HESI Question Bank
A toddler is admitted after taking an unknown number of acetaminophen tablets. Which of the following early symptoms would the nurse expect to find on her assessment? Select all that apply. A. Pallor B. Hot, dry skin C. Pain in the upper right quadrant D. Severe burning pain in stomach E. Nausea, vomiting F. Coughing and inability to clear secretions
A. Pallor E. Nausea, vomiting
The nurse notes that a client is quite suspicious during an assessment interview and believes that her family is under investigation by the CIA. What would be appropriate nursing interventions with this client? Select all that apply. A. Use active listening skills to seek information from the client. B. Encourage the client to describe the problem as she sees it. C. Ask the client to tell you exactly what she thinks is happening. D. Tell the client that she is delusional and you can help her. E. Explain to the client that most people are not investigated by the CIA or FBI. F. Reassure the cleint that you are not with the CIA.
A, B, C: The client is demonstrating paranoid behavior, which necessitates a matter-of-fact approach that is nonjudgmental and accepting of the client's statements and shows the nurse's willingness to listen attentively to the issue. Telling the client that she is delusional, explaining that most people are not investigated by the CIA or FBI, reassuring the client that you are not with the CIA do not help the paranoid client gain trust to talk with the nurse.
Which of the following would be important to include in a continuing service education program on prevention of needle-stick injuries? Select all that apply. A. Maintain a sharps injury log in the unit. B. Recap needles in the home health care setting only. C. Plan safe handling of and disposal of needles before beginning procedures. D. Avoid using needles when needleless systems are available. E. Always use the one-handed needle recapping technique. F. Remove the automatic needle sheath guards to avoid contamination.
A, C, D: Recommendations from the Occupational Safety and Health Administration (OSHA) regarding exposure to bloodborne pathogens and needlestick or other sharps injuries include the following: maintain a sharps injury log on the unit, including type and brand of device involved and location and description of the incident; maintain privacy of injured employee; do not recap any needle in any setting; plan safe handling of and disposal of needles before beginning procedures; and avoid using needles when needleless systems are available. Special syringes are designed with a sheath or guard that covers the needle after it is withdrawn from the skin. This guard or sheath must not be removed because it immediately covers the needle, thus eliminating the chance of a needlestick injury.
A teacher notifies the school nurse that many of the students in her third-grade class have been scratching their heads and complaining of intense itching of the scalp. The nurse notices tiny white material at the base of a student's hair shaft. What condition does this assessment reflect? A. Tinea capitis B. Pediculosis capitis C. Dandruff D. Scabies
B: Pediculosis capitis (head lice) is characterized by tiny white nits (eggs) that attach to the base of the hair shaft and are highly contagious. Tinea capitis is characterized by a red, scaly, rash with central clearing in the well-define margins. Dandruff is often mistake for head lice, but dandruff can be easily removed from the hair shaft. Nits adhere to the hair shaft and are not easy to remove. Scabies forms burrows under the skin and cause intense nighttime itching.
The nurse is caring for a client who is experiencing a severe anaphylactic reaction caused by an allergy to peanuts. After administering subcutaneous epinephrine and beginning oxygen administration, what would be the next most important nursing action? A. Administer analgesics to relieve the pain. B. Start an IV for fluid administration. C. Insert a catheter to determine urinary output. D. Obtain a history of possible reactions to penicillin.
B: Shock is a common problem in anaphylactic reactions; therefore it is important to establish an IV for fluid and medication administration. There should be no pain, and there is no reason the client cannot void on his or her own. A history can be taken at a later time.
The nurse enters data on a paper chart and then discovers the entry was written on the wrong chart. How is this error best corrected? A. White-out the wrong information and write over it. B. Recopy the page with the error so that the chart will be neat. C. Draw a straight line through the error, initial, and date. D. Obliterate the error so that it will not be confusing.
C: Drawing a straight line through the error and initialing and dating it is the recommended procedure for correcting an error. Errors in charting on a paper chart should never by obliterated, recopied, or covered with correction fluid. When the erroneous information is not legible, it raises questions as to what the person was trying to cover up.
