HESI questions Basic

Place the stages of the grieving process according to Kübler-Ross in the correct order. 1.Denial Correct 2.Anger Correct 3.Bargaining Correct 4.Depression Correct

1.Denial Correct 2.Anger Correct 3.Bargaining Correct 4.Depression Correct

Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5.5 hours. How much heparin has the client received?

11,000 units.

The nurse prepares a 1,000 ml IV of 5% dextrose and water to be infused over 8 hours. The infusion set delivers 10 drops per milliliter. The nurse should regulate the IV to administer approximately how many drops per minute?

21

The healthcare provider prescribes an IV infusion of 1,000 ml of Ringer's Lactate with 30 Units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound infant by cesarean section. The tubing has been changed to a 20 gtt/ml administration set. The nurse plans to set the flow rate at how many gtt/min?

83 gtt/min. gtt/min = 20gtt/ml X 1000 ml/4hrs X 1 hr/60 min =

While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement?

Acknowledge that she is supporting the arm correctly.

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 instructs a client that, in addition to building bones and teeth, calcium is also important for what? 1 Bile production 2 Blood production Correct3 Blood clotting 4 Digestion of fats

Blood clotting

The nurse is helping a client and her or his family to set and meet goals. Which professional role is the nurse displaying?

Caregiver

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

Commend the client for selecting a high biologic value protein.Correct

Which term refers to the exaggeration of the posterior curvature of the thoracic spine? 1 Lordosis 2 Scoliosis Correct3 Kyphosis 4 Osteoporosis

Correct3 Kyphosis

A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the infusion site. The nurse observes erythema, swelling, and a red streak along the vessel above the IV access site. Which action should the nurse take at this time?

Initiate an alternate site for the IV infusion of the medication.Correct

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

Keep gloved hands above the elbows.

Examination of a client complaining of itching on his right arm reveals 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.

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

Mix each medication individually.

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.

The nurse assigns a 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.

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

Request and document the name of the certified translator.Correct

When assisting an 82-year-old client to ambulate, it is important for the nurse to realize that the center of gravity for an elderly person is the

Upper torso.

The nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per minute should the client receive?

124 gtt/min. Correct

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.

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.

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. Correct

The nurse assesses an older adult client with cognitive impairment. Which statement(s) made by the client confirm the nurse's conclusion? Select all that apply. One, some, or all responses may be correct. Correct1 "I have difficulty judging things." 2 "I forget to take medicines." Correct3 "I am unable to do financial calculations." 4 "I get confused about the proper date and time." Correct5 "I am unable to recall words during conversations with my family."

Correct1 "I have difficulty judging things." Correct3 "I am unable to do financial calculations." Correct5 "I am unable to recall words during conversations with my family."

The nurse is assessing a client who arrived at the health care facility for an appointment. Which action by the nurse will be beneficial during the interview? Correct1 Asking about the client's current concerns 2 Ensuring the interview follows a strict agenda 3 Asking questions that promote short responses by the client 4 Telling the client what he or she should expect from the visit

Correct1 Asking about the client's current concerns

Which action would the nurse take for a client whose right radial pulse is weak and thready? Select all that apply. One, some, or all responses may be correct. Correct1 Assessing all peripheral pulses Correct2 Assessing and comparing both radial pulses Correct3 Asking a second nurse to assess the client's pulses Correct4 Assessing for edema or other issues that may be restricting peripheral blood flow Correct5 Observing for pallor/skin temperature differences distal to the weak pulse

Correct1 Assessing all peripheral pulses Correct2 Assessing and comparing both radial pulses Correct3 Asking a second nurse to assess the client's pulses Correct4 Assessing for edema or other issues that may be restricting peripheral blood flow Correct5 Observing for pallor/skin temperature differences distal to the weak pulse

