HESI Practice Qs Flashcards
Which statement is an example of a correctly written nursing problem statement?
Altered tissue perfusion related to heart failure.
Altered urinary elimination related to urinary tract infection.
Risk for impaired tissue integrity related to the client’s refusal to turn.
Ineffective coping related to an inadequate level of perception of control.
Ineffective coping related to an inadequate level of perception of control.
A male client has a nursing problem of “spiritual distress.” Which intervention is best for the nurse to implement when caring for this client?
Use distraction techniques during times of spiritual stress and crisis.
Reassure the client that his faith will be regained with time and support.
Consult with the staff chaplain and ask that the chaplain visits with the client.
Use reflective listening techniques when the client expresses spiritual doubts.
Use reflective listening techniques when the client expresses spiritual doubts.
When the nurse enters a client’s room to do an initial assessment, the client shouts, “Get out of my room! I’m tired of being bothered!” How should the nurse respond?
“There is no reason to be so angry.”
“Why do I need to leave your room?”
“What is concerning you this morning?”
“Let me call the client advocate for you.”
“What is concerning you this morning?”
A male client with acquired immunodeficiency syndrome (AIDS) develops cryptococcal meningitis and tells the nurse he does not want to be resuscitated if his breathing stops. Which action should the nurse implement?
Document the client’s request in the medical record.
Ask the client if this decision has been discussed with his healthcare provider.
Inform the client that a written, notarized advance directive, is required to withhold resuscitation efforts.
Advise the client to designate a person to make healthcare decisions when the client is unable to do so.
Ask the client if this decision has been discussed with his healthcare provider.
Advance directives are written statements of a person’s wishes regarding medical care, and verbal directives may be given to a healthcare provider with specific instructions in the presence of two witnesses. To obtain this prescription, the client should discuss his choice with the healthcare provider (B). (A) is insufficient to implement the client’s request without legal consequences. Although (C and D) provide legal protection of the client’s wishes, the present request needs additional action.
The nurse formulates the nursing problem of, “Ineffective health maintenance related to lack of motivation” for a client with Type 2 diabetes. Which finding supports this nursing problem?
Does not check capillary blood glucose as directed.
Occasionally forgets to take daily prescribed medication.
Cannot identify signs or symptoms of high and low blood glucose.
Eats anything and does not think diet makes a difference in health.
Eats anything and does not think diet makes a difference in health.
When preparing to administer an intravenous medication through a central venous catheter, the nurse aspirates a blood return in one of the lumens of the triple lumen catheter. Which action should the nurse implement?
Flush the lumen with the saline solution and administer the medication through the lumen.
Determine if a PRN prescription for a thrombolytic agent is listed on the medication record.
Clamp the lumen and obtain a syringe of a dilute heparin solution to flush through the tubing.
Withdraw the aspirated blood into the syringe and use a new syringe to administer the medication.
Flush the lumen with the saline solution and administer the medication through the lumen.
Aspiration of a blood return in the lumen of a central venous catheter indicates that the catheter is in place and the medication can be administered. The nurse should flush the tubing with the saline solution, administer the medication, then flush the lumen with saline again. The aspirated blood can be flushed back through the closed system into the client’s bloodstream and does not need to be withdrawn.
The nurse is caring for a client who is weak from inactivity because of a 2-week hospitalization. In planning care for the client, the nurse should include which range of motion (ROM) exercises?
Passive ROM exercises to all joints on all extremities four times a day.
Active ROM exercises to both arms and legs two or three times a day.
Active ROM exercises with weights twice a day with 20 repetitions each.
Passive ROM exercises to the point of resistance and slightly beyond.
Active ROM exercises to both arms and legs two or three times a day.
Active, rather than passive, ROM is best to restore strength, and doing it two to three times a day is an effective schedule. ROM is not performed beyond the point of resistance or pain because of the risk of damage to underlying structures.
A client who has moderate, persistent, chronic neuropathic pain due to diabetic neuropathy takes gabapentin and ibuprofen daily. If Step 2 of the World Health Organization (WHO) pain relief ladder is prescribed, which drug protocol should be implemented?
