BSN 266 HESI PRACTICE TEST
QUESTIONS WITH CORRECT
ANSWERS
Which assessment finding by the nurse during a client's clinical breast examination
requires follow-up?
A. Newly retracted nipple.
B. A thickened area where the skin folds under the breast.
C. Whitish nipple discharge.
D. Tender lumpiness noted bilaterally throughout the breasts. - Answer-A. Newly
retracted nipple.
Rationale
A newly retracted nipple, compared to a life-long finding, may be an indication of breast
cancer and requires additional follow-up.
A client has been taking oral corticosteroids for the past five days because of seasonal
allergies. Which assessment finding is of most concern to the nurse?
A. White blood count of 10,000 mm3.
B. Serum glucose of 115 mg/dl.
C. Purulent sputum.
D. Excessive hunger. - Answer-C. Purulent sputum.
Rationale
Steroids cause immunosuppression, and a purulent sputum is an indication of infection,
so this symptom is of greatest concern.
The nurse is completing an admission interview and assessment on a client with a
history of Parkinson's disease. Which question provides information relevant to the
client's plan of care?
A. "Have you ever experienced any paralysis of your arms or legs?"
B. "Have you ever sustained a severe head injury?"
C. "Have you ever been 'frozen' in one spot, unable to move?"
D. "Do you have headaches, especially ones with throbbing pain?" - Answer-C. "Have
you ever been 'frozen' in one spot, unable to move?"
Rationale
Clients with Parkinson's disease frequently experience difficulty in initiating, maintaining,
and performing motor activities. They may even experience being rooted to a spot and
unable to move, refer to as being "frozen" in one spot.
The nurse working on a telemetry unit finds a client unconscious and in pulseless
ventricular tachycardia (VT). The client has an implanted automatic defibrillator. What
action should the nurse implement?
,A. Prepare the client for transcutaneous pacemaker.
B. Shock the client with 200 joules per hospital policy.
C. Use a magnet to deactivate the implanted pacemaker.
D. Observe the monitor until the onset of ventricular fibrillation. - Answer-B. Shock the
client with 200 joules per hospital policy.
Rationale
The client must be externally shocked 200 joules per hospital policy to restore an
effective cardiac rhythm. The automatic defibrillator is obviously malfunctioning.
In assessing a client diagnosed with primary hyperaldosteronism, the nurse expects the
laboratory test results to indicate a decreased serum level of which substance?
A. Sodium.
B. Antidiuretic hormone.
C. Potassium.
D. Glucose. - Answer-C. Potassium.
Rationale
Clients with primary hyperaldosteronism exhibit a profound decline in the serum levels
of potassium (hypokalemia). Hypertension, along with the hypokalemia are the most
prominent and universal signs for this condition. If both of these findings are present,
there is 50% likelihood the client to be diagnosed with hyperaldosteronism.
The healthcare provider prescribes aluminum and magnesium hydroxide (Maalox), