HESI practice

A male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead. What should be the nurse's first response?

"It is important that you continue your medication while learning to meditate."

Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse?

"The body's receptors adapt over time as they are exposed to heat."

A client who is 5 foot 5 inches tall and weighs 200 pounds is scheduled for surgery the next day. Which question is most important for the nurse to include during the preoperative assessment?

"What vitamin and mineral supplements do you take?"

A client with multiple sclerosis is prescribed Dantrolene (Dantrium) 0.1 grams PO bid for spasticity. Dantrolene is available in 100 mg capsules. How many capsules should the nurse administer? (Enter numeric value only.)

1

A client's daily PO prescription for aripiprazole (Abilify) is increased from 15 mg to 30 mg. The medication is available in 15 mg tablets, and the client already received one tablet today. How many additiona l tablets should the nurse administer so the client receives the total newly prescribed dose for the day? (Enter numeric v alue only.)

1

A client who has a sinus infection is receiving a prescription for amoxicillin/clavulanate potassium (Augmentin) 500 mg PO q8 hours. The available form is 250 mg amoxicillin/125mg clavulanate tablets. How many tablets should the nurse administer for each dose? (Enter numeric value only.)

2

A client with pericardial effusion has phrenic nerve compression resulting in recurrent hiccups. The healthcare provider prescribes metoclopramide (Reglan) liquid 10 mg PO q 6 hours. Reglan is available as 5 mg/5 ml. A measuring device marked in teaspoons is being used. How many teaspoons should the nurse administer?

2

A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the nurse advise the client to follow?

8 a.m., 4 p.m., and midnight.

What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults?

A decreased flow rate could result in the formation of a thrombosis.

The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein?

A lactating woman nursing her 3-day-old infant.

A client's spouse is learning passive range-of-motion for the client's contracted shoulder. The nurse observes that the spouse is holding the client's arm above and below the elbow. Which nursing action should the nurse implement?

Acknowledge that the spouse is supporting the arm correctly.

A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take?

After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube.

Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention?

Assess for bladder distention.

A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the nurse implement first?

Assist the ambulating client back to the bed.

The nurse is teaching a client with numerous allergies how to avoid allergens. Which instruction should be included in this teaching plan?

Avoid any types of sprays, powders, and perfumes.

The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler?

During the inhalation.

During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement?

Encourage additional oral intake of juices and water.

A client with acute hemorrhagic anemia is to receive four units of packed red blood cells ( RBCs) as rapidly as possible. Which intervention is most important for the nurse to implement?

Ensure the accuracy of the blood type match.

Which assessment data provides the most accurate determination of proper placement of a nasogastric tube?

Examining a chest x-ray obtained after the tubing was inserted.

The nurse is administering medications through a nasogastric tube (NGT) which is connected to suction. After ensuring correct tube placement, which action should the nurse take next?

Flush the tube with water.

An older client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings through a gastrostomy tube (GT). What is the best position for the client for administration of the bolus tube feedings?

Fowler's

The nurse is completing a mental assessment for a client who is demonstrating slow thought processes, personality changes, and emotional lability. Which area of the brain controls these neuro-cognitive functions?

Frontal lobe

An older client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care?

Gently lift the client when moving into a desired position.

A client who is in hospice care reports increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement?

Give an around-the-clock schedule for administration of analgesics.

A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV every 24 hours is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement?

Give the missed dose at 1300 and change the schedule to administer daily at 1300.

A resident in a skilled nursing facility for short-term rehabilitation after a hip replacement tells the nurse, "I don't want any more blood taken for those useless tests." Which narrative documentation should the nurse enter in the client's medical record?

Healthcare provider notified of client's refusal to have blood specimens collected for testing.

At the beginning of the shift, the nurse assesses a client who is admitted from the post-anesthesia care unit (PACU). When should the nurse document the client's findings?

Immediately after the assessments are completed.

The nurse is using a genogram while conducting a client's health assessment and past medical history. What information should the genogram provide?

Inherited familial health disorders.

An African-American grandmother tells the nurse that her 4-year-old grandson is suffering with "miseries." Based on this statement, which focused assessment should the nurse conduct?

Inquire about the source and type of pain.

Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse?

Instruct the client that the stoma will become smaller when the initial swelling diminishes.

A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse document that is most accurate?

Is disoriented to place and time.

Which action is most important for the nurse to implement when donning sterile gloves?

Keep gloved hands above the elbows.

During the daily nursing assessment, a client begins to cry and states that the majority of family and friends have stopped calling and visiting. What action should the nurse take?

Listen and show interest as the client expresses these feelings.

The nurse is examining a male client who reports itching on his right arm, The nurse observes a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the nurse record this finding?

Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter.

When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first?

Loosen the right wrist restraint.

When conducting an admission assessment, the nurse should ask the client about the use of complementary healing practices. Which statement is accurate regarding the use of these practices?

Many complementary healing practices can be used in conjunction with conventional practices.

A nurse is preparing to give medications through a nasogastric feeding tube. Which nursing action should prevent complications during administration?

Mix each medication individually.

An older client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgment?

The nurse who transferred the client to the chair when the fall occurred.

The unlicensed assistive personnel (UAP) working on a chronic neuro unit asks the nurse to help determine the safest way to transfer an older client with left-sided weakness from the bed to the chair. Which method describes the correct transfer procedure for this client?