The nurse understands that the following are general adverse effects of antineoplastic drugs. Select all that apply. A. Urinary retention B. Infertility C. Stomatitis D. Bone marrow depression E. Extravasation F. Nausea
C, D, F: Adverse effects of antineoplastic drugs can be classified as acute, delayed, or chronic. Acute toxicity includes nausea, vomiting, arrhythmias, and allergic reactions. Delayed side effects include stomatitis, alopecia, and bone marrow depression. Chronic toxicity involves organ damage. Common urinary problems include cystitis and nephrotoxicity. Extravasation is not an adverse effect but a complication of an infiltrated IV running a chemotherapy medication that is a vesicant.
A nurse case worker suspects older adult neglect. Which assessment finding during a home visit would confirm this? Select all that apply. A. Confusion and disorientation B. Recent hip fracture C. Poor nutrition and hygience D. Dirty dishes in the sink E. Outdated prescription bottles F. Missing hearing aids
C, E, F: Lack of assistive devices, medication mismanagement, and access to basic physiologic needs such as hygienic care, food, and water are characteristics of neglect in the older adult. A hip fracture is typically caused by osteoporosis in older adults, not neglect. Confusion and disorientation are signs of dementia. Dirty dishes in the sink is not a sign of neglect.
A client is receiving chemotherapy with several antineoplastic agents. Which nursing observation is considered a common side effect of chemotherapy? A. Slow, slurred speech B. Increased leukocytes on complete blood count C. Stomatitis and oral ulcers D. Sinus dysrhythmias with bradycardia
C: A common side effect of chemotherapy is stomatitis. It may be manifested as inflammation of the gums and ulcerations in the mouth. There is a decrease in leukocytes, making the client less resistive to infection. Dysrhythmias are not common in cancer therapy; they may occur with electrolyte imbalances secondary to chemotherapy. The slowed speech may occur with hypercalcemia as a complication involving the parathyroid gland.
A postoperative client receives a dinner tray with gelatin, pudding, and vanilla ice cream. Based on the foods on the client's tray, what would the nurse anticipate the cleint's current diet order to be? A. Bland diet B. Soft diet C. Full liquid diet D. Regular diet
C: A full liquid diet includes liquids, as well as foods that are liquid at room temperature, such as ice cream, custards, puddings, and some refined cereals. A bland diet consists of foods that are soft, not very spicy, and low in fiber. A soft diet or low-residue includes foods that are low fiber and easily digested, such as pastas, casseroles, canned fruits, and vegetables. A regular diet has not restrictions.
Which of the following is not considered a component of the medical assets stored in a Strategic National Stockpile? A. Antibiotics B. Ventilators C. Chemical antidotes D. Personal protective equipment
C: Chemical antidotes are stored in CHEMPACK containers used int he forward deployment for response to a chemical terrorist event. Antibiotics, ventilators, and personal protective equipment are all components of a Strategic National Stockpile push pack.
A client has just received 250mL of packed red blood cells and is now receiving 1000mL of D5W at 150mL/hr. The client tells the nurse that he feels dizzy and has a headache. The nurse observes the distended jugular veins with the client in a semi-Fowler's position. What would be the nurse's initial response? A. Notify the physician with the client's vital signs and complaints. B. Check vital signs and place the client in semi-Fowler's position. C. Reduce the D5W infusion to keep vein open rate. D. Increase the rate of the IV because of the obvious signs of dehydration.
C: Headache and dizziness in a client receiving IV fluid are frequently signs of fluid overload from the increase in circulating volume, which increases cerebral vascular pressure. After decreasing the IV rate, the nurse should continue with the assessment of the vital signs. If other assessment findings (increased blood pressure, lethargy, bounding pulse, weight gain, adventitious breath sounds) confirm the problem, the physician needs to be notified. If the increase in circulating volume continues, it can cause pulmonary edema.
Which of the following events is an example of a Level III disaster? A. A small building collapse that traps 115 workers B. A bus accident carrying 13 passengers C. An 8.0 scale earthquake in a major city D. F-4 tornado destruction through 3 cities
C: Level III disasters consume local, state, and federal resources to the fullest extent and require an extended response time of the nurse, which would be an 8.0 scale earthquake in a major city. A small building collapse is a Level II disaster that requires the nurse to respond in a greater capacity using larger casualty practices in coordination with regional response agencies. A bus accident is a Level I disaster that includes local emergency medical systems and the community to provide medical support. An F-4 tornado is a Level II disaster that requires the nurse to respond in a greater capacity using larger casualty practices in coordination with regional response agencies.
