2013 Hesi Version 1 1. Pregnancy Induced Hypertension: 2. A client is comatose upon arrival to the emergency room department after falling from the roof. The client flexes with painful stimuli, and the nurse determines the client’s Glasgow Coma Scale (GCS) is 6. Which intervention should the nurse prepare to implement to maintain the client’s airway. 3. A client with rheumatoid arthritis reports a new onset of increasing fatigue. What intervention should the nurse implement first? Answer: Answers available here https://bit.ly/2y1Xx2U 4. A client experiencing intracranial hypertension from a traumatic brain injury is admitted to the trauma unit. How should the nurse position the client? Answers available here https://bit.ly/2y1Xx2U 5. Risk management: pt fell while using some equipment… charge nurse trying to find out what happened- how? 6. The nurse is assessing a 48-year-old client with Guillain-Barre syndrome. What symptom is this client most likely to exhibit? 7. Preop pt should be npo and pt had a glass of h2o-what to do8. The nurse is caring for a client diagnosed with myasthenia gravis. Which nursing action is best to promote independence in this client? 9. The nurse is assessing a 2-week-old breastfeeding infant. To obtain information about the adequate nutrition, which question should the nurse ask the breastfeeding mother? 10. Answers available here https://bit.ly/2y1Xx2U 11. Zyvox & suprainfection – 12. Potassium Chloride13. The nurse has identified four nursing problems for a 13-year-old admitted for depression and anxiety. What is the priority problem? 14. (Audio/visual)- ask to hear heart sounds15. The nurse is teaching a client newly diagnosed with diabetes mellitus the signs of hypoglycemia. What symptom should be included in the description of early signs of hypoglycemia? Answers available here https://bit.ly/2y1Xx2U 15. When you are giving asthma med… which one would you give 1st: 16. A male client diagnosed with hypertension has a nursing goal of, “the client will be able to verbalize ways to decrease blood pressure.” What statement by the client indicates that this outcome has been met? Answers available here https://bit.ly/2y1Xx2U 17. (Select all that apply) Determining pain level for 3mo old infant- infant will clinch fists, 18 Penicillin G procaine (Wycillin) 135,000 units IM is prescribed for an infant with a middle ear infection. The drug is available in a vial of 1,200,000 units /2ml. How many ml should the nurse administer? 19. Depressed client and best activity20.The nurse is teaching a client’s caregiver how to cleanse around a wound drain. What is the besy way to explain the proper cleansing technique? 21. CPR priority Arrange in other -1. Establish unresponsiveness. 2. Call for help. 3. Assess patent airway. 4. Assess pt carotid pulses. 155. A client with endometrial carcinoma is receiving brachytherapy and has radioactive Cesium (Cs) loaded in a vaginal applicator. What action should the nurse implement? 22. Math question with heparin you are given the ml/hr and the units you have to figure out how much the patient is receiving which the answer is 23.Alupent administration- The usual single dose is two to three inhalations. With repetitive dosing, inhalation should usually not be repeated more often than about every three to four hours. Total dosage per day should not exceed 12 inhalations. Answers available here https://bit.ly/2y1Xx2U 24. In scheduling home visits, which client is best for the home health charge nurse to begin to assign to the licensed practical nurse? 25. A 65-year-old female client arrives in the emergency department with shortness of breath and chest pain. The nurse accidentally administers 10 mg of morphine sulfate instead of 4 mg as prescribed by the healthcare provider. Later, the client's respiratory rate is 10 breaths/minute, oxygen saturation is 98%, and she states that her pain has subsided. What is the legal status of the nurse? # 26. In completing the treatment plan for an 11-year-old who has bipolar disorder, the nurse plans outcomes for the nursing diagnosis, “Risk for violence towards peers related to impulsivity.”Which outcome is important? Answers available here https://bit.ly/2y1Xx2U 27. The nurse is teaching a childbirth education class t prospective parents and describing possible signs of labor. Class participants should be taught that which sign should be reported to the healthcare provider immediately? 28.The nurse is performing a surgical hand scrub prior to entering the operating room. In what order should the nurse perform the steps of this procedure? (Arrange from first on top on the last bottom). 29. How to do surgical scrubbing ( arrange in order)= 30. An elderly client is admitted with a diagnosis of pneumonia. What sign or symptom would require immediate intervention by the nurse? . Answers available here https://bit.ly/2y1Xx2U 31. A client with gestational diabetes at 39-weeks gestation is in the second stage of labor. After delivery of the fetal head, the nurse recognizes that shoulder dystocia is occurring. What intervention should the nurse implement first? 