HESI practice questions MIXED
A nurse determines that the client's apical pulse rate is higher than the radial pulse and documents the pulse deficit. What does the nurse consider is the primary reason for the pulse deficit? 1 The client's heart may be beating faster temporarily. 2 The nurse may not know how to take an accurate pulse. 3 The radial pulse site may be surrounded by too much subcutaneous fat. 4 The client may have atrial fibrillation.
The client may have atrial fibrillation. Clients who have atrial fibrillation have a pulse deficit caused by reduction of preload. An accelerated heart rate is known as tachycardia, not a pulse deficit. It is unlikely the nurse does not know how to take a pulse accurately; nurses are trained in assessment. If a pulse deficit identified at a pulse site is attributed to the presence of excessive subcutaneous fat, the nurse should obtain the peripheral pulse at a different site.
A new mother is concerned that her 1-month-old infant is nursing every 2 hours. Which response by the nurse is most appropriate? 1 "It's common for newborns to nurse this often. Let's talk about how you're adjusting with the new baby." 2 "Breast milk is easily digested; giving your infant a little rice cereal will keep him full longer." 3 "It sounds as though your baby is a little spoiled; try to resist feeding more often than every 4 hours." 4 "You may not be producing enough milk; it'll be important for you to supplement feedings with formula."
1 "It's common for newborns to nurse this often. Let's talk about how you're adjusting with the new baby." Newborns typically nurse every 2 to 3 hours. Although breast milk is easily digested, feeding solids to an infant is not recommended at this age. Feeding satisfies a fundamental need; one does not spoil an infant by nursing as needed. Adequate intake is evidenced in infant weight gain and adequate urinary and bowel elimination. Supplementing feedings with formula may lead to decreased milk production.
A client with cellulitis of the leg asks why bed rest has been prescribed to prevent sepsis. Which purpose will the nurse explain to the client?
1 This decreases catabolism to promote healing at the site of injury. 2 This lowers the metabolic rate in an attempt to help reduce the fever. Incorrect3 This reduces the energy demands on the body in the presence of infection. Correct4 This limits muscle contractions that may force causative organisms into the bloodstream. Exercise will promote extension of the local infection from the leg into the circulation, causing septicemia (sepsis). Although bed rest does decrease catabolism to promote healing at the site of injury, it is not the purpose for bed rest in this situation. Although bed rest does reduce the energy demands on the body in the presence of infection and lowers metabolic rate, it is not the purpose for bed rest in this situation.
Which functions does the nurse associate with the epidermis? Select all that apply.
1 Serves as an energy reserve Incorrect2 Provides cells for wound healing Incorrect3 Serves as a mechanical shock absorber Correct4 Inhibits proliferation of microorganisms Correct5 Allows the photoconversion of 7-dehydrocholesterol to vitamin D The epidermis inhibits the proliferation of microorganisms because of its dry external surface. It also allows the photoconversion of 7-dehydrocholesterol to vitamin D. The subcutaneous tissue serves as an energy reserve. The dermis helps in providing cells for wound healing. Subcutaneous tissue acts as a mechanical shock absorber.
The serum potassium level of a client who has diabetic ketoacidosis is 5.4 mEq/L (5.4 mmol/L). What would the nurse expect to see on the ECG tracing monitor? 1 Abnormal P waves and depressed T waves 2 Peaked T waves and widened QRS complexes 3 Abnormal Q waves and prolonged ST segments 4 Peaked P waves and an increased number of T waves
2 Peaked T waves and widened QRS complexes Potassium is the principal intracellular cation, and during ketoacidosis it moves out of cells into the extracellular compartment to replace potassium lost as a result of glucose-induced osmotic diuresis; overstimulation of the cardiac muscle results. The T wave is depressed in hypokalemia. Initially, the QT segment is short, and as the potassium level rises, the QRS complex widens. P waves are abnormal because the PR interval may be prolonged and the P wave may be lost; however, the T wave is peaked, not depressed. The ST segment becomes depressed. The PR interval is prolonged, and the P wave may be lost. QRS complexes and thus T waves become irregular, and the rate does not necessarily change.