Which of the following are agents listed by the CDC as agents most likely to be involved in bioterrorism? Select all that apply. A. Influenza B. West Nile virus C. Cryptosporidiosis D. Anthrax E. Plague F. Smallpox
D, E, F: Anthrax, smallpox, and plague are all bioterrorism agents that may be spread through the air and cause significant morbidity and mortality. Influenza is a viral respiratory infection. West Nile virus is a vector-borne disease. Cryptosporidiosis is a waterborne diarrheal disease.
The nurse is preparing a client for surgery. Which of the following items on the client's pre-surgery laboratory results would indicate a need to contact the surgeon? A. Platelet count of 325,000mm3 B. Total cholesterol of 325mg/dL C. Blood urea nitrogen (BUN) 17mg/dL D. Hemoglobin 9.5g/dL
D. Hemoglobin 9.5g/dL Low Hemoglobin needs to be reported to surgeon.
The nurse stopped on the highway at a multiple fatal accident to provide assistance. Immediately after the incident, the family members were appreciative of the help the nurse provided. They offered to replace the nurse's soiled clothes. If the nurse accepts, which rights were in violation? A. ANA Code of Ethics B. HIPAA C. Patient Self-Determination Act D. Good Samaritan Act
D: The nurse was in violation of the Good Samaritan Act. Allowing the family to replace the soiled clothes was a form of compensation, which is in direct violation of the Good Samaritan Act. None of the other choices are applicable to the situation. The ANA Code of Ethics provides principles to facilitate ethical problem solving. HIPAA is a law providing confidentiality for the client to protect written and verbal communication about the client. The Patient Self-Determination Act requires that hospitalized patients indicate whether they have an advanced directive.
A nurse is teaching a client how to administer subcutaneous (subQ) insulin injections. Which injection site should the client use? Deltoid Rectus femoris Vastus lateralis Anterior aspect of the thigh
SubQ injection sites, which are relatively distant from bones and major blood vessels, include the lateral aspects of the upper arm, the anterior aspects of the thigh, and the abdomen. The deltoid, rectus femoris, and vastus lateralis are I.M. injection sites.
The nurse is documenting information regarding an IV insertion. What information is important to include? Select all that apply. A. Time and date of insertion B. Type of catheter and size C. Name of vein used D. Status of fluids infusing E. Protective measures used F. Who ordered the IV and at what time
A, B, D: The specific name of the vein is not necessary; however, the general location of the site is important. Standard precautions are used for everyone, and it is not necessary to chart that they were used. The order and time for the IV should be on the client's chart; it is not necessary to repeat it in the documentation. The question did not ask for all the information that could be charted.
The doctor has ordered ampicillin and gentamicin are to be given piggyback in the same hour, every 6 hours (12-6-12-6). How would the nurse administer these drugs? A. Combine the drugs into 100mL NS and administer. B. Give each drug separately, flushing between drugs. C. Retrograde both drugs into the tubing. D. Give one drug every 4 hours and the other every 6 hours.
B: Only one antibiotic should be administered at a time; therefore, if the medications are given during the same hour, the IV tubing will need to be be flushed between administrations. Both drugs should be administered at the time ordered.
The nurse receives report on assigned clients. One client is reported to be at the nadir for his cancer chemotherapy. How will this affect the nursing care plan? A. Implement bleeding precautions. B. Reinforce measures and teaching regarding preventing infections. C. Anticipate nutritional problems caused by nausea and vomiting. D. Assess for problems with fluid balance.
B: The nadir refers to the point in the chemotherapy when the leukocytes or neutrophils are at the lowest level. The client's ability to resist infections is at the lowest point, and the client is at the highest risk for developing an infection. Bleeding precautions are implemented with thrombocytopenia or decreased platelets. Nutritional problems are common throughout chemotherapy, and there is no increased risk for development of problems with fluid balance.