32.While assessing a client’s blood pressure using an aneroid sphygmomanometer, the nurse inflates the cuff to an initial reading of 160 mm calibration. Upon release of the air valve, the nurse immediately hears loud Korotkoff sounds. What action should the nurse implement next? . 33. A 6-month-old male with bronchiolitis is admitted to the hospital. I monitoring the respiratory status of the child, which symptom indicates to the nurse that he is experiencing respiratory distress? Answers available here https://bit.ly/2y1Xx2U 34.Child w/ scabies what would u do to prevent complication- 35 The healthcare provider prescribes oxytocin synthetic (Pitocin), 10 units/L via IV drip to augment a client’s labor because she is experiencing a prolonged active phase. Because the client is receiving Pitocin, the nurse should closely monitor for which complication? 36. Hepatic encepahlopathy – Answers available here https://bit.ly/2y1Xx2U 37. A client with a deep vein thrombosis is receiving a heparin protocol based on a target partial thromboplastin time (PPT) of 65 to 95 seconds. The client’s current PTT result is 35 seconds. What action should the nurse implement? 38. Female pt who being sexually and physically abused by bf and states I cant take it anymore= 39. A male Muslim client with pneumonia is scheduled to receive a dose of an intravenous antibiotic but refuses to allow the nurse to begin the medication, stating he cannot allow fluids to enter his body once he is cleansed for prayer. What action should the nurse implement? 40. Following the vaginal delivery of a 10-pound infant, the nurse assesses a new mother’s vaginal bleeding and finds that she has saturated two pads in 30 minutes and has a boggy uterus. What action should the nurse take first? 41. A 16-year-old female client who attempted suicide that morning is admitted to the psychiatric unit. To determine the seriousness of the adolescent’s suicide attempt which question is most important for the nurse to ask the family? 42. What nursing intervention should the nurse include in the plan of care for a client following a bone marrow aspiration? Answers available here https://bit.ly/2y1Xx2U 43.A client is admitted to the emergency room because of an overdose of acetaminophen (Tylenol). Following gastric lavage, the nurse should expect to administer which medication? 44. The nurse observes that a client who is to avoid any weight-bearing on the left leg is using a 3point crutch gait for ambulation. What is the best action for the nurse to initiate? 45.For increase magnesium level – 46.The practical nurse (PN) reports the patterns of urinary frequency and volume for several clients. Which finding necessaitates assessment by the RN? 47. Feedings for low albumin – 48. Prioritrize question about tube feeding and how do you check it. 49. A client with endometrial carcinoma is receiving brachytherapy and has radioactive Cesium (Cs) loaded in a vaginal applicator. What action should the nurse implement? Answers available here https://bit.ly/2y1Xx2U 50. A client who suffered a stroke and is now on a ventilator receives nutritional supplements by the tube feedings three times a day. The nurse checks the client for a residual volume before administering the next feeding. Which statement best describes the rationale for this nursing intervention? 51.Motion sickness – 52. Which client is at the greatest risk for suicide and should be managed with close observation? 54.Know the best diet for Crohns DiseaseAnswers available here https://bit.ly/2y1Xx2U 55. Is concerned about the type of legal consequences that can result from breaching client confidentiality. What source states the legal requirements nurses must follow to protect client confidentiality in a nurse-patient relationship? 56.Which nursing intervention has the highest priority when completing discharge teaching for a client with Helicobacter pylori (H.pylori) induced peptic ulcer disease (PUD)? 57. An older client is transferred to the rehabilitation unit with the diagnosis of cerebrovascular accident with left sided hemiplegia. The nurse addresses the client from the right side, and the client points to the left leg and states, “There is someone’s leg in my bed!” What is the best response by the nurse? 58. A mother tells the clinic that the healthcare provider wants her to begin introducing solid foods to her 4-month-old infant. The nurse should recommend introducing foods in what order? (Arrange first on top and last on the bottom) 59. Cultural Stereotyping – 60. The nurse’s assessment of a client admitted with a diagnosis of diabetic ketoacidosis (DKA) include: scant urinary output, serum potassium level of 2.5 mEq/l, blood pH of 7.26, temperature 98ºF, pulse 128 beats/minute, respirations 36 breaths/minute, and blood pressure 90/52. Which prescription is most important for the nurse to implement? 