The nurse is assessing a 5-year-old child using the Glasgow Coma Scale after surgery. What rating should the nurse assign if the child shows a confused verbal response? 1 2 3 Correct4 4
4 According to the Glasgow Coma Scale, a confused verbal response indicates a score of 4. When the child gives no response, the score is a 1. If the child makes incomprehensible sounds, then the score is a 2. When the child speaks inappropriate words, then the score is a
A client in the thirty-eighth week of gestation exhibits a slight increase in blood pressure. The primary healthcare provider advises her to remain in bed at home in a side-lying position. The client asks why this is important. What is the nurse's response regarding the advantage of this position? 1 "It increases blood flow to the fetus." 2 "It decreases intra-abdominal pressure." 3 "It increases the mean arterial pressure." 4 "It prevents the development of thrombosis."
A. "It increases blood flow to the fetus." The side-lying position decreases blood pressure and moves the gravid uterus off the great vessels of the lower abdomen, increasing venous return, improving cardiac output, and promoting kidney and placental perfusion. The side-lying position does not influence intra-abdominal pressure. While a pregnant woman is on bed rest the blood pressure decreases. The side-lying position does not prevent thrombosis; bed rest and immobility may increase the risk of thrombosis.
An infant with a diaphragmatic hernia undergoes corrective surgery. What nursing assessment indicates that the infant's respiratory condition has improved? 1 Cessation of crying 2 Retention of 1 oz (30 mL) of formula 3 Reduction of arterial blood pH to 7.31 4 Auscultation of breath sounds bilaterally
Auscultation of breath sounds bilaterally Bilateral breath sounds indicate that the lungs are expanded and functioning. Lack of crying is not a reliable indicator that the respiratory status is improving; it may indicate that the infant is hypoxic and too fatigued to cry. The expected pH is 7.35 to 7.45; a decreasing pH indicates respiratory acidosis, which can be attributed to decreased gas exchange. Retention of formula is unrelated to gas exchange.
A client with a dysrhythmia is admitted to telemetry for observation. In the morning, the client asks for a cup of coffee. What is the nurse's best response?
Coffee has caffeine, which can affect your heart. It should be avoided."
A nurse is caring for a toddler who has undergone bone marrow transplantation. What clinical finding(s) should the nurse anticipate if an infection develops? 1 Fever and lethargy 2 Positive blood antibody titers 3 A delay in the growth of bone 4 Neutropenia and lymphocytopenia
Fever and lethargy A fever occurs with an infection because pyrogens affect the temperature-regulating center in the hypothalamus; lethargy occurs with an infection because of the related increased basal metabolic rate. Antibody titers indicate exposure to microorganisms, not the presence of an actual infection. Delayed bone growth is not an indication of infection. After a bone marrow transplant, neutropenia and lymphocytopenia are present until the bone marrow is fully repopulated. An altered white blood cell count is not a reliable indicator of infection.
A nurse reinforces teaching a client about Coumadin (warfarin) and concludes that the teaching is effective when the client states, "I must not drink:
cranberry juice
A nurse is monitoring a client's laboratory results for a fasting plasma glucose level. Within which range of a fasting plasma glucose level does the nurse conclude that a client is considered to be diabetic? 1 40 to 60 mg/dL (2.2 to 3.3 mmol/L) 2 80 to 99 mg/dL (4.5 to 5.5 mmol/L) 3 100 to 125 mg/dL (5.6 to 6.9 mmol/L) 4 126 to 140 mg/dL (7.0 to 7.8 mmol/L)
126 to 140 mg/dL (7.0 to 7.8 mmol/L) Results in the range 126 to 140 mg/dL (7.0 to 7.8 mmol/L) indicate diabetes. Results in the range 40 to 60 mg/dL (2.2 to 3.3 mmol/L) indicate hypoglycemia. Results in the range 80 to 99 mg/dL (4.5 to 5.5 mmol/L) are considered expected (normal). Results in the range 100 to 125 mg/dL (5.6 to 6.9 mmol/L) indicate prediabetes according to the American Diabetes Association. (Results in the range of 6.1 to 6.9 mmol/L indicate prediabetes according to the Canadian Diabetes Association Guidelines.)