Which of the following signs and symptoms would the nurse assess for in a client with possible lithium toxicity? A. Hypotension, bradycardia, polyuria B. Tachycardia, hypertension, convulsions C. Diarrhea, ataxia, seizures, lethargy D. Urinary frequency, vomiting, fever
C: Lithium toxicity is a serious problem for clients with bipolar disorder. Symptoms include diarrhea, confusion, ataxia, slurred speech, hypotension, seizures, oliguria, coma, and death.
Which term describes the sorting of clients according to medical need when resources are unavailable for all persons to be treated? A. Tasking B. Delegating C. Triage D. Prioritize
C: Triage can be used by lightly trained emergency department (ED) personnel and is not to supersede or instruct medical techniques. A common triage system used is known as START (simple triage and rapid treatment). Triage is used during natural disasters and mass casualty events. Delegation, assigning tasks, and prioritizing care are daily functions of the nurse manager.
Which of the following clients would be at an increased risk for the development of a pulmonary embolus? A. A man with a fractured femur who is in balanced skeletal traction B. An older adult woman with a fractured hip who is in physical therapy C. A woman who gave birth 2 days ago and is going home D. A man who had a thoracotomy 2 days ago and has chest tubes
A: The man with the fractured femur is in traction, which means he is immobilized. The immobilization is necessary to prevent rotation and/or further movement of the fracture site after the repair. The client who is immobilized is at the highest risk for venous stasis, particularly in the large pelvic veins in the abdomen. The other clients listed are all mobile - the client with the fractured hip is in physical therapy, postpartum client is going home, and the post-thoracotomy client should be out of bed 2 or 3 times a day. Clients with chest tubes should be ambulated, when possible, to enhance pulmonary expansion.
A client has extensive burns with eschar on the anterior trunk. What is the nurse's primary concern regarding eschar formation? A. It prevents fluid remobilization in the first 48 hours after burn trauma. B. Infection is difficult to assess before the eschar sloughs. C. It restricts the ability of the client to move about. D. Circulation to the extremities is diminished because of edema formation.
B: The primary concern would be watching for infection because the eschar makes it difficult to visually examine the healing skin. Removal of the eschar enhances healing and prevents infection, which occurs because of the moist, enclosed area under the eschar. Eschar formation will not prevent fluid remobilization. It might restrict mobility if the eschar were involving the arms, legs, or joint areas. Circulation to the extremities would not be affected by eschar on the anterior trunk; that would be the case if the eschar were on the extremities.
An older adult client has an order for continuous fluid replacement at 75mL/hr. The nurse is preparing to start the IV. What site would be appropriate, and what is the equipment of choice? A. A 22-gauge butterfly needle, right arm antecubital area B. An 18-gauge, 3-inch IV cannula, inserted in the left hand C. An 18-gauge, 1-inch IV cannula, in the antecubital area of left arm D. A 22-gauge, 1-inch IV cannula, top of the left hand
D: With a continuous flow at 75mL/hr, a small gauge IV cannula (22 gauge, 1 inch {2.5cm} is appropriate. Butterfly needles are used for short-term infusions and drawing blood. IVs should be started in the lowest vein possible and progress upward. The antecubital area is not a preferred area for continuous fluid replacement.
Which of the following statements are correct about latex allergy? Select all that apply. A. Typical reactions include skin redness, urticaria, and rhinitis. B. Latex allergy involves only type I allergic reactions. C. The more frequent the exposure to the latex, the more likely a person will develop an allergy. D. Hand lotions should be applied before putting on gloves to reduce exposure. E. Wash hands with mild soap after removing gloves. F. Persons should wear a medic alert bracelet and carry an epinephrine pen.
A, C, E, F: It is important for the nurse to recognize symptoms of latex allergy - skin rash, hives, flushing, and itching; nasal, eye, and sinus symptoms; asthma, and (rarely) anaphylaxis; the nurse should also be aware of latex-containing products - gloves, blood pressure cuffs, stethoscopes, tourniquets, IV tubing, syringes, electrode pads, oxygen masks, tracheal tubes, colostomy and ileosotomy tubes, urinary catheters, anesthetic masks, and adhesive tape. The use of nonlatex gloves and powder-free gloves, along with the elimination of oil-based hand creams or lotions when wearing gloves, can reduce exposure. Always wash hands after removing gloves. Individuals with latex allergy should wear a medic alert bracelet if latex sensitive. The more frequent and prolonged the exposure to latex, the greater the likelihood of developing latex allergy. There are two types of latex allergy - type IV allergic contact dermatitis (delayed reaction) and type I allergy reaction (immediate response).
