Level 1 HESI Exam

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

Ensure the accuracy of the blood type match.

A 35-year-old female client with cancer refuses to allow the nurse to insert an IV for a scheduled chemotherapy treatment, and states that she is ready to go home and die. What intervention should the nurse initiate?

Evaluate the client's mental status for competence to refuse treatment.

The nurse is preparing to catheterize an 8-year-old child. Before starting the procedure, which action should the nurse take first?

Explain to the child and the parents that the procedure needs to be done.

The nurse is completing an admission interview and assessment on a client with a history of Parkinson's disease. Which question provides information relevant to the client's plan of care?

Have you ever been "frozen" in one spot, unable to move?

The nurse removes the dressing on a client's heel that is covering a pressure sore one-inch in diameter and finds that there is straw-colored drainage seeping from the wound. What description of this finding should the nurse include in the client's record?

One-inch pressure sore draining serous fluid. Rationale: Serous drainage is clear watery plasma.

A 67-year-old woman who lives alone tripped on a rug in her home and fractured her hip. Which predisposing factor probably led to the fracture in the proximal end of her femur?

Osteoporosis resulting from hormonal changes.

On admission to a residential care facility, an elderly female client tells the nurse that she enjoys cooking, quilting, and watching television. Twenty-four hours after admission, the nurse notes that the client is withdrawn and isolated. It is best for the nurse to encourage this client to become involved in which activity?

Participate in a group quilting project.

A 73-year-old female client had a hemiarthroplasty of the 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.

A client who was in a motor vehicle collision was admitted to the hospital and the right knee was placed in skeletal traction. The nurse has documented this nursing diagnosis in the client's medical record: "Potential for impairment of skin integrity related to immobility from traction." Which nursing intervention is indicated based on this diagnosis statement?

Provide back and skin care while maintaining the contraction.

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 client before attempting to suction again.

The nurse observes an unlicensed assistive personnel (UAP) taking 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. What action is most important for the nurse to implement?

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

To take the vital signs of a 4-month-old child, which order will give the most accurate results?

Respiratory rate, heart rate, then rectal temperature.

A client with multiple sclerosis has experienced an exacerbation of symptoms, including paresthesias, diplopia, and nystagmus. Which instruction should the nurse provide?

Schedule extra rest periods.

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.

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.

A 4-year-old boy was admitted to the emergency room with a fractured right ulna and a short arm cast was applied. When preparing the parents to take the child home, which discharge instruction has the highest priority?

Call the healthcare provider immediately if his nail beds appear blue.

A medication is prescribed to be given QID. What schedule should the nurse use to administer this prescription?

0800, 1200, 1600, 2000

After the fourth dose of gentamicin sulfate (Garamycin) IV, the nurse plans to draw blood samples to determine peak and trough levels. When are the best times to draw these samples?

5 minutes before and 30 minutes after the next dose.

When plotting a 20-week-old infant's weight on a standardized growth chart, the nurse determines that the child's weight is between the 2nd and 3rd percentile. Based on this finding, which action should the nurse take?

Compare this weight with previous weights recorded in the child's record.

A 2-year-old child with Down syndrome is brought to the clinic for his regular physical examination. The nurse knows which problem is frequently associated with Down syndrome?

Congenital heart disease

When assessing a newborn infant's heart rate, which technique is most important for the nurse to use?

Count the heart rate for at least one full minute.

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.

Before administering a client's medication, the nurse assesses a change in the client's condition and decides to withhold the medication until consulting with the healthcare provider. After consultation with the healthcare provider, the dose of the medication is changed and the nurse administers the newly prescribed dose an hour later than the originally scheduled time. What action should the nurse implement in response to this situation?

Document the events that occurred in the nurses' notes.

When caring for an immobile client, what nursing diagnosis has the highest priority?

Impaired gas exchange.

The nurse knows that lab values sometimes vary for the older client. Which data would the nurse expect to find hen reviewing laboratory values of an 80-year-old male?

Increased protein in the urine, slightly increased serum glucose levels.

A 57-year-old male client is scheduled to have a stress-thallium test the following morning and is NPO after midnight. At 0130, he is agitated because he cannot eat and is demanding food. Which response is best for the nurse to provide to this client?

The test you are having tomorrow requires that you have nothing by mouth tonight.

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.

Which presentation of an infectious disease is acquired through an indirect transmission?

Malaria following exposure in a mosquito-infested area.

During lung assessment, the nurse places a stethoscope on a client's chest and instructs him/her to say "99" each time the chest is touched with the stethoscope. What should be the correct interpretation if the nurse hears the spoken words "99" very clearly through the stethoscope?

May indicate pneumonia.

A nurse working on a mental health unit receives a community call from a person who is tearful and states, "I just feel so nervous all of the time. I don't know what to do about my problems. I haven't been able to sleep at night and have hardly eaten for the past 3 or 4 days." The nurse should initiate a referral based on which assessment?

Moderate levels of anxiety.

A male client has a nursing diagnosis of "spiritual distress." What intervention is best for the nurse to implement when caring for this client?

Use reflective listening techniques when the client expresses spiritual doubts.

A female teenager is taking oral tetracycline (Achromycin V) for acne vulgaris. What is the most important instruction for the nurse to include in this client's teaching plan?

Use sunscreen when laying by the pool.

A 14-year-old female client tells the nurse that she is concerned about the acne she has recently developed. Which recommendation should the nurse provide?

Wash the hair and skin frequently with soap and hot water.