HESI Practice Exam Flashcards
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.
Rationale: the first action taken by the nurse should be to assess the skin for any possible thermal injury. If no injury to the skin has occurred, the nurse can take the other actions as needed.
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/ml
Rationale: Convert pounds to kg: 182/2.2 = 82.73 kg. Determine the dosage for this client: 5 mcg x 82.73 kg = 413.65 mcg/min. Determine how many mcg are contained in 1 ml: 250/50,000 mcg = 200 mcg per ml. The client is to receive 413.65 mcg/min, and there are 200 mcg/ml; so the client is to receive 2.07 ml per minute. With a drip factor of 60 gtt/ml, then 60 × 2.07 = 124.28 gtt/min.
Which assessment data pro provides the most accurate determination of proper placement of a nasaogastric tube?
Examining a chest x-ray obtained after the tube was inserted.
Rationale: both A (aspirating gastric contents to assure a pH value of four or less) and B (hearing air pass in the stomach after injecting air into the tubing), are methods used to determine proper placement of the NG tubing. However, the answer above is the best indicator that the tubing is properly placed.
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 appear smaller when the initial swelling diminishes.
Rationale: Postoperative swelling causes enlargement of the stoma. The nurse can teach the client that the stoma will become smaller when the swelling is diminished. This will help reduce the clients anxiety and promote acceptance of the colostomy.
A female client with a nasal gastric tub attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasal gastric tube in the last two hours. What action should the nurse first take?
Reposition the client on her side
Rationale: the immediate priority is to determine if the tube is functioning correctly, which would then relieve the client’s nausea. The least invasive intervention (above) should be attempted first, followed by A (irrigate the nasogastric tube with sterile normal saline) and C (advance, the nasal gastric tube, and additional 5 cm), unless either of these interventions is contraindicated. If these measures are unsuccessful, the client may require an antiemetic.
A hospitalized male client is receiving nasogastric to feedings via a small-bore tubing 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.
Rationale: coughing, vomiting, and suctioning and precipitate displacement of the tip of the small boar feeding tube upward into the esophagus, placing the client at increased risk for aspiration. Checking the sample of fluid withdrawn from the tube(after clearing the tube with 30 mL of air) acidic acid (stomach) or alkaline (intestine) values is a more sensitive method for these tubes, and the nurse should assess tube placement in this way prior to taking other actions.
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 type in place.
Rationale: the client is exhibiting disorientation.
A client with chronic kidney disease (CKD) select a scrambled egg for his breakfast. What action should the nurse take?
Commend the client for selecting a high biologic value protein.
Rationale: foods such as eggs and milk are high biologic proteins, which are allowed because they are complete proteins and supply the essential amino acids that are necessary for growth and cell repair.
When assisting an 82-year-old client ambulate, it is important for the nurse to realize that the center of gravity for an elderly person is the
Upper torso
Rationale: the center of gravity for adults is the hip. However, as a person grows older, a stooped posture is common because of the changes from osteoporosis and normal bone, degeneration, and the knees, hips, and elbows flex. This stooped posture results in the upper torso, becoming the center of gravity for older persons.
In developing a plan of care for a client with with dementia, the nurse should remember that confusion in the elderly
Often follows relocation to new surroundings.
Rationale: relocation often results and confusion among elderly client — moving is stressful for anyone.
A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client’s readiness to manage his wound care after discharge? The client.
Demonstrates the wound care procedure correctly.
Rationale: a return demonstration of a procedure provides an objective assessment of the client’s ability to perform a task.
A client who is 5’,5” tall and weighs 200 pounds is scheduled for surgery the next day. What question is the most important for the nurse to include during the preoperative assessment?
What vitamin and mineral supplements do you take?
Rationale: vitamin and mineral supplements, may impact medication use during the operative.
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.
Rationale: Dark amber, urine is a characteristic of fluid volume deficit, and the client should be encouraged to increase fluid intake. Caffeine is a diuretic, and may worsen the fluid volume deficit.
Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention?
Assessed for bladder distention.
Rationale: Urinary retention is the inability to void. All urine collected in the bladder, which leads to uncomfortable bladder distention.
A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is the most important for the nurse to implement?
Ensure the accuracy of the blood type match.
Rationale: all interventions should be implemented prior to administering blood, but this has the highest priority. Anytime blood is administered, the nurse should ensure the accuracy of the blood type match in order to prevent a possible hemolytic reaction.
A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he has to take three doses of 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 AM, 4 PM, and midnight.
Rationale: Theophylline should be administered on a regular around-the-clock schedule, to provide the best bronco dilating effect, and reduce the potential for adverse effects.
