HESI practice problems
During routine prenatal screening, a nurse tells a client that her blood sample will be used for alpha fetoprotein (AFP) testing. Which statement best describes what AFP testing indicates?
"This test will screen for spina bifida, Down syndrome, or other genetic defects."
A young client diagnosed with schizophrenia is talking with the nurse and says, "You know, when I thought everyone was out to get me, I was staying in my apartment all the time. Now, I would like to get out and do things again." What is the best initial response by the nurse?
"What activities did you enjoy in the past?"
A client is newly diagnosed with asthma. While learning to use a metered dose inhaler (MDI) for delivery of a short-term beta agonist, the client asks if a spacer is appropriate to use with this device. What is the nurse's best response?
"Yes, a spacer is recommended because it increases the amount of medication that is delivered to the lungs."
The nurse is discontinuing an intravenous catheter on a 10-year-old client with hemophilia. What would be the most important intervention for this client?
Apply firm pressure on the site for 5 minutes after removal.
A client with an uncomplicated term pregnancy arrives at the laborand-delivery unit in early labor saying that she thinks her water has broken. What is the nurse's best action?
Ask what time this happened and note the color, amount, and odor of the fluid.
A well-known public official of a small community is admitted to the emergency department following an episode of chest pain. Several nurses from the medical unit are aware of the admission and access the official's electronic medical record to obtain a status update. What is the best response for the nurse manager to make to the nurses regarding this situation?
Assessing the official's medical record is a breach of confidentiality.
A nurse suspects that the laboring client may have been physically abused by her partner. What is the most appropriate intervention by the nurse?
Collaborate with the interprofessional team to make a referral to social services
A nurse is caring for a female client before surgery. The client states that she is glad that she will not be going through menopause as a result of her surgery and is only having her uterus removed. The nurse reviews the consent form and notes that the surgery is for a total abdominal hysterectomy with a salpingo-oophorectomy. What should the nurse do in this situation?
Contact the surgeon to explain that the client needs further clarification regarding surgery
The nurse is planning care for a client who had surgery for abdominal aortic aneurysm repair 2 days ago. The pain medication and the use of relaxation and imagery techniques are not relieving the client's pain, and the client refuses to get out of bed to ambulate as prescribed. The nurse contacts the health care provider (HCP), explains the situation, and provides information about drug dose, frequency of administration, the client's vital signs, and the client's score on the pain scale. The nurse requests a prescription for a different, or stronger, pain medication. The HCP tells the nurse that the current prescription for pain medication is sufficient for this client and that the client will feel better in several days. What should the nurse do next?
Explain to the HCP that the current pain medication and other strategies are not helping the client and it is making it difficult for the client to ambulate as prescribed.
A school-age client with diabetes is placed on an intermediate acting insulin and regular insulin before breakfast and before dinner. She will receive a snack of milk and cereal at bedtime. What does the nurse tell the client the snack is intended to do?
Prevent late night hypoglycemia
A four-year-old child is diagnosed as having acute lymphocytic leukemia. The white blood cell (WBC) count, especially the neutrophil count, is low. What is the most important intervention the nurse should teach the parents?
Protect your child from infections because his resistance to infection is decreased
When a client returns from the recovery room postmastectomy, an initial postoperative assessment is performed by the nurse. What is the nurse's priority assessment?
assessing the vital signs and oxygen saturation levels
A client is recovering from an infected abdominal wound. Which foods should the nurse encourage the client to eat to support wound healing and recovery from the infection?
chicken and orange slices
A client has a soft wrist-safety device. Which assessment finding should the nurse investigate further?
cool, pale fingers
A client with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron deficiency anemia?
dyspnea, tachycardia, and pallor
A client with a history of hypertension has been prescribed a new antihypertensive medication and is reporting dizziness. Which is the best way for the nurse to assess blood pressure?
in the supine, sitting, and standing positions
When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes
limiting abbreviations to those approved for use by the institution
The nurse is caring for a client with influenza. The most effective way to decrease the spread of microorganisms is:
washing the hands frequently