Continue gabapentin.
Discontinue ibuprofen.
Add aspirin to the protocol.
Add oral methadone to the protocol.
Continue gabapentin.
Based on the WHO pain relief ladder, adjunct medications, such as gabapentin, an antiseizure medication, may be used at any step for anxiety and pain management, so continuing gabapentin should be implemented. Nonopioid analgesics, such as ibuprofen and aspirin are Step 1 drugs. Steps 2 and 3 include opioid narcotics, and to maintain freedom from pain, drugs should be given around the clock rather than by the client’s PRN requests.
The home health nurse visits an older female client who had a stroke three months ago and is now able to ambulate with the assistance of a quad cane. Which assessment finding has the greatest implications for this client’s care?
The husband, who is the caregiver, begins to weep when the nurse asks how he is doing.
The client tells the nurse that she does not have much of an appetite today.
The nurse notes that there are numerous scatter rugs throughout the house.
The client’s pulse rate is 10 beats higher than it was at the last visit one week ago.
The nurse notes that there are numerous scatter rugs throughout the house.
The nurse is administering an intermittent infusion of an antibiotic to a client whose intravenous (IV) access is an antecubital saline lock. After the nurse opens the roller clamp on the IV tubing, the alarm on the infusion pump indicates an obstruction. Which action should the nurse take first?
Check for a blood return.
Reposition the client’s arm.
Remove the IV site dressing.
Flush the lock with saline.
Reposition the client’s arm.
Rationale
If the client’s elbow is bent, the IV may be unable to infuse, resulting in an obstruction alarm, so the nurse should first attempt to reposition the client’s arm to alleviate any obstruction. After other sources of occlusion are eliminated, the nurse may need to check for a blood return, remove the dressing, or flush the saline lock and then resume the intermittent infusion.
A 75-year-old client who has a history of end-stage renal failure and advanced lung cancer recently had a stroke. Two days ago the healthcare provider discontinued the client’s dialysis treatments, stating that death is inevitable, but the client is disoriented and will not sign a DNR directive. Which is the priority nursing intervention?
Review the client’s most recent laboratory reports.
Refer the client and family members for hospice care.
Notify the hospital ethics committee of the client’s situation.
Determine who is legally empowered to make decisions.
Determine who is legally empowered to make decisions.
Rationale
When death is impending, it is essential for the nurse to determine who is legally empowered to make decisions regarding the use of life-saving measures for the client.
When making the bed of a client who needs a bed cradle, which action should the nurse include?
Teach the client to call for help before getting out of bed.
Keep both the upper and lower side rails in a raised position.
Keep the bed in the lowest position while changing the sheets.
Drape the top sheet and covers loosely over the bed cradle.
Drape the top sheet and covers loosely over the bed cradle.
Rationale
A bed cradle is used to keep the top bedclothes off the client, so the nurse should drape the top sheet and covers loosely over the cradle. A client using a bed cradle may still be able to ambulate independently and does not require raised side rails.
As the nurse prepares the equipment to be used to start an IV on a 4-year-old boy in the treatment room, he cries continuously. Which intervention should the nurse implement?
Take the child back to his room.
Recruit others to restrain the child.
Ask the mother to be present to soothe the child.
Show the child how to manipulate the equipment.
Ask the mother to be present to soothe the child.
Rationale
A 4-year-old typically has a vivid imagination and lacks concrete thinking abilities. The mother’s assistance can provide a stabilizing presence to help soothe the child, who may perceive the invasive procedure as mutilating. To preserve the child’s sense of security associated with the hospital room, it is best to perform difficult or painful procedures in another area.
The nurse overhears the healthcare provider explaining to the client that the tumor removed was nonmalignant and that the client will be fine. However, the nurse has read in the pathology report that the tumor was malignant and that there is extensive metastasis. Who should the nurse consult with first regarding the situation?
Healthcare provider.
Client’s family.
Case manager.
Chief of staff.
Healthcare provider.