61. Hep A- preicteric phase- 62.Fluids are restricted for a 4-year-old boy with acute poststreptococcal glomerulonephritis (AP SGN). Which nursing intervention makes the fluid restriction less obvious to the child? Answers available here https://bit.ly/2y1Xx2U 63. The nurse tests a client’s visual acuity and determines that the uncorrected vision is 20/100 in the right eye and 20/80 in the left eye. What does this finding indicate? . Answers available here https://bit.ly/2y1Xx2U 64. The nurse knows that the blood urea nitrogen (BUN) can be expected to change as one ages. Which statement best explains this expected change? 65. An infant has a medical diagnosis of tracheosophageal fistula (TEF). What nursing intervention is indicated for his infant prior to surgical repair? 67. An Elderly man is having trouble urinating and unsteady he uses a wheelchair to walk to the bathroom what should the nurse implement? 68. The healthcare provider hands a newborn to the circulating nurse during a cesarean delivery. What action should the nurse implement first? 69 Treatment for VF- 70.A client is known to have an irregular respiratory rate with periods of apnea lasting 10 to 15 seconds. Currently, the nurse counts 22 respiratory cycles in a 30 second interval followed by an apneic period. What intervention should the nurse implement? 71. A patient with inverted nipples what should the nurse do for the client? 72. Anterior FontanelAnswers available here https://bit.ly/2y1Xx2U 73. The alarm of a client’s pulse oximeter sounds and the nurse notes that the oxygen saturation rate is indicated at 85%. What action should the nurse take first? 74. A client who developed Syndrome of inappropriate Antidiuretic Hormone (SIADH) associated with small cell carcinoma of the lung is preparing for discharge. When teaching the client about selfmanagement with demeclocycline (Declomycin), the nurse should instruct the client to report which condition to the healthcare provider? 75. Prioritrize question about tube feeding and how do you check it the answers are Answers available here https://bit.ly/2y1Xx2U 76. 147. Community Planning Interventions for Mothers- 77. Which approach is best for the nurse to use when communicating with a client with amyotrophic lateral sclerosis (ALS) 78. What action should the nurse implement first when delegating nursing activities to an unlicensed assistive personnel (UAP) Answer: 79. At 28 wks gestation- 80. The nurse is triaging victims of a tornado that hit a housing area outside of town. Which client would the nurse issue a black disaster tag to? 81. Genital herpes medication – 82. An adult male who admits to abusing IV drugs obtains the results of HIV testing. When informed that the results are positive, he states that he does not want his wife to know. What action should the nurse take? Answers available here https://bit.ly/2y1Xx2U 83. The nurse observes that a client who is to avoid any weight-bearing on the left leg is using a 3point crutch gait for ambulation. What is the best action for the nurse to initiate? 84. 5yr old burn victim has pot of hot liquid fall on him,what should nurse tell mother to do first- 85. When planning nursing care for immobilized clients, the nurse should consider which physiological alterations that frequently occur with immobility? (Select all that apply.) 86. Secondary polycythemia – 87. A female client with fibromyalgia asks the nurse to arrange for hospice care to help her manage the severe, chonic pain. Which interdisciplinary team member should the nurse consult to assist the client? 88. A one-day old neonate is awaiting surgical correction of a myelomeningocele. During the preoperative period what is the priority nursing intervention? Answers available here https://bit.ly/2y1Xx2U 89. Chest tube disconnect( 90. A 50 year old male client has just been informed that he will require open heart surgery. He tells the nurse, “This will change my whole life. Nothing will ever be the same again.” What action should the nurse implement? 91. Client has a Lithium Rx level of 0.54 (know Lithium ranges- Low, so the answer 92. The nurse is assessing a client with hypothyroidism and knows that these clients are at risk for myxedema coma. What symptoms indicate that the client is developing this condition? Answers available here https://bit.ly/2y1Xx2U 93. In establishing goals for the client’s plan of care, which information is most important for the nurse to consider? 94. You conduct CPR on intubated client and detects palpable pulse during 2-min cycle of chest compressions, absent breath sounds over left lung, what to do Next- 95. Mother believes baby is evil- 96. Following a precipitous labor, a client has a continuous trickling of bright red blood from her vagina. Her uterus is firm and her vital signs are within normal limits. The nurse determines that the client’s symptoms may indicate which condition? 