A client who is receiving combination chemotherapy for stage II Hodgkin disease is at risk for stomatitis. The nurse's teaching plan should include instructions to:
Clean the mouth with a soft toothbrush or a gentle spray Chemotherapy destroys the rapidly dividing cells of the oral mucosa; frequent gentle oral hygiene limits additional trauma. Although it is recommended to rinse the mouth every 2 hours, the client does not need to brush teeth and clean the mouth as often. Lemon juice is too caustic to the compromised mucosa. Flossing can disrupt and traumatize the gum surfaces; oral hygiene is needed more than once a day. Commercial mouthwashes contain alcohol, which is irritating to the mucosa.
The primary health care provider prescribes a transfusion of two units of packed red blood cells for a client. When caring for the patient receiving administering blood, the priority nursing intervention is to:
Make sure the blood is infused at a slow rate during the first 15 minutes
A client has a colon resection with an anastomosis. What assessments by the nurse support a suspicion of impending shock? Select all that apply. 1 Oliguria 2 Lethargy 3 Irritability 4 Hypotension 5 Slurred speech
Oliguria Irritability Hypotension Decreased blood flow to the kidneys leads to oliguria or anuria. Irritability, along with restlessness and anxiety, occurs because of a decrease in oxygen to the brain. Hypotension and a narrowing of the pulse pressure occur because of declining blood volume. Restlessness, not lethargy, usually occurs because of decreased cerebral blood flow. There are various changes in sensorium, but slurred speech is not a manifestation of shock.
Which technology would the nurse use to reduce chronic ulcers by removing fluids from the wound?
1 Electrical stimulation 2 Topical growth factors 3 Hyperbaric oxygen therapy Correct4 Negative pressure wound therapy Negative pressure wound therapy is a new technology used to reduce chronic ulcers by removing fluids from the wound and enhancing granulation. Electrical stimulation is done by the application of low-voltage current to a wound area to increase blood vessel growth and promote granulation. Topical growth factors are the normal body substances that stimulate cell movement and growth. Hyperbaric oxygen therapy is the administration of oxygen under pressure, raising the tissue oxygen concentration.
A client with a history of endometriosis has abdominal surgery to remove abdominal adhesions. What should this client's postoperative plan of care include? 1 Encouraging the client to ambulate in the hallway 2 Elevating the client's legs by gatching the bed 3 Helping the client dangle her legs over the side of the bed 4 Maintaining the client on bed rest until the dressings have been removed
1 Encouraging the client to ambulate in the hallway Muscle contraction during ambulation improves venous return, which prevents venous stasis and thrombus formation. Gatching the bed and dangling the legs each place pressure on the popliteal spaces, limiting venous return and increasing the risk of thrombus formation. Bed rest is associated with venous stasis, which increases the risk of thrombus formation.
A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and PCO2 of 60 mm Hg. These blood gases require nursing attention because they indicate which condition? 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis
3 Respiratory acidosis Rationale: The normal blood pH range is 7.35 to 7.45; therefore, a blood pH of 7.25 indicates acidosis. The parameter for respiratory function is CO2 and the acceptable range of arterial PCO2 is 35 to 45 mm Hg; therefore, 60 mm Hg is elevated, resulting in respiratory acidosis. HCO3 is the parameter for metabolic functions. A pH of 7.25 is acidic, indicating acidosis and not alkalosis.