The nurse is preparing discharge teaching for a woman newly diagnosed with SLE. What will be important for the nurse to include in the teaching plan? Select all that apply. A. Wear sunscreen and protective clothing when in direct sunlight. B. Avoid nonsteroidal anti-inflammatory drugs to prevent bleeding episodes. C. Plan activities that encourage range of motion in extremities. D. Advise the client that pregnancy is contraindicated. E. Observe fingertips for changes in circulation. F. Help the client prioritize self-care activities.
A, C, E, F: The client with systemic lupus erythematosus is photosensitive and needs protection from sunlight. The client needs to keep joints mobilized because of the invasion of the lupus erythematosus cells into the joints. This condition also affects the circulation in the fingertips, and Raynaud's phenomenon is characteristic of the disease. Fatigue is a problem, and the client needs to prioritize activities of daily living. Non-steroidal anti-inflammatory drugs (NSAIDs) are frequently used to reduce the musculoskeletal discomforts. Although individual disease progression and course of therapy need to be considered in consultation with health care providers, there is no specific contraindication to pregnancy. The woman should be advised regarding individual risk, but she can carry and deliver a healthy infant.
A client is scheduled for a total hip replacement, and he has a history of using several herbal and vitamin products. What would the nurse advise the client to discontinue at least 2 weeks before surgery? Select all that apply. A. Garlic B. Vitamin C C. Ginger root D. St. John's wort E. Ma huang F. Black cohosh
A, C, E: Garlic and ginger root can prolong bleeding time by suppressing platelet aggregation. Ma huang is ephedra and affects the blood pressure. St. John's wort, vitamin C, and black cohosh are safe to continue before surgery.
The nurse is designing a teaching plan for a 3-year-old in preparation for a surgical procedure. What teaching strategies should be included in the plan of care? Select all that apply. A. Include the child's parents in the teaching. B. Intellectual development moves from abstract to concrete. C. Prevent separation anxiety. D. Provide anatomy and physiology information. E. A "no" response from the child means he or she is not ready to learn.
A, C: Parents should be included in the teaching of the pediatric client, and separation anxiety should be minimized. If the client is younger than 4 years, he or she will generally not benefit from anatomy and physiology information; simple explanations are better. A "no" response from a toddler is usually an assertion of independence, rather than an indication that the child is not ready to learn. Learning moves from concrete to abstract.
The nurse is caring for a client who had a stroke 3 months ago and is taking warfarin 5mg PO. The client tells the nurse she has started taking some herbal and vitamin supplements. She gives the nurse a list of the supplements she is taking. What supplements would cause concern for the client who is on warfarin? Select all that apply. A. Garlic B. Cyanocobalamin (vitamin B12) C. St. John's wort D. Vitamin E E. Saw palmetto F. Ginkgo biloba
A, D, F: Garlic, ginkgo biloba, and vitamin E may interfere with platelet aggregation and increase the risk for bleeding in clients who are taking warfarin.
Which of the following conditions satisfies a "green" triage tag in an emergency triage scenario? A. A broken thumb from falling debris B. Burns over 98% of body from a chemical fire C. A 3-inch laceration on the forearm from window glass in a building explosion D. Tension pneumothorax
A: A "green" triage tag, also referred to as the "walking wounded", would be a broken thumb from falling debris. Burns over 98% of the body are declared "black" because the injured person is not likely breathing and is beyond the scope of available medical assistance. A 3-inch laceration on the arm is labeled "yellow" because such injured persons can be assisted after "immediate (red)" clients, such as the person with a tension pneumothorax, are medically cared for first.
Which of the following biologic agents are disseminated by airborne release? A. Botulism and anthrax B. Anthrax and plague C. Plague and smallpox D. Botulism and smallpox
A: Both anthrax and botulism can be aerosolized and inhaled and disseminated by airborne release. Plague and smallpox are spread person-to-person.