Which client(s) would be considered for assessing the carotid pulse? Select all that apply. One, some, or all responses may be correct. Correct1 Client with cardiac arrest 2 Client indicated for Allen test Correct3 Client under physiological shock 4 Client with impaired circulation to foot 5 Client with impaired circulation to hand

Correct1 Client with cardiac arrest Correct3 Client under physiological shock

The nurse provides care for a Chinese client who is experiencing leg pain. The client states, "I don't want to take any medication that I may get addicted to." Which is the correct nursing intervention in this situation? Correct1 Give ibuprofen to the client with hot tea. 2 Give morphine to the client with hot tea. 3 Give ibuprofen to the client with cold water. 4 Postpone medication administration to the client.

Correct1 Give ibuprofen to the client with hot tea.

A client suffering from cancer is near the end of life. Which action(s) would be performed by the nurse to support the client's family members? Select all that apply. One, some, or all responses may be correct. Correct1 Helping the family set up hospice 2 Taking time to make sure that the family is comfortable 3 Staying with the client in the absence of family members Correct4 Giving the family information about the dying process Correct5 Making sure that the family knows what to do at the time of death

Correct1 Helping the family set up hospice Correct4 Giving the family information about the dying process Correct5 Making sure that the family knows what to do at the time of death

The nurse applies an ice pack to a client's leg for a total of 20 minutes. Which physiological effect would occur because of applying cold therapy? Correct1 Local anesthesia 2 Peripheral vasodilation 3 Depression of vital signs 4 Decreased viscosity of blood

Correct1 Local anesthesia

A client who is in a late stage of pancreatic cancer intellectually understands the terminal nature of the illness. Which behaviors indicate the client is emotionally accepting the impending death?

Correct1 Revising the client's will and planning a visit to a friend

The nurse is assessing a client after abdominal surgery. Which assessment findings would the nurse use to form a data cluster? Select all that apply. One, some, or all responses may be correct. Correct1 The client reports pain with movement. Correct2 The client has pain over the surgical area. 3 The client wants to know when he can go home. Correct4 The client rates the pain as 8 on a scale of 0 to 10. 5 The client has concerns about caring for the wound

Correct1 The client reports pain with movement. Correct2 The client has pain over the surgical area. Correct4 The client rates the pain as 8 on a scale of 0 to 10.

Which are the advantages of the team nursing model of providing nursing care? Select all that apply. One, some, or all responses may be correct. Correct1 The nursing care conferences help solve client problems. 2 Client satisfaction is highest compared with other models. Correct3 The model provides a high level of autonomy for the team leader. 4 Registered nurses are responsible for planning care for each client. Correct5 The model facilitates a high level of collaboration between team members.

Correct1 The nursing care conferences help solve client problems. Correct3 The model provides a high level of autonomy for the team leader. Correct5 The model facilitates a high level of collaboration between team members.

Which information would the nurse provide in a presentation to a group of women about ways to decrease their risk for becoming victims of crime? Select all that apply. One, some, or all responses may be correct. Correct1 Use night-lights. 2 Carry a weapon. Correct3 Install exterior lighting. Correct4 Attach whistle to key ring. 5 Park far from the building.

Correct1 Use night-lights. Correct3 Install exterior lighting. Correct4 Attach whistle to key ring.

The registered nurse (RN) is teaching the nursing student about interventions for cognitively impaired older adults. Which statement made by the nursing student indicates a need for further education? 1 "I should encourage fluid intake." Correct2 "I should provide conditional positive support." 3 "I should promote social interaction based on abilities." 4 "I should provide ongoing assistance to family caregivers."

Correct2 "I should provide conditional positive support."

An adult child of a dying client says to the nurse, "I am so upset because my parent is always angry at me." Which would be the correct response by the nurse? 1 "Your parent is frightened by impending death." Correct2 "Your parent is working through acceptance of the situation." 3 "Your parent is attempting to reduce your need for dependency." 4 "Your parent is hurt that you will not provide physical care at home."

Correct2 "Your parent is working through acceptance of the situation."