Rationale
The nurse should address the healthcare provider with the written report and discuss why he/she did not tell the client the truth – this may be at the family’s request.
On the third postoperative day following thoracic surgery, a client reports feeling constipated. Which intervention should the nurse implement to promote bowel elimination?
Remind the client to turn every two hours while lying in bed.
Provide warm prune juice before the client goes to bed at night.
Teach the client to splint the incision while walking to the bathroom.
Administer an analgesic before the client attempts to defecate.
Provide warm prune juice before the client goes to bed at night.
Rationale
Prune juice is a natural laxative that stimulates peristalsis, and warming the prune juice facilitates peristalsis.
Which action by the nurse demonstrates culturally sensitive care?
Asks permission before touching a client.
Avoids questions about male-female relationships.
Explains the differences between Western medical care and cultural folk remedies.
Applies knowledge of a cultural group unless a client embraces Western customs.
Asks permission before touching a client.
Rationale
Physical contact, such as touching the head, in some cultures, is a sign of respect, whereas, in others, it is strictly forbidden. So asking permission before touching a client demonstrates culturally sensitive care.
When assessing a client with a nursing problem of fluid volume deficit, the nurse notes that the client’s skin over the sternum tents when gently pinched. Which action should the nurse implement?
Confirm the finding by further assessing the client for jugular vein distention.
Offer the client high-protein snacks between regularly scheduled mealtimes.
Continue the planned nursing interventions to restore the client’s fluid volume.
Change the plan of care to include a nursing diagnosis of impaired skin integrity.
Continue the planned nursing interventions to restore the client’s fluid volume.
Rationale
Skin turgor is assessed by pinching the skin and observing for tenting. This finding confirms the diagnosis of fluid volume deficit, so the nurse should continue interventions to restore the client’s fluid volume.
When caring for an immobile client, what nursing problem has the highest priority?
Risk for fluid volume deficit.
Impaired gas exchange.
Risk for impaired skin integrity.
Altered tissue perfusion.
Impaired gas exchange.
Rationale
The ABCs of caring for clients are airway, breathing, and circulation. Impaired gas exchange implies that the client is having trouble breathing, which has the highest priority of the nursing problems listed.
The nurse is completing the plan of care for a client who is admitted for benign prostatic hypertrophy. Which data should the nurse document as a subjective finding?
Reports inability to empty bladder.
Temperature of 99.8 °F (37.7 °C) and pulse of 108.
Postvoided residual volume of 750 mL.
Specimen collection for culture and sensitivity.
Reports inability to empty bladder.
Rationale
The nurse should document the client’s complaints of inability to empty bladder as subjective data – symptoms only the client can describe.
What is the rationale for using the nursing process in planning care for clients?
As a scientific process to identify nursing problems based on a clients’ healthcare diagnoses.
To establish a nursing theory that incorporates the biopsychosocial nature of humans.
As a tool to organize thinking and clinical decision-making about clients’ healthcare needs.
To promote the management of client care in collaboration with other healthcare professionals.
As a tool to organize thinking and clinical decision-making about clients’ healthcare needs.
The nurse removes the dressing on a client’s heel that is covering a pressure injury one inch in diameter and finds that there is straw-colored drainage seeping from the wound. Which description of this finding should the nurse include in the client’s record?
Stage 1 pressure injury draining serosanguineous drainage.
Pressure injury at bony prominence with exudate noted.
One-inch pressure injury draining serous fluid.
Pressure injury on the heel with a small amount of purulent drainage.
One-inch pressure injury draining serous fluid.
Which intervention should the nurse include in the plan of care for a client who is being treated with compression dressings for leg ulcers due to chronic venous insufficiency?
Check capillary refill of toes on the lower extremity with venous compression dressings.
Apply dressing to the wound area before applying the venous compression dressings.
Wrap the leg from the knee down towards the foot.
Remove the venous compression dressings every 8 hours to assess wound healing.
Check capillary refill of toes on the lower extremity with venous compression dressings.
Venous compression dressings can be applied too tightly. Thus, it is important to check distally for adequate circulation.