The nurse is assisting a client with his antiretroviral therapy. What can the nurse do to help the client take his medication as prescribed? A. Assess the client's activities of daily living and his lifestyle routine to determine when he can most easily remember to take his medications. B. Provide the client with brochures that explain the side effects of the medications and why it is is so important for him to adhere to his medication schedule. C. Plan for him to visit with other clients who use the same antiretroviral therapy and have them explain to the client how they handle their medications. D. Emphasize to the client how important it is to take the medications on the schedule prescribed so that the virus will not get stronger.
A: It is important to identify the client's routines and discuss how he can adapt those routines to take his medications as prescribed. Discussing with the client the importance of taking the medications does not assist him to identify ways in which he can incorporate the medications into his daily routines. Talking to and working with another client is positive, but it still does not incorporate the medication routine into his own daily living routines.
The nurse is reviewing the health care provider's orders for a new client. The client has just returned from the surgical recovery area. The client is NPO. He has a nasogastric tube, and his vital signs are stable. Which order would the nurse question? A. 20mEq potassium IV push B. 1000mL D5 1/2 NS to infuse at 125mL/hr C. Assist client to dangle at bedside in morning D. Mefoxin 1 gm IV in 50mL D5W over 30 minutes
A: Potassium should never be administered IV push. It is extremely irritating and painful at the catheter site, as well as dangerous to the client. It should be diluted in an IV solution and run over the time of the total infusion (1000mL D5W with 40mEq potassium over 8 hours), or small amounts should be given in less solution (potassium 10mEq in 250mL D5W to run over 3 hours). The other orders listed are all within acceptable limites for a postoperative client.
Which of the following most clearly represents a situation of assault? A. In the emergency department, a client is intoxicated and verbally abusive; the nurse tells him she will put him in restraints if he does not quit talking. B. A client is in labor and has not received any medication for pain; she tells the nurse she does not want anything for pain; the nurse administers the pain medication ordered. C. The client advises the nurse that he is leaving; the nurse tells the client he cannot leave and threatens to restrain him if necessary. D. A pastor calls regarding a client's condition; the nurse provides the pastor with detailed information regarding the client's condition.
A: The nurse in the emergency department has threatened the client with physical restraint if he does not quit being verbally abusive; the threat is considered an assault. When the nurse gives a mediation the client does not want, it is a situation of battery or abuse, as well as nonconsensual touching. The nurse is committing false imprisonment when she threatens the client with physical restraint to prevent him from leaving. When the nurse does not check to see whether the pastor had permission from the client to receive this information, it describes a breach of confidentiality and invasion of privacy.
To evaluate the progress of the client's systemic lupus erythematosus (SLE), the nurse evaluates which data? A. Increased serum complement fixation, which correlates with reduction of "butterfly" rash B. Increasing levels of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) C. Overall bone marrow proliferation, which correlates with symptoms of inflammation D. Presence of antinuclear antibodies (ANA), which correlates with a diminishing immune process
B: The ESR and the CRP are indicators of inflammation in the body. Neither is diagnostic of SLE; however, the level of inflammation is an index to the progress of the condition. Presence of ANA is a characteristic of SLE, but it does not indicate progression. Complement fixation does not indicate progression, nor does absence or presence of the butterfly rash.
A client comes to the outpatient clinic with impetigo on his left arm. What information would the nurse give this client? A. Apply antibiotic ointment to the crusted lesions. B. Wash the lesions with soap and water, and then apply a steroid ointment. C. Soak the scabs off the lesions and apply an antibiotic ointment. D. Wash the lesions with hydrogen peroxide and apply an antifungal cream.
C: Teaching should include the use of warm saline or aluminum acetate soaks followed by soap and water removal of crusts and application of a suitable antibiotic ointment, such as mupirocin. Hydrogen peroxide has little ability to reduce bacteria in wounds and can actually inflame healthy skin cells that surround a lesion, increasing the amount of time the wounds take to heal. Impetigo is caused by group A beta-hemolytic streptococcus or Staphylococcus species, which are bacterial and would not be treated by an antifungal cream. If lesions are on the face, a systemic antibiotic also may be given.
