyme phenylalanine hydroxylase prevents metabolism (hydroxylation to tyrosine) of the amino acid phenylalanine. The increased fluid level of phenylalanine in the body and the alternate metabolic by-products (phenylketones) are associated with severe cognitive impairment if PKU is not identified and treated early. Testing for PKU cannot be done until after several days of milk ingestion. Medications are not part of therapy for PKU. PKU is transmitted by an autosomal recessive gene.

A child is prescribed intravenous mannitol. The nurse understands mannitol belongs to which classification of diuretics? 1 Loop 2 Osmotic 3 Potassium sparing 4 Carbonic anhydrase inhibitor

2 Osmotic diuretics, such as mannitol, increase the osmotic pressure of glomerular filtrate and thus decrease absorption of sodium; they are used to treat cerebral edema and increased intraocular pressure.

Chemotherapy via regional perfusion is the treatment of choice for a client's malignant sarcoma of the liver. Which reason would the nurse provide to explain to the client why this method of medication administration probably was selected? 1 Medication therapy can be continued at home with little difficulty. 2 Larger doses of medications can be delivered to the actual site of the tumor. 3 Toxic effects of the chemotherapeutic medications are confined to the area of the tumor. 4 Combinations of medications are used to attack neoplastic cells at various stages of the cell cycle.

2 Regional perfusion therapy permits relative isolation of the tumor area and saturation with the medication(s) selected. This method of medication administration requires medical and nursing supervision and cannot be continued at home. Although toxic effects are confined mainly to the treated area, some migration may still occur. Combinations of chemotherapeutic medications are administered via intravenous or oral routes, not via regional perfusion.

Which clinical manifestation is associated with hypernatremia in burns? 1 Fatigue 2 Seizures 3 Paresthesias 4 Cardiac dysrhythmias

2 Seizures are the clinical manifestation of hypernatremia in burns. Fatigue, paresthesias, and cardiac dysrhythmias are clinical manifestations of hyperkalemia.

Which clinical finding in a newly delivered client requires immediate investigation? 1 An inflamed episiotomy 2 A slow trickle of blood from the vagina 3 An estimated blood loss of half a liter during a vaginal birth 4 A boggy fundus that becomes firm after prolonged massage

2 Vaginal bleeding may be an early sign of hemorrhage; hypovolemic shock can develop. An inflamed episiotomy is an expected finding; ice packs help resolve the inflammation. Expected blood loss for a vaginal birth is 300 to 500 mL. A fundus that has been overstretched or is multiparous may require prolonged massage until it becomes firm.

Which major group of substances in human milk are of special importance to the newborn and cannot be reproduced in a bottle formula? 1 Amino acids 2 Gamma globulins 3 Essential electrolytes 4 Complex carbohydrates

2 The gamma globulin antibodies in human milk provide the infant with immunity against all or most of the pathogens that the mother has encountered. Amino acids and essential electrolytes are present in commercial formulas. Complex carbohydrates are not required by the infant.

A client had a laparoscopic cholecystectomy. Postoperatively, the client experiences nausea and vomiting and is admitted overnight for observation and hydration. What would the nurse include in the teaching plan when preparing this client for discharge? Select all that apply. One, some, or all responses may be correct. 1 Wash the puncture sites with strong soap and hot water daily. 2 Call the health care provider for a fever of 100°F (37.8°C) or higher more for 2 days. 3 Remove the tape strips over the puncture sites 1 week after surgery. 4 Check the puncture sites daily for redness, tenderness, swelling, heat, or drainage. 5 Ease the discomfort from the gas used to insufflate the abdomen during surgery by applying a heating pad to the left shoulder.

2, 4

Which actions would the nurse take to help a client with obsessive-compulsive disorder discuss how anxiety influences feelings and the ability to function? Select all that apply. One, some, or all responses may be correct. 1 Identify manipulative behaviors. 2 Explore anxiety-provoking situations. 3 Introduce the client to socializing situations. 4 Assist the client in examining coping mechanisms. 5 Assess the quality of interpersonal relationships.

2, 4

Which immunomodulatory agent is beneficial for the treatment of clients with multiple sclerosis? 1 Interleukin 2 2 Interleukin 11 3 Beta interferon 4 Alpha interferon

3

After a thoracentesis for pleural effusion, a client returns to an outpatient clinic for a follow-up visit. The nurse suspects a recurrence of pleural effusion when the client makes which statement? 1 "Lately I can only breathe well if I sit up." 2 "During the night I sometimes get the chills." 3 "I get a sharp, stabbing pain when I take a deep breath." 4 "I'm coughing up large amounts of thicker mucus for the past several days."

3 Tension is placed on the pleura at the height of inspiration and causes pain.

The nurse is caring for a client with a 30% total body surface area burn. Which assessment finding indicates that the client's fluid replacement is adequate? 1 Increasing hematocrit level 2 Urinary output of 15 to 20 mL/h 3 Slowing of a previously rapid pulse rate 4 Central venous pressure progressing from 5 to 1 mm Hg

3 The pulse rate is one indicator of optimum vascular fluid volume; the pulse rate decreases as intravascular volume normalizes. An increasing hematocrit level indicates hemoconcentration resulting from hypovolemia. Urinary output of 0.5 to 1 mL/kg/h indicates inadequate kidney perfusion; if adequate, output should be greater than 30 mL/h. Central venous pressure decreasing from 5 to 1 mm Hg indicates hypovolemia.