A nurse performs full range-of-motion exercises on a client's extremities. When putting an ankle through range-of-motion exercises, what must the nurse perform? 1 Flexion, extension, and rotation 2 Abduction, flexion, adduction, and extension 3 Pronation, supination, rotation, and extension 4 Dorsiflexion, plantar flexion, eversion, and inversion
4 Dorsiflexion, plantar flexion, eversion, and inversion Dorsiflexion, plantar flexion, eversion, and inversion movements include all possible ranges of motion for the ankle joint. Although the ankle can be moved in a circular motion, flexion and extension more specifically are called dorsiflexion and plantar flexion in relation to the ankle. Also, eversion and inversion should be done when manipulating the ankle. The ankle cannot be abducted or adducted but can be inverted and everted. Pronation, supination, rotation, and extension refer to the upper extremities.
Which practice would be suitable in the prevention of a pressure ulcer? 1 Positioning a client directly on the trochanter 2 Keeping the client's skin directly off plastic surfaces 3 Keeping the head of the bed elevated above 30 degrees 4 Placing a rubber ring or donut under the client's sacral area
Correct2 Keeping the client's skin directly off plastic surfaces For the prevention of a pressure ulcer, the client's skin should be kept directly off plastic surfaces. While the client is positioned on his or her side, direct positioning on the trochanter should be avoided. The head of the bed should not be kept elevated above 30 degrees. This is to prevent shearing. A rubber ring or donut under the client's sacral area should be avoided.
During change of shift report the night nurse indicates that a client cannot tolerate the prescribed intermittent tube feedings. Which action should the receiving nurse take first? 1 Suggest that an antiemetic be prescribed 2 Change the feeding schedule to omit nights 3 Request that the type of solution be changed 4 Gather more data from the night nurse about the technique used
Gather more data from the night nurse about the technique used Rapid administration, incorrect positioning, and inadequate solution temperature are common causes of intolerance to tube feedings. Although suggesting that an antiemetic be prescribed may be done eventually, the feeding technique should be assessed first. Feedings generally are tolerated better if given frequently in small amounts over the entire 24 hours. Although changing the feeding schedule to omit nights and requesting that the type of solution be changed may be done eventually, the feeding technique should be assessed first.
A nurse is caring for a client who is receiving radiation therapy. Which information about skin care should the nurse include in the teaching plan?
Incorrect1 "Cover the area with a sterile gauze bandage." 2 "Put warm compresses on the site once a day." 3 "Limit lying on the back and unaffected side when sleeping." Correct4 "Avoid applying lotions and powders over the area." Lotions and powders can cause a skin reaction on irradiated areas and should be avoided. Gauze and tape may irritate the skin further and should be avoided. Warm compresses are contraindicated because they may precipitate skin breakdown. The client can assume a position of comfort.
A nurse is assessing a newly admitted client with the pressure ulcer indicated in the picture. Which pressure ulcer stage should the nurse document on the admission history and physical?
Incorrect1 Stage I Correct2 Stage II 3 Stage III 4 Stage IV A stage II pressure ulcer is a partial-thickness ulceration of epidermis or dermis; it presents as an abrasion, blister, or shallow crater; has a red/pink wound bed, has no tissue sloughing, and may have an intact/open serum-filled blister. A stage I ulcer has tissue injury with intact skin with nonblanchable redness of a localized area; the ulcer may appear with persistent red, blue, or purple hues. A stage III pressure ulcer has full-thickness ulceration involving the epidermis, dermis, and subcutaneous tissue; sloughing may be present. It presents as a deep crater with or without undermining, and bone, tendon, and muscle are not exposed. A stage IV pressure ulcer involves full-thickness skin loss and damage to muscle, bone, or tendon; sloughing or eschar may be present on parts of the wound bed, and it often includes undermining and tunneling.