Which is a characteristic of the primary nursing model? 1 Care can be delegated. Correct2 Care is provided by the registered nurse (RN) to the client during a stay in a facility. 3 The registered nurse (RN) is responsible for all aspects of care for one or more clients during a shift of care. 4 The registered nurse (RN) leads a team of other registered nurses, practical nurses, and unlicensed assistive personnel.

Correct2 Care is provided by the registered nurse (RN) to the client during a stay in a facility.

A 78-year-old client who has hypertension is beginning treatment with furosemide. Considering the client's age, which would the nurse teach the client to do? 1 Limit fluids at bedtime. Correct2 Change positions slowly. 3 Take the medication between meals. 4 Assess the skin for breakdown daily

Correct2 Change positions slowly.

Which position is indicated to assess the musculoskeletal system but is contraindicated in clients with respiratory difficulties? 1 Sims position Correct2 Prone position 3 Supine position 4 Knee-chest position

Correct2 Prone position

The nurse would assess a client who underwent a paracentesis with 1500 mL removed for which complication? 1 Dry mouth Correct2 Tachycardia 3 Hypertensive crisis 4 Increased abdominal distention

Correct2 Tachycardia

Which client would have a health promotion nursing diagnosis? 1 The client with acute pain due to appendicitis Correct2 The client who is willing to take a 30-minute walk daily 3 The older adult client with dementia admitted to the health care facility Incorrect4 The client with reduced cognitive ability while recovering from surgery

Correct2 The client who is willing to take a 30-minute walk daily

Which principles would promote learning in older adults? Select all that apply. One, some, or all responses may be correct. 1 Emphasize abstract material. Correct2 Use past experiences while teaching. 3 Teach by presenting multiple examples at a time. Correct4 Keep the environmental distractions to a minimum. Correct5 Use audio, visual, and tactile cues to enhance learning.

Correct2 Use past experiences while teaching. Correct4 Keep the environmental distractions to a minimum. Correct5 Use audio, visual, and tactile cues to enhance learning.

A client asks the nurse, "Should I tell my partner that I just found out I'm human immunodeficiency virus (HIV) positive?" Which is the nurse's most appropriate response? 1 "Do not tell your partner unless asked." 2 "This is a decision you alone can make." Correct3 "You are having difficulty deciding what to say." 4 "Tell your partner that you don't know how you became sick."

Correct3 "You are having difficulty deciding what to say."

Which clinical indicator(s) would the nurse expect a client with hyperkalemia to exhibit? Select all that apply. One, some, or all responses may be correct. 1 Tetany 2 Seizures Correct3 Confusion Correct4 Weakness Correct5 Dysrhythmias

Correct3 Confusion Correct4 Weakness Correct5 Dysrhythmias

The nurse reviews the medical record of a client with ascites. Which client condition is a contributing factor to the development of ascites? 1 Portal hypotension 2 Kidney malfunction Correct3 Diminished plasma protein level 4 Decreased production of potassium

Correct3 Diminished plasma protein level

Which critical thinking skill is being used when the nurse applies knowledge and experience to client care? 1 Analysis 2 Evaluation Correct3 Explanation 4 Interpretation

Correct3 Explanation

Which nursing interventions would help a terminally ill client cope with feelings related to death? Select all that apply. One, some, or all responses may be correct. 1 Providing medications and therapies for pain management 2 Teaching the client about the importance of complementary medicine Correct3 Helping the client find meaning and purpose in life by listening to his or her concerns Correct4 Allowing time for religious readings, spiritual visitations, or attendance at religious services Correct5 Encouraging the client to pray if he or she wishes by facilitating privacy and a proper environment

Correct3 Helping the client find meaning and purpose in life by listening to his or her concerns Correct4 Allowing time for religious readings, spiritual visitations, or attendance at religious services Correct5 Encouraging the client to pray if he or she wishes by facilitating privacy and a proper environment

A client with hemiplegia becomes frustrated when performing skills. Which nursing intervention would motivate the client toward independence? 1 Establish long-range goals for the client. 2 Identify errors that the client can correct. Correct3 Reinforce success in tasks accomplished. 4 Demonstrate ways to promote self-reliance.