97. Pre bed bath assessment – what would you say to CNA on the activity level of the pt 98. The nurse is administering sodium polystyrene sulfonate (Kayexalate) to a client in acute renal failure. Which normal finding indicates that the medication has been effective? 99. Pressure Ulcer: Turning the pt n noticing no pressure, redness, and pt doesn’t complain of pain 100. Before administering a prescribed dose of tetracycline (ACHROMYCIN), what serum lab test should the nurse monitor? 101. Diabetes Insipidus – Answers available here https://bit.ly/2y1Xx2U 102. An infant admitted to the neonatal intensive care unit is tachypneic, tachycardia, and has bounding brachial pulses. The healthcare provider suspects that the infant has coarctation of the aorta. Which intervention is most important for the nurse to include in this infant’s plan of care? 103. The nurse is assessing an unresponsive client who ingested an unknown number of meperidine (DEMOROL) 50mg tablets. Naloxone (NARCAN) 0.4mg IV is administered, and the client is now responding to verbal stimuli. Which finding in the next hour requires immediate action by the nurse? 104. The nurse is caring for a client in the Medical Intensive Care Unit. What problem is a client probably experiencing who has an easily obliterated radial pilse and below-normal pressures, including blood pressure (BP), central venous pressure (CVP), pulmonary artery pressure (PAP), and pulmonary under pressure? 105. Cystic Fibrosis – (Autosomal recessive) know the inheritance, what are the chances the children will get it if both parents are carriers? Answers available here https://bit.ly/2y1Xx2U 106. PRI interval 107. K+ and lasix… 109. The charge nurse is implementing a quality assurance policy and accompanies a nurse while administering medications. The nurse identifies a male client by asking him to state his name prior to administering the medication.Which action should the charge nurse implement? . Answers available here https://bit.ly/2y1Xx2U 110. Which surveillance clues are specific potential indicators of a bioterrorism attack? (Select all that apply.) 111. While assigned to care for clients on a surgical unit, the nurse receives a personal phone call about a family emergency that requires the nurse to leave immediately. What action by the nurse is most important? 112. A female client is instructed to do Kegel exercises. What statement indicates to the nurse that the client understands how to perform these exercises? 113. Which is the highest for carcinogenic shock= pt Answers available here https://bit.ly/2y1Xx2U 114. When obtaining a health history a male client tells the nurse that, he has become impotent. What part of his health information is likely to be most significant to the sexual dysfunction he is experiencing? 115. Coreg Risk 116. TURP – assessment for pain117. Drug: Percodia - drug containing aspirin – 118. Pathophysiology of Guillian Barré Syndrome!!! – Guillain-Barre Syndrome is a disorder in which your body's immune system attacks the nerves. Weakness and tingling in the extremities are usually the first symptoms. These sensations can quickly spread, eventually paralyzing your whole body. In its most severe form, Guillain-Barre syndrome is a medical emergency requiring hospitalization. 119. Know which position for a pt that had bone marrow taken out. 120. A client admitted to the hospital is suspected of having meningitis. The nurse should plan to prepare the client for which diagnostic test? 121. The nurse is performing an intake interview at a prenatal clinic. Which planned activities described by the client who is at 6 weeks gestations will the nurse investigate first? Answers available here https://bit.ly/2y1Xx2U 122. A client in acute renal failure has a serum potassium level of 6.3 mEq/L. What medication can the nurse expect the healthcare provider to prescribe? 123. The nurse is administering oxygento a client with pulmonary edema when a family member asks the nurse why the client needs oxygen. Which pathophysiological mechanism should the nurse explain to his family member? 124. During shift report, the nurse learns that a postoperative client has atelectasis. What nursing diagnosis should the nurse expect to include in the clients plan of care? Answers available here https://bit.ly/2y1Xx2U 125. Fibrocystic Breast = Answer = Caffeine- the disease is painful, lumpy breasts Some women feel that eating chocolate, drinking caffeine, or eating a high-fat diet can cause their symptoms, but there is no clear proof of this, worse right before the menstrual period. 126. Triage - put in order: 127. A hospitalized client’s bronchoscopy specimen culture result indicates the presence of the Mycobacterium tuberculosis organism. Which intervention is most important for the nurse to implement? 128. A client with gestational diabetes at 39-weeks gestation is in the second stage of labor. After delivery of the fetal head, the nurse recognizes that shoulder dystocia is occurring. What intervention should the nurse implement first? 