HESI Review

Which would the nurse understand about the secondary level of prevention? A. Focuses on early stage of diseases B. Promotes wellness activities C. Helps clients regain function D Minimizes long term disability

A

The most common cause of aspiration in adults during oral feeding is: A. Stomatitis B. Dysphasia C. Esophageal stricture D. Inadequate mastication

B

A client on hospice care is receiving palliative treatment. Which is the goal of palliative care for this client? A. Restore the client's health B. Promote the client's recovery C. Relieve the client's discomfort D. Support the client's significant others

C

Which drug administration route is most likely to result in reduced drug bioavailability? A. Enteral B. Intravenous C. Transdermal D. Subcutaneous

A

The health care provider prescribes 7500 unites of erythropoietin to be administered subcutaneously weekly. The vial reads 10,000 units per milliliter. How many milliliters of erythropoietin will the nurse administer for each weekly dose? Record your answer using two decimal places and include a leading zero if applicable. _____ mL A. 0.075 B. 0.75 C. 7.5 D. 75

B

The nurse should recognize that all of the following physical changes of the head and face are associated with the aging client except: A. pronounced wrinkles on the face B. decreased size of the nose and ears C. increased growth of facial hair D. neck wrinkles

B

At which site would the nurse obtain a sterile urinalysis from a client with an indwelling catheter? A. Tubing injection port B. Distal end of the tubing C. Catheter insertion site D. Urinary drainage bag

A

The nurse at a community health care center focuses on providing primary preventative care. Which is the focus of primary preventive care? A. Health promotion B. Treatment C. Preventing complication D. Rehabilitation

A

A client scheduled for brain surgery has a signed advance directive in the medical record. In which situation would this document be used? A. Discharge planning that is not covered by insurance B. Postoperative complications occur that require additional treatment C. If the client dies and belongings are left in the room D. If the client cannot consent to surgery

D

A patient who uses a fentanyl (Duragesic) patch for chronic cancer pain complains to the nurse of the rapid onset of pain at a level 9 (0-10 scale) and requests "something for pain That will work quickly". The nurse will document this as A. somatic pain B. referred pain C. neuropathic pain D. breakthrough pain

D

An eighty five year old man was admitted for surgery. Preoperatively he was alert, oriented, cooperative, and knowledgeable about his surgery. Several hours after surgery, the evening nurse found his acutely confused, agitated, and trying to climb over the protective side rails on his bed. The most appropriate nursing intervention that will calm and agitated client is: A. Limit visits by staff B. encourage family phone calls C. position in a bright, busy area D. speak soothingly and provide quiet music

D

An older adult client is admitted to the health care facility following a stroke. Which action is correct when the client's cousin asks to see the client's health record? A. Confirm the clients relationship first B. Ask the client's primary health care provider C. Inform the manager and show the records D. Explain the health records are confidential

D

The nurse is assessing a client with arthritis. Which statement made by the client indicated a precipitating factor? A. "My pain is in my joints" B. "My knee swells when I am having the pain" C. "My pain is dull and throbbing" D. "My pain occurs after I exercise"

D

The nurse leader is teaching the staff that the health care provider strives to work effectively within the cultural context of a client. Which cultural principle is the nurse leader explaining? A. Cultural diversity B. Cultural sensitivity C. Cultural imposition D. Cultural competency

D

The patient has been in bed for several days and needs to be ambulated. Before ambulation, the nurse A. Removes the gait belt to allow for unrestricted movement B. Has the patient get up from bed before he has a chance to get dizzy C. Has the patient look down to watch his feet to prevent tripping D. Dangles the patient on the sides of the bed

D

What is the best way for the nurse to determine a patient's need for pain medication on the second day after an abdominal surgery? A. Check when the patient last received medication for pain B. Assess the patient's facial expression and vital signs C. Consider the patient's age and ethnicity D. Ask the patient to rate his or her pain

D

The medication prescribed for an infant is to be given intramuscularly. Which site will the nurse select for administration of the medication? A. Vastus lateralis B. Ventrogluteal C. Dorsogluteal D. Deltoid

A

The nurse is caring for a two day post-surgery hip-replacement client who has had a bowel movement. Which nursing intervention would the nurse perform next? A. provide perineal care B. turn and position the client C. give a complete bed bath D. document the bowl movement

A

Which example indicates that the nurse is following evidence-based practice? A. Documents care in the EHR B. Reads current nursing journals to learn latest best practice C. Uses flowcharts and diagrams to record the client's progress D. Encourage's the client's family to bring food from home

B

Which factor would elevate a client's oxygen saturation? A. Nail polish B. Carbon monoxide C. IV contrast dye D. skin pigmentation

B

Which instruction would the nurse include when teaching a client how to perform diaphragmatic breathing? A. Take rapid, deep breaths B. Expand the abdomen on inhalation C. Breathe with hands on hips D. Lean forward from a sitting position

B

Which of the following is ht abbreviation of drops? A. Gtt. B. Gtts. C. Dp. D. Dr.