Which tocolytic agent inhibits prostaglandin activity and is given along with sucralfate to help manage preterm labor? 1 Nifidipine 2 Indomethacin 3 Calcium gluconate 4 Magnesium sulfate
Indomethacin is the most effective tocolytic currently available and inhibits prostaglandin activity. Indomethacin is a nonsteroidal antiinflammatory agent that may cause gastric irritation so sucralfate is administered along with this drug. Nifidipine is a calcium channel blocker used to manage preterm labor. Calcium gluconate is used to reverse magnesium sulfate toxicity. Magnesium sulfate is used to manage preterm labor and pregnancy-induced hypertension.
An infant is found to have developmental dysplasia of the hip (DDH) 6 weeks after birth. The parents ask a nurse at the clinic why their infant must be restrained in a harness at such an early age. How should the nurse respond? Infants are easier to manage in a harness than are toddlers. 2 Mobility will be delayed if correction is postponed until later. 3 Adduction devices cannot be used as effectively after the toddler age. 4 Infants' hip joints are cartilaginous, allowing molding of the acetabulum.
Infants' hip joints are cartilaginous, allowing molding of the acetabulum. The cartilaginous nature of infants' hip joints is the basis for the use of abduction devices (e.g., Pavlik harness) when the infant is very young. Although an infant is easier to manage in a harness than is a toddler, the main reason for the use of a harness so early in life is the easy moldability of the bones at this age. Traction may be used before surgery to correct contractures; these treatments are more traumatic than the harness, which is applied before the infant can walk. Hip dysplasia is usually not painful and does not limit ambulation for the young child. Abduction, not adduction, devices are used; abduction devices are ineffective by the time the child reaches the toddler age.
A client undergoes removal of a pituitary tumor through a transsphenoidal approach. What should the nurse implement postoperatively? 1 Provide oral hygiene and include brushing the teeth 2 Encourage the client to deep breathe and cough frequently 3 Maintain the head of the bed at a 30-degree angle continuously 4 Continue giving nothing by mouth until the nasal packing is removed
Maintain the head of the bed at a 30-degree angle continuously Maintaining the head of the bed at a 30-degree angle continuously decreases pressure on the sella turcica and promotes venous return, thus limiting cerebral edema. Gentle oral hygiene is performed, excluding brushing of teeth, to prevent trauma to the surgical site. Although deep breathing is encouraged, initially coughing is discouraged to prevent increasing intracranial pressure. There is no need to limit oral fluids because of the presence of nasal packing.
Which nursing intervention prevents footdrop in a client with osteomyelitis? 1 Elevating the foot with the use of pillows 2 Consistently flexing the affected extremity 3 Encouraging the client to change positions 4 Neutral positioning of the foot with the use of a splint
Neutral positioning of the foot with the use of a splint A client with osteomyelitis is at an increased risk for footdrop, which results in an abnormal gait. Neutral positioning of the foot with the use of a splint can reduce the risk of footdrop in the client with osteomyelitis. Elevating the client's foot on pillows can reduce the risk of edema. Asking the client with osteomyelitis to flex the affected extremity can result in flexion contracture. Encouraging the client with osteomyelitis to change positions helps prevent complications associated with immobility and promotes comfort; carefully handle the involved limb and avoid excessive manipulation which may lead to a pathologic fracture.
Which nursing theory focuses on the client's self-care needs? 1 Roy's theory 2 Orem's theory 3 Watson's theory 4 Leininger's theory A nurse is caring for a client recovering from a minor hand fracture who is preparing to be discharged. The nurse gives details on the ways to bathe, dress, groom, and eat without needing the help of family members. Which theory is appropriate for this situation?
Orem's theory Orem's self-care deficit theory focuses on the client's self-care needs. According to Roy's theory, the goal of nursing is to help a person adapt to changes in physiological needs, self-concept, role function, and interdependent relations during health and illness. Watson's theory of transpersonal caring defines the outcome of nursing activity with regards to the humanistic aspects of life. The major concept of Leininger's theory is cultural diversity, with the goal of nursing care being to provide the client with culturally specific nursing care.