129. While assessing a client with wrist restraints the nurse first slides two fingers under the restraints and then notes that the ties are secured to the side rail using a quick-release tie. What action should the nurse implement? 130. While reporting a client’s blood glucose results to the nurse the LPN states that, the glucometer was not calibrated prior to use because the report given by the night shift staff ran late. What action is most important for the nurse to perform? Answers available here https://bit.ly/2y1Xx2U 131. Patient is on radioactive chemotherapy = 132. Understand the reason for Z track method( it use for IM) – 133. A client from a nursing home is admitted with urinary sepsis and has a single-lumen, peripherallyinserted central catheter (PICC). Four medications are prescribed for 9:00 a.m.and the nurse is running behind schedule. Which medication should the nurse administer first : 134. During a family baseball game, an adult male is hot on the head with a bat, and he is suspected of sustaining an epidural bleed. What Is the most important information for the emergency center nurse to obtain form the client’s spouse, who witnessed his injury? Answers available here https://bit.ly/2y1Xx2U 135. An 86-year-old female client complains to the nurse that she does not like to eat as much as she used to because things taste differently to her now that she is older. The nurse’s response should be based on which fact? 136. A client with a compound fracture of the left ankle is being discharged with a below-the-knee cast. Before being discharged, the nurse should provide the client with what instructions? 137. A 9-month old child with diarrhea, vomiting and malaise= 138. An infant who is jittery and I think it said crying, what should the nurse do firs t= 139. A client in acute renal failure has serum potassium of 7.5mEq/L. based on this finding, the nurse should anticipate implementing which action? 140. A pt with COPD who state that he is using is inhaler right, what should the nurse indicate the pt is not using the inhaler properly= 141. CPR for a pregnant lady= 142. Pyelonephritis symptoms Answers available here https://bit.ly/2y1Xx2U 143. The nurse observes tha a client has received 250 ml of 0.9% normal saline through the IV line in the last hour. The client is now tachypneic, and has a pulse rate of 120 beats/minute, with a pulse volume of +4. In addition to reporting the assessment findings to the healthcare provider, what action should the nurse implement? 144. On osteoporosis= 145. Education about DM= 146. Cerebral palsy – 147. A 60yrs Pt with advance prostate cancer which response indicate that he accept his prognosis or illness = Pt admits that he has support of family & friends – 148. The risk for metabolic shock syndrome – 149. Side effects of aspirin- 150. The nurse is reviewing the medical history of a client who is scheduled for a parathyroidectomy. Which disorder in the client’s history is most likely to be impacted by the surgery? 151. A female client reports that she drank ¾ of a liter of a solution to cleanse her intestines for a colonoscopy. How many ml of fluid intake should the nurse document? (Enter numeric value only. If rounding is required, round to the nearest whole number.) Answers available here https://bit.ly/2y1Xx2U 152. The nurse is instructing a client who is newly diagnosed with Addison's disease. Which of the following should the nurse include when discussing the manifestations of this disease with the client? 153. A client is admitted to the nursing unit with a possible bowel obstruction. The nurse osculates high-pitched bowel sounds in the upper quadrants of the client’s abdomen. What is the significance of this finding? 154. Inserting NG tube in client that becomes cyanotic- 155. Client in labor, you call the provider and he has slurred words, loud noise in background, and seems intoxicated- 156. After a sexual assault, the nurse collects evidence for 6hrs then should do whatAnswers available here https://bit.ly/2y1Xx2U 157. A 93 year-old male client is brought to the emergency room by a group of fraternity brothers after a hazing event at the university. The client arrives with a blood alcohol level (BAL) of 3.8 and a Glasgow Coma Scale of 3. Which action should the nurse implement first? Initiate IV access using Lactated Ringer’s solution 1000ml with thiamine 100mg. 158. The nurse is preparing to administer vancomycin (Vancocin) 500mg in 200 ml of D6W, and based on the manufacturer’s recommendation, the nurse plans to administer the dosage over 90 minutes. The secondary infusion pump should be set to administer how many ml/hour? (Enter numeric value only. If rounding is required, round to the nearest whole number.) 159. BNP prescribed diuretic 160. Pancreatitis maintain IV: Answers available here https://bit.ly/2y1Xx2U