B

Which safety consideration is the nurse following when checking for a medical alert bracelet? A. Risk for Error B. Identification of Client C. Risk for staff injury D. Environmental Risk

B

Nurse Maria is administering a cleansing enema to a client with severe constipation. She will place the client in which position? A. Low followers position B. High fowlers position C. Left Sim's position D. Right Sim's position

C

Which action would be appropriate to implement when collecting a 24-hour urine test? A. Start the time of the test after discarding the first voiding B. Discard the last voiding for the 24 hour period C. Insert a urinary retention catheter to promote the collection of urine D. Strain the urine after each voiding

A

Which culturally based behavior would the nurse expect to observe in an Asian client who has symptoms of anxiety and panic? A. Reluctance to take medication B. Minimal eye contact C. Desire to have an Asian nurse D. Offense at being touched

B

Which description is correct for Alzheimer's disease? A. Emerges in the fourth decade of life B. Is a slow, relentless deterioration of the mind C. Occurs only in later years D. Is diagnosed through lab tests

B

The nurse teaches a patient who has a body mass index (BMI) of 39 kg/m2 about weight loss. Which dietary change would be appropriate for the nurse to recommend to their patient? A. Limit fat intake and control portion size B. Increase protein intake and avoid carbohydrates C. Decrease fluid intake and increase vegetables D. Decrease complex carbohydrates and limit fiber

A

The restored nurse (RN) is teaching the student nurse about various sites for assessing body temperature. Which statement made by the student nurse is correct? A. The axilla is the preferred site for an unconscious patient B. The oral cavity should be used if the patient has epilepsy C. A rectal temperature should be used if the patient has a bleeding tendency D. The tympanic membrane should be used for all adults

A

When the nurse manager is evaluating the care of a client receiving oxygen through a nasal cannula, which finding indicated a need to more staff education about oxygen therapy? A. O2 flow rate of 8 L/min B. Bubbling in the humidifier C. Padding behind ears D. No smoking signs posted

A

A nurse anticipates that a laboratory test that will be ordered for a client to determine an evaluation of the client's protein status is: A. serum albumin B. hematocrit and hemoglobin C. ammonia level D. cholesterol level

A

In which scenario is the nurse providing tertiary prevention? A. Education about the need for wheelchair ramps into community businesses B. Education about environmental sanitation C. Education about carcinogens in the community D. Education about the importance of mammograms

A

1800 mL is equal to how many liters? A. 1.8 B. 18000 C. 180 D. 2800

A

Which action would the nurse take to minimize ambiguity and confusion when entering a client's data in the electronic health record? A. Use standardized terminology consistently B. Document in the patient's presence C. Enter the data in the client's native language D. Upload scanned copies of the handwritten records

A

Which activities would the nurse recommend to a client who asks for advice about insomnia? A. Go to bed at the same time very night B. Exercise vigorously just prior to going to sleep C. Drink alcohol at bedtime D. Eat a heavy meal just prior to bedtime

A

Which are examples of invasion of privacy? A. A nursing student tells her friend that she took care of Brittney Spears in the hospital yesterday at clinical. B. The nurse tells the primary HCP that the client has a history of drug addiction. C. The nurse deliberately administers a larger than prescribed dose of narcotic. D. The nurse calls DHR when a 14 year old describes having sex with her 26 year old step-father.

A

Which describes the focus of hospice care? A. To ease pain B. To provide a cure C. To assist with ADLs D. To adapt to physical limitations

A

Which ethical principle is violated when the nurse forgets to give a a painkiller to a client as promised? A. Fidelity B. Justice C. Veracity D. Nonmalificence

A

Which instruction would the nurse give to the client having a bladder scan for residual urine? A. Empty the bladder before the bladder scan is performed B. Void immediately after the bladder scan C. Attempt to void while undergoing the bladder scan D. A catheter will be inserted prior to the bladder scan

A

Which intervention will the nurse include in a care plan for a client with Alzheimer disease? A. Limit choices B. Use all side rails C. Discourage self care activities D. Ask open ended questions only

A

Which of the following is the FIRST priority in preventing infections when providing care for a client? A. Handwashing B. Wearing gloves C. Using a barrier between clients furniture and nurse's bad D. Wearing gowns and goggles

A

Which principle refers to a professional obligations of the nurse the assume responsibility for actions? A. Accountability B. Individually C. Responsibility D. Bioethics

A

While assessing an older adult during a regular health checkup, the nurse finds signs of elder abuse. Which physical findings would further confirm the nurse's suspicion? select all that apply. One, some, or all responses may be correct. A. presence of burns from cigarettes B. presence of bed sores C. prescience of cognitive impairment D. presence of unexplained bruises E. presence of poor skin turgor on the back of the hands