When evaluating a client 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.
Rationale: First, the nurse should review which actions in the original plan were not implemented in order to determine why the original plan did not produce the desired outcome. Appropriate revisions can then be made, which may include revising the expected outcome, or identifying a new nursing diagnosis.
Which snack food is best for the nurse to provide a client with myasthenia gravis who is at risk for altered nutrition status?
Chocolate pudding
Rationale: The client with myasthenia gravis is at high risk for altered nutrition because of fatigue and muscle weakness, resulting in dysphagia. Snacks that are semi-solid, such as pudding, are easy to swallow and require minimal chewing, effort, and provide calories and protein.
The nurses instructing a client with high cholesterol about diet and lifestyle 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.
Rationale: Living saturated, fat from animal food sources to know more than 4 ounces per week is an important diet modification for low cholesterol. To be effective in reducing cholesterol, the client should exercise 30 minutes per per day, or at at least 4 to 6 times per week. Red meat and all proteins. Do not need to be eliminated to Laura cholesterol, but should be restricted to lien cuts of red meat and smaller portions (2-ounce servings).
An obese male client discusses with the nurses 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.
Rationale: the most most important teaching is so that the client will not begin a dangerous level of exercise when he is not sufficiently fit. This might result in chest pain, a heart, attack, or stroke.
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 of the inhaler?
During the inhalation.
Rationale: The client should be instructed to deliver the medication during the last part of inhalation. After the medication is delivered, the client should remove the mouthpiece, keeping his/her lips closed, and breath held for several seconds to allow for the distribution of the medication.
The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via essential line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take?
Infused 10% dextrose and water at 54 ml/hr.
Rationale: TPN is discontinued gradually to allow the client to adjust to decrease the levels of glucose. Administering 10% dextrose in water at the prescribed rate will keep the client from experiencing hypoglycemia until the next TPN solution is available. The client could experience a hypoglycemic reaction if the current level of glucose is not maintained, or if the TPN is discontinued abruptly.
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.
Rationale: macules are localized flat skin discoloration less than 1 cm in diameter. However, when recording such a finding the nurse should describe the appearance rather than simply naming the condition.
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. What would an appropriate response to the client’s silence be?
“It is OK if you don’t want to talk about your surgery. I will be available when you are ready.”
Rationale: this display sensitivity and understanding without judging the client.
The nurse is evaluating a client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that the client understands the dietary restrictions?
Skim milk, turkey salad, roll, and vanilla ice cream.
Rationale: Skim milk, turkey salad, bread, and ice cream, well, containing some sodium, are considered low-sodium foods.
An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings through a gastrostomy tube. What is the best client position for administration of the bolus tube feedings?
Fowler’s
Rationale: The client should be positioned in a semi-sitting (Fowler’s) position during feeding to decrease the occurrence of aspiration. A gastrostomy tube, known as a PEG tube, due to placement by a percutaneous endoscopic gastrostomy procedure, is inserted directly to the stomach through an incision in the abdomen for long-term, administration of nutrition and hydration in the debilitated client.
Which action is most important for the nurse to implement when donning sterile gloves?
Keep gloves, hands above the elbows.
Rationale: gloved hands held below waist level are considered un sterile.
The nurse is teaching a client with numerous allergies, how to avoid allergens. Which instructions should be included in this teaching plan?
Avoid any types of sprays, powders, and perfumes.
Rationale: The client with allergies should be instructed to reduce any exposure to pollen, dust, fumes, odors, sprays, powders, and perfumes. The client should be encouraged to wear a mask when working around duster pollen. Clients with allergies to avoid any clothing that causes itching; washing clothes will not prevent an allergic reaction to some fabrics. Pollen count is related to allergens, and the client should be instructed to stay indoors when the pollen count is high.
A 73-year-old female 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 instructions should the nurse include in the clients teaching plan?
“Place a pillow between your knees while lying in bed to prevent hip dislocation.”
Rationale: Client affected hip joint falling a hemiarthroplasty (partial hip replacement) is at risk of dislocation for six months to year following the procedure. Hip precautions to prevent dislocation include placing a pillow between the knees to maintain abduction of the hips. (Clients should be instructed to avoid bending at the wrist, to seek assistance for both standing and walking until they are stable on a walker or cain, and to take pain medication 30 minutes prior to a PT session).
The nurse is performing nasaotracheal suctioning. After suctioning the client’s trachea for 15 seconds, large amounts of thick yellow secretions return. What’s action should the nurse implement next?
Re-oxygenate the client before attempting to section again.
Rationale: Sectioning should not be continued for longer than 10 to 15 seconds, since the client’s oxygenation is compromised during this time.