Move the chair parallel to the right side of the bed, and stand the client on the right foot.

When evaluating a client's plan of care, the nurse determines that a desired outcome was not achieved. Which action should the nurse implement first?

Note which actions were not implemented.

An older resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first?

Notify the healthcare provider of the family's request.

A young mother of three children complains of increased anxiety during her annual physical exam. What information should the nurse obtain first?

Nutritional history.

The nurse observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first?

Observe the appearance of the skin under the ice pack.

An older client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting from a fall. In reviewing hip precautions with the client, which instruction should the nurse include in this client's teaching plan?

Place a pillow between your knees while lying in bed to prevent hip dislocation.

An older client who is a resident in a long term care facility has been bedridden for a week. Which finding should the nurse identify as a client risk factor for pressure ulcers?

Rashes in the axillary, groin, and skin fold regions.

Which response by a client with a nursing diagnosis of "Spiritual distress," indicates to the nurse that a desired outcome measure has been met?

Accepts that punishment from God is not related to illness.

The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective?

"I will limit my intake of beef to 4 ounces per week."

At the time of the first dressing change, the client refuses to look at her mastectomy incision. The nurse tells the client that the incision is healing well, but the client refuses to talk about it. Which is the best response to this client's silence?

"It is OK if you don't want to talk about your surgery. I will be available when you are ready."

A male client with obesity discusses with the nurse his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide?

"Be sure to have a complete physical examination before beginning your planned exercise program."

The nurse notices that the Hispanic parents of a toddler who returns from surgery offer the child only the broth that comes on the clear liquid tray. Other liquids, including gelatin, popsicles, and juices, remain untouched. What explanation is most appropriate for this behavior?

"Hot" remedies restore balance after surgery, which is considered a "cold" condition.

A client is receiving alprazolam (Xanax) 0.75 mg PO bid for anxiety. Alprazolam is available in 0.5 mg scored tablets. How many tablets should the nurse administer? (Enter numeric value only.)

1.5

Secobarbital (Seconal) 150 mg is prescribed at bedtime for a male client who is scheduled for surgery in the morning. The scored tablets are labeled 0.1 gram/tablet. How many tablets should the nurse administer? (Enter the numerical value only. If rounding is required, round to the nearest tenth.)

1.5

Docusate sodium (Colace) 0.3 grams is prescribed for a client who has frequent constipation. Each capsule contains 100 mg. How many capsules should the nurse administer?

3

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?

Battery.

A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs?

Blood transfusions are forbidden.

Which snack food is best for the nurse to provide a client with myasthenia gravis who is at risk for altered nutritional status?

Chocolate pudding.

During the admission interview, which technique is most efficient for the nurse to use when obtaining information about signs and symptoms of a client's primary health problem?

Closed-ended questions.

A client with chronic kidney disease (CKD) selects a scrambled egg for his breakfast. Which action should the nurse take?

Commend the client for selecting a high biologic value protein.

The nurse notices that the mother of a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the nurse take?

Continue asking the mother questions about the child.

During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure?

Degree of flexion and extension of the client's knee joint.

A postoperative client will need to perform daily dressing changes after discharge. Which outcome response best demonstrates the client's readiness to manage wound care after discharge?

Demonstrating the wound care procedure correctly.

After completing an assessment and determining that a client has a problem, which action should the nurse perform next?

Determine the etiology of the problem.

The nurse is developing a plan of care for a client with dementia. Which feature of confusion in the elderly is accurate?

Disorientation often follows relocation to new surroundings.

The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next?

Re-oxygenate the client before attempting to suction again.

The nurse observes an unlicensed assistive personnel (UAP) checking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. Which action is most important for the nurse to implement?

Reassess the client's blood pressure using a larger cuff.

The nurse assigns an unlicensed assistive personnel (UAP) to obtain vital signs from a very anxious client. What instructions should the nurse give the UAP?

Report the results of the vital signs to the nurse.

An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP?

Reposition in a Sims' position with the client's weight on the anterior ilium.

A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last two hours. Which action should the nurse take first?

Reposition the client on her side.

A female client asks the nurse to find someone who can translate her treatment concerns into her native language. Which action should the nurse take?

Request and document the name of the certified translator.

The nurse is evaluating a client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands the dietary restrictions?

Skim milk, turkey salad, roll, vanilla ice cream.

A Sub-Saharan African widowed immigrant woman lives with her deceased husband's brother and his family, which includes the brother-in-law's children and the widow's adult children. Each family member speaks fluent English. Surgery is recommended for this client. What is the best plan to obtain consent for surgery for this client?

Tell the surgeon that the brother-in-law will decide after explanation of the proposed surgery is provided to him and the widow.

The nurse witnesses the signature of a client who has signed an informed consent. Which statement best explains this nursing responsibility?

The client voluntarily signed the form.

Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an adolescent?

Upper arm circumference.

The nurse is assisting an 82-year-old client to ambulate. Which is the center of gravity for an elderly person?

Upper torso.

During shift change report, the nurse receives report that a client has abnormal heart sounds. Which placement of the stethoscope should the nurse use to hear the client's heart sounds?

Use the stethoscope bell over the valvular areas of the anterior chest.

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?

client