Correct3 Reinforce success in tasks accomplished.

The primary health care provider instructs the nurse to manage fluid replacement therapy in a client with cancer. Which type of care is the client receiving? 1 Palliative care 2 Comfort care Correct3 Supportive care 4 End-of-life care

Correct3 Supportive care

Which assessment would the nurse exclude when dealing with a client with receptive and expressive aphasia? 1 Ask the client to read simple sentences aloud. 2 Point to a familiar object and ask the client to name it. Correct3 Test the mental status by asking for feedback from the client. 4 Ask the client to respond to simple verbal commands such as "stand up."

Correct3 Test the mental status by asking for feedback from the client.

The nurse is providing care to a client after surgery to correct an upper urinary tract obstruction. Which assessment finding would the nurse report to the surgeon? 1 Incisional pain 2 Absent bowel sounds Correct3 Urine output of 20 mL/h 4 Serosanguineous drainage on the dressing

Correct3 Urine output of 20 mL/h

A client becomes hostile when learning that amputation of a gangrenous toe is being considered. After the client's outburst, which is the best indication that the nurse-client interaction has been therapeutic? 1 Increased physical activity 2 Absence of further outbursts Correct3 Relaxation of tensed muscles 4 Denial of the need for further discussion

Correct3 Relaxation of tensed muscles

Once an infant is stabilized after a choking incident, which statement made by the parents indicates a need for teaching? 1 "The baby is always buckled into the stroller or infant seat." 2 "The spaces between the slats of the crib are only 2 inches wide." 3 "The pacifier is never placed on a string around our baby's neck." Correct4 "The crib is filled with many small stuffed animals with button noses."

Correct4 "The crib is filled with many small stuffed animals with button noses."

The registered nurse (RN) is caring for a client who is on isolation precautions. Which tasks can be safely assigned to the nursing assistive personnel? Select all that apply. One, some, or all responses may be correct. 1 Assessing vital signs 2 Administering injections 3 Assessing wound drainage Correct4 Bringing equipment to the client's room Correct5 Transporting the client to a diagnostic test

Correct4 Bringing equipment to the client's room Correct5 Transporting the client to a diagnostic test

While caring for a client with a portable wound drainage system, the nurse observes that the collection container is half full. The nurse empties the container. Which nursing intervention would the nurse do next? 1 Encircle the drainage on the dressing. 2 Irrigate the suction tube with sterile saline. 3 Clean the drainage port with an alcohol wipe. Correct4 Compress the container before closing the port.

Correct4 Compress the container before closing the port.

After teaching the parents of an infant the ways to prevent sudden infant death syndrome (SIDS), which action indicates a need for further teaching? 1 Removes pacifiers from strings 2 Uses snug-fitting sheets in crib 3 Eliminates bumper pads from crib Correct4 Places the infant on stomach to sleep

Correct4 Places the infant on stomach to sleep

A client who was exposed to hepatitis A asks why an injection of gamma globulin is needed. Which would the nurse consider teaching about how gamma globulin provides passive immunity? Incorrect1 It increases production of short-lived antibodies. 2 It accelerates antigen-antibody union at the hepatic sites. 3 The lymphatic system is stimulated to produce antibodies. Correct4 The antigen is neutralized by the antibodies that it supplies.

Correct4 The antigen is neutralized by the antibodies that it supplies.

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

Flush the tube with water.

The nurse is providing interventions to give support services for delivery of care. According to the Nursing Intervention Classification (NIC) taxonomy, which domain does this care belong to? 1 Behavioral 2 Community 3 Physiological Correct4 Health system

Health System

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.