Which action is most important for the nurse to implement when placing a client in the lateral recumbent position?
Raise the bed to a waist-high working level.
Elevate the head of the bed 45 degrees.
Place a pillow behind the client’s back.
Bring the client to one edge of the bed.
Raise the bed to a waist-high working level.
Rationale
A waist-high bed height is a comfortable and safe working height to maintain the nurse’s proper body mechanics and prevent back injury.
Which statement correctly identifies a written learning objective for a client with peripheral vascular disease?
The nurse will provide client instruction for daily foot care.
The client will demonstrate proper trimming toenail technique.
Upon discharge, the client will list three ways to protect the feet from injury.
After instruction, the nurse will ensure the client understands the foot care rationale.
Upon discharge, the client will list three ways to protect the feet from injury.
An objective should contain four elements: who will perform the activity or acquire the desired behavior, the actual behavior that the learner will exhibit, the condition under which the behavior is to be demonstrated, and the specific criteria to be used to measure success. “Upon discharge, the client will list three ways to protect the feet from injury” is a concise statement that is a learning objective that defines exactly how the client will demonstrate mastery of the content.
Which nursing intervention is most beneficial in reducing the risk of urosepsis in a hospitalized client with an indwelling urinary catheter?
Ensure that the client’s perineal area is cleansed twice a day.
Maintain accurate documentation of the fluid intake and output.
Encourage frequent ambulation if allowed or regular turning if on bedrest.
Obtain a prescription for removal of the catheter as soon as possible.
Obtain a prescription for removal of the catheter as soon as possible.
Rationale
The best intervention to reduce the risk of urosepsis (the spread of an infectious agent from the urinary tract to systemic circulation) is the removal of the urinary catheter as quickly as possible.
A male client with an infected wound tells the nurse that he follows a macrobiotic diet. Which type of foods should the nurse recommend that the client select from the hospital menu?
Low fat and low sodium foods.
Combination of plant proteins to provide essential amino acids.
Limited complex carbohydrates and fiber.
Increased amount of vitamin C and beta carotene-rich foods.
Combination of plant proteins to provide essential amino acids.
Rationale
A macrobiotic diet is high in whole-grain cereals, vegetables, sea vegetables, beans, and vegetarian soups, and the client needs essential amino acids to provide complete proteins to heal the infected wound. Although a macrobiotic diet contains no source of animal protein, essential amino acids should be obtained by combining plant (incomplete) proteins to provide complete (all essential amino acids) proteins for anabolic processes.
A client has a nursing problem of, “Spiritual distress related to a loss of hope, secondary to impending death.” Which intervention is best for the nurse to implement when caring for this client?
Help the client to accept the final stage of life.
Assist and support the client in establishing short-term goals.
Encourage the client to make future plans, even if they are unrealistic.
Instruct the client’s family to focus on positive aspects of the client’s life.
Assist and support the client in establishing short-term goals.
Hopefulness is necessary to sustain a meaningful existence, even close to death. The nurse should help the client set short-term goals, and recognize the achievement of immediate goals, such as seeing a family member or listening to music.
A 73-year-old Hispanic client is seen at the community health clinic with a history of protein malnutrition. Which information should the nurse obtain first?
Amount of liquid protein supplements consumed daily.
Foods and liquids consumed during the past 24 hours.
Usual weekly intake of milk products and red meats.
Grains and legume combinations used by the client.
Foods and liquids consumed during the past 24 hours.
The nurse is digitally removing a fecal impaction for a client. The nurse should stop the procedure and take corrective action if which client reaction is noted?
Temperature increases.
Pulse rate decreases from 78 to 52 beats/min.
Respiratory rate increases from 16 to 24 breaths/min.
Blood pressure increases from 110/84 to 118/88 mm/Hg.
Pulse rate decreases from 78 to 52 beats/min.
Rationale
Parasympathetic reaction can occur as a result of digital stimulation of the anal sphincter, which should be stopped if the client experiences a vagal response, such as bradycardia.
A client is demonstrating a positive Chvostek’s sign. Which action should the nurse take?
Observe the client’s pupil size and response to light.