A, B, D

A terminally ill client is considering "allow natural death" (AND) rather than the traditional "do not resuscitate" (DNR). Which feeling will the AND assuage for the client and family? A. Anger B. Guilt C. Denial D. Sadness

B

An adult patient is diagnosed with anemia related to inadequate intake of essential nutrients. Which intervention would be appropriate for the nurse to include in the plan of care for this patient? A. Assist the patient to select soft, bland, and nonacidic foods B. Provide the patient with foods high in protein, iron, vitamin C, and folate C. Schedule 30 minutes of rest after every meal D. Give the patient a list of medications that inhibit iron absorption

B

Several clients are admitted to an adult medical unity. The nurse would ensure airborne precautions for a client with which of the following medical conditions? A. A diagnosis of AIDS and cytomegalovirus B. A positive PPD with an abnormal chest x-ray C. A tentative diagnosis of viral pneumonia D. Advanced carcinoma of the lung

B

The charge nurse is educating a new nurse on culturally competent communication techniques. Which response(s) made by the new nurse indicates a need for follow-up? Select all that apply. One, some, or all responses may be correct. A. "I should identify the clients' needs to create the plan of care." B. "I should use a language interpreter for all culturally, diverse groups." C. "I should use the client's perspective on health to help lead the conversation." D. "I should recognize my own biases and address known stereotypes with the client."

B

The client having a nasogastric tube inserted is disoriented. The nurse should: A. Notify the physician B. Request assistance with the insertion C. Administer a hypnotic medication D. Continue the procedure as with any other client

B

The nurse is discussing nutrition with a woman who is 50-years-old, perimenopausal, and has a history of hypertension. What food choices would be best to help meet the dietary needs of this client? A. Cheese and macaroni, fresh fruit, and milk shake B. Cottage cheese, glass of skim milk, and fresh spinach salad C. Roast beef with whole wheat break, potato, and lettuce salad D. Cheeseburger, French fries, and milk shake

B

The nurse is providing hygiene care to an immobile client who was admitted for exacerbation of chronic obstructive pulmonary disease (COPD). Which nursing intervention is priority when the client becomes short of breath during the care? A. Obtain a pulse oximeter to determine the client's oxygen saturation level. B. Put the client in a high Fowler position C. Darken the lights and provide a rest period of at least 15 minutes. D. Continue the hygiene activities while reassuring the client

B

Upon entering an examination room for assessment of a confused client, which action would the nurse take? A. Perform an assessment quickly B. Plan a focused physical assessment C. Skip the examination until the client is reoriented D. Eave the room to find the health care provider

B

Which situation would the nurse address first according to Maslow's hierarchy? A. As history of being injured from sudden falls B. Complains of sleeplessness due to pain post surgery C. Reports that they feel lonely and socially isolated D. Conveys to the nurse that they want to become the manager of the company

B

A client with a methicillin-resistant Staphylococcus aureus (MRSA) infected wound is scheduled for a computed tomography (CT) scan. To ensure client and visitor safety during transport, the nurse would implement with precaution? A. Put an isolation gown on the patient and transporter B. Drape the patient with a covering labeled biohazard C. Cover the infected site with a dressing D. No special precautions are required

C

A client with metastatic cancer reports severe continuous pain. Which route of administration should the nurse use to provide the most effective continuous analgesia? A. Oral B. Intravenous C. Transdermal D. Intramuscular

C

A patient is being seen in the clinic for complains of fainting episodes that started last week. How should you proceed with the examination? A. Take his BP in both arms and thighs B. Assist him to a lying position and begin taking his BP C. Record his blood pressure in the lying, sitting, and standing positions D. Record his blood pressure in the lying and sitting positions and average these numbers the obtain a mean BP

C

The nurse is admitting a patient with dehydration and watery diarrhea after a 10-day course of antibiotic therapy for bacterial pneumonia. It is most important for the nurse to take which action? A. Instruct visitors to use the alcohol-based hand sanitizer B. Wear a mask to prevent transmission of the respiratory tract infections C. Don gloves and a gown before entry into the patient's room D. Obtain vital signs and wipe equipment with ammonia-based disinfectant

C

Which action by the new graduate demonstrates patient-centered care? A. Maintains eye contact with the clients B. Spends more time with the clients who have few visitors C. Provides food in accordance with the client's preferences D. Avoids holding the client's hand when interacting with them

C

Which action is appropriate when caring for an elderly client admitted to a health care facility? A. Stand closely, next to the client's ear, when speaking B. Speak to the client in a loud voice C. Invite the family member to join the conversation D. Have the room as bright as possible

C

While the nurse is administering medications to a client, the client states "I do not want to take that medicine today." Which of the following responses by the nurse would be best? A. "That's OK, its alright to skip your medication now and then." B. "I will have to call your doctor and report this." C. "Is there a reason why you don't want to take your medicine?" D. "Do you understand the consequences of refusing your prescribed treatment?"

C