Hesi Questions practice quiz - exam 3

Question 1

When obtaining a health history from the newly admitted clinet who has chronic pain in the right knee, which pain assessment data would the nurse include?

Answer 1

Pain history : including location, intestity, and quality of pain
Pain pattern: including percipiating and alleviating factors

Question 2

Which action would the nurse take for a patient whose right radial pulse is weak and thready?

Answer 2

• Assessing all peripheral pulses
• assessing and comparing both radial pulses
• asking a second nurse to assess
• assessing for edema or other issues that may restrict peripheral blood flow
• observing for pallor/skin temp differences. Distal to the weak pulse

Question 3

Which question would the nurse ask the pt when obtaining their health history?

Answer 3

• tell me about your food habits?
• do you use alcohol or tabacco?
• have you ever experience any allergic reactions?

Question 4

Testing pulse assessment- Dorsalis pedis

Answer 4

located on the top of foot, this site is used to assess the status of circulation in the foot

Question 5

Testing pulse assessment- ulnar site

Answer 5

located on the ulnar side of the forearm at the wrist- this site is used to assess the status of circulation to the hand

Question 6

Testing pulse assessment-Carotid

Answer 6

found along the medial edge of the sternocleidomastoid muscle of the neck- mainly used in time of physiological shock

Question 7

Testing pulse assessment- Posterior tibial

Answer 7

below the medial malleolus it is used to assess the status of circulation in the foot

Question 8

which action would the nurse take first when caring for a postop client who reports pain?

Answer 8

perform a focused assessement of the patient

Question 9

to assess the status of circulation to to the foor which sitw ould the nurse monitor for a pulse?

Answer 9

• dorsalis pedis artery
• posterior tibial artety

Question 10

what artery is good in assessing the circulation to the lower leg?

Answer 10

femoral artery

Question 11

The nursing student, under the supervison of the RN plans to perform a pulse assessment. While preparing the assess the pt, the RN asks the student to check the apical pulse after assessing the radial pulse. Which rational supports the RN request ?

Answer 11

the client may have a dysrhythmia

Question 12

When assessing a client reporting SOB, which activity best ensures the nurse obtains accurate and complete data to prevent a nursing diagnostic error?

Answer 12

assess the clinets lungs

Question 13

when preparing to assess the four abdominal quadrants of a pt who reports stomach pain, when would the nurse assess the sympotomatic quadrant?

Answer 13

Last
the nurse would systematically assess the abdomen concluding with the symptomatic area which is the area the pt reports pain

Question 14

Upon noticing a pt with heart disease has digital cyanosis, which site would the nurse assess to confirm cyanosis?

Answer 14

the lips

Question 15

A client is transferred to an acute care nursing unit after surgery. Which action of the nurse is MOST important and would be perfromed first?

Answer 15

assess the patency of airway
the nurse would assess the airway first because surgery and anesthesia may impair the patency of airway

Question 16

which step of the nursing process invloves the nurse interviewing a client about a current health problem and obtaining the clients VS?

Answer 16

Assessement

Question 17

Which documentaion is MOST informative for an assessment of drainage on a surgical dressing?

Answer 17

a 10mm- diameter area of drainage at 1900 is objective data and gives specific details

Question 18

which information would the RN provide to a SN about the importance of nurisng documention for risk management?

Answer 18

• a nurse documentation is the evdence of care that a pt receives
• the nurse would note assessments and significant changes in the clients health
• nurse would always document the primary health care providers responses whenever they are contracted

Question 19

a RN is teaching a NS about the proper techniques of an abdominal assessment. which order of assessment indiciates effective learing?

Answer 19

• inspects abdominal mobility
• note the position of the umbilicus
• auscultate
• palpate abdomen

Question 20

In which situation would the nurse consider family members the primary source of information

Answer 20

• the pt is an infant or child
• the pt is brought in as an emergency
• the pt is critically ill and disoriented

Question 21

The nurse performs a respiratory assessment and ascultates high-pitched, creaking, and accentuated breath. Sounds on expiration. Which term describes the findings?

Answer 21

Wheezes

Question 22

While assessing a Pt ROM, the nurse explains adduction to the UAP. Which UAP statement indicated effective?

Answer 22

” I will ask the pt to move their arm toward their body”

Question 23

Which physical assessment technique involves listening to the sounds of the body?

Answer 23

Auscultation

Question 24

Which reliable site would the nurse utilize to assess a pt for Jaundice?

Answer 24

• Sclera

Question 25

in which order to assess the abdomen?

Answer 25

inspection
auscultation
percussion
palpation

Question 26

While assessing a pt with dehydration, the nurse notices disminished skin elasticity, which portion of the nurses hand would the nurse perform this assessment?

Answer 26

fingertips

Question 27

the nurse assess a pt pulse and documents the strength of the pulse as 3+. what is the pulse strength?

Answer 27

Full

Question 28

which pt assessment finding would the nurse document as subjective data?

Answer 28

pain rating of 5

Question 29

while assessing a pts vascular system the nurse finds a disminished and barly palpable pulse strength. Which documentation would the nurse utilize?

Answer 29

1+

Question 30

When assessing the carotid pulses, which term refers to a blowing sound created by blood turbulence when passing through narrowed arteries?

Answer 30

Bruit- an audible blowing sound associated with turbulent blood flow through a carotid artery

Question 31

The nurse assess the lungs of a pt and auscultates soft, crackling, bubbling breath sounds that are more obvious on inspiration. Which term would the nurse use to document these sounds?

Answer 31

Crackles

Question 32

Which cranial nerve does the nurse assess the function when asking the pt to shrug shoulders and turn head against passive resistance?

Answer 32

cranial nerve XI

Question 33

When assessing a pt who experiences an accident, the nurse found the client was unable to move her eyes laterally. Damage to which nerve?

Answer 33

Abducens nerve VI