A 2-year-old child is admitted to the pediatric unit with a diagnosis of bacterial meningitis. Which is the most important safety measure for the nurse to institute immediately after the child has a seizure? 1 Monitoring the child's vital signs 2 Padding the side rails of the toddler's crib 3 Placing the child in the side-lying position 4 Bringing suction equipment to the bedside

3 The side-lying position promotes a patent airway; the tongue can move away from the back of the pharynx, and saliva can flow out of the mouth by gravity. Although monitoring vital signs is important, a patent airway is the priority. The crib sides should have been padded as a part of seizure precautions before the seizure. If the seizure was unexpected and seizure precautions were not previously instituted, they should be instituted after the immediate respiratory and safety needs of the toddler have been met. Suctioning may be unnecessary; the child should not be left alone while equipment is obtained.

Which complication is most likely to occur in the immediate postoperative period after a client has had a splenectomy? 1 Infection 2 Peritonitis 3 Hemorrhage 4 Intestinal obstruction

3 Because the spleen is highly vascular, hemorrhage may occur in the immediate postoperative period. Although risk for some types of infection is higher after splenectomy because of lower immunoglobulin levels, risk for immediate postoperative infection is not higher than usual after splenectomy. Peritonitis is possible after splenectomy, but it would not be apparent in the immediate postoperative period and is not a common complication. The incidence of intestinal obstruction is not higher than for other abdominal surgery, and symptoms would not be apparent in the immediate postoperative period.

normal phosphate levels

3-4.5

A client with laryngeal cancer is receiving chemotherapy. Which laboratory report is most important for the nurse to monitor when considering the effects of chemotherapy? 1 Platelets 2 Hemoglobin level 3 Red blood cell count 4 White blood cell count

4 Antineoplastic medications depress bone marrow, which results in leukopenia; the client must be protected from infection, which is a primary cause of death in the client with cancer. Platelets may decrease rapidly, but complications may be limited by infusions of platelets. Although the hemoglobin level diminishes, a transfusion with packed red blood cells (PRBCs) will alleviate the anemia. RBCs diminish slowly and may be replaced with a transfusion of PRBCs.

Which effect has resulted in the avoidance of tetracycline use in children under 8 years old? 1 Birth defects 2 Allergic responses 3 Severe nausea and vomiting 4 Permanent tooth discoloration

4 Tetracycline use in children under the age of 8 years has been discontinued because it causes permanent tooth discoloration. Birth defects, allergic responses, and severe nausea and vomiting are not prevalent reasons for the discontinuation of tetracycline medications in children under 8 years old.

Which statement will the nurse include when teaching the family of a child with asthma about peak flow meters (PFMs)? 1 "This device measures the peak amount of air that your child can inhale." 2 "This device will improve medication delivery to the lungs when it's used with an inhaler." 3 "Your child should make sure to use a short-acting bronchodilator before using the PFM." 4 "A PFM can help you identify when asthma is getting worse even before your child has symptoms."

4 The PFM is used to measure the maximal amount of exhalation. In doing this, it can identify when airway obstruction is occurring before the obstruction is sufficient to cause symptoms. PFMs are used to measure exhalation, not inhalation. PFMs are not used for medication administration. The use of a PFM should not be preceded by administration of a bronchodilator.

Where is the nurse positioned when performing a Romberg test? 1 Sitting next to the client 2 Standing behind the client 3 Standing in front of the client 4 Standing to the side of the client

4 The nurse would be standing to the side of the client when performing a Romberg test because the client is most likely to sway side to side. Sitting does not safely position the nurse to rescue an unbalanced client. Standing behind or in front of the client is not optimal for safety because the client is most likely to sway side to side.

Which point requires correction regarding the use of restraints? 1 Less restrictive interventions must have been unsuccessful before applying restraints. 2 All other alternatives must have been tried and exhausted before applying restraints. 3 Restraints may be applied to ensure the physical safety of the resident or other residents. 4 A written order for restraints is not required.

4 Restraints can be used only on the written order of a health care provider. Restraints can be used when less restrictive interventions are not successful. Restraints may be used after all available alternatives have been tried and exhausted. Restraints can be used only to ensure the physical safety of the resident or other residents.

Which foods would the nurse recommend to a client who is concerned with ensuring that her diet is not deficient in folic acid (folate)? Select all that apply. One, some, or all responses may be correct. 1 Lean ground beef 2 Milk and cheese 3 Chicken breast meat 4 Black and pinto beans 5 Enriched bread and pasta

4, 5

a normal calcium level is

9-10.5

Cushing's triad

Signs of increased intracranial pressure: 1. hypertension w/ widened pulse pressure 2. bradycardia 3. irregular respiration's