Ask the client about numbness or tingling in the hands.
Assess the client’s serum potassium level.
Restrict dietary intake of calcium-rich foods.
Ask the client about numbness or tingling in the hands.
Which action should the nurse implement to mitigate the formation of a hip pressure injury for a client who is immobile?
Maintain in a lateral position using protective wrist and vest devices.
Partial side lying with hip elevated to 30 degrees (30-degree lateral position).
Raise the head and knee gatch when lying in a supine position.
Transfer into a wheelchair close to the nurse’s station for observation.
Partial side lying with hip elevated to 30 degrees (30-degree lateral position).
Rationale
The partial side-lying position with hip elevation maintains alignment and provides the best pressure relief over the hip bony prominence. Raising the head and bed gatch may reduce shearing forces due to sliding down in bed, but it interferes with venous return from the legs and places pressure on the sacrum, predisposing to pressure injury formation. Sitting in a wheelchair places the body weight over the ischial tuberosities and predisposes it to a potential pressure point.
Which client assessment data is most important for the nurse to consider before ambulating a postoperative client?
Respiratory rate.
Wound location.
Pedal pulses.
Pain rating.
Respiratory rate.
Mobilization and ambulation increase oxygen use, so it is most important to assess the client’s respiratory rate (A) before ambulation to determine tolerance for activity. (B, C, and D) are also important, but are of lower priority than (A).
The nurse determines a client’s IV solution is infusing at 250 mL/hr. The prescribed rate is 125 mL/hr. Which action should the nurse take first?
Determine when the IV solution was started.
Slow the IV infusion to keep vein open rate.
Assess the IV insertion site for swelling.
Report the finding to the healthcare provider.
Slow the IV infusion to keep vein open rate.
Rationale
The nurse should first slow the IV flow rate to keep vein open (KVO) rate to prevent further risk of fluid volume overload, then gather additional assessment data, such as when the IV solution was started and the appearance of the IV insertion site before contacting the healthcare provider for further instructions.
A client in hospice care develops audible gurgling sounds on inspiration. Which nursing action has the highest priority?
Ensure cultural customs are observed.
Increase oxygen flow to 4L/minute.
Auscultate bilateral lung fields.
Inform the family that death is imminent.
Inform the family that death is imminent.
An audible gurgling sound produced by a dying client is characteristic of ineffective clearance of secretions from the lungs or upper airways, causing a “rattling” sound as air moves through the accumulated fluid. The nursing priority in this situation is to convey to the family that the client’s death is imminent (D). Although culturally sensitive care should be observed throughout the client’s plan of care (A), this is not the priority at this time. Administration of oxygen may be expected care, but a flow rate greater than 2 L/minute (B) is not palliative care. (C) may provide additional information, but is not necessary as death approaches.
The nurse is preparing to irrigate a client’s indwelling urinary catheter using an open technique. Which action should the nurse take after applying gloves?
Empty the client’s urinary drainage bag.
Draw up the irrigating solution into the syringe.
Secure the client’s catheter to the drainage tubing.
Use aseptic technique to instill the irrigating solution.
Draw up the irrigating solution into the syringe.
Rationale
To irrigate an indwelling urinary catheter, the nurse should first apply gloves, then draw up the irrigating solution into the syringe. The syringe is then attached to the catheter and the fluid is instilled, using aseptic technique. Once the irrigating solution is instilled, the client’s catheter should be secured to the drainage tubing. The urinary drainage bag can be emptied whenever intake and output measurement is indicated, and the instilled irrigating fluid can be subtracted from the output at that time
A healthcare provider is performing a sterile procedure at a client’s bedside. Near the end of the procedure, the nurse observes the healthcare provider contaminating a sterile glove and the sterile field. Which is the best action for the nurse to implement?
Report the healthcare provider for the violation in aseptic technique.
Allow the completion of the procedure.
Ask if the glove and sterile field are contaminated.
Identify the break in surgical asepsis and provide another set of sterile supplies.
Identify the break in surgical asepsis and provide another set of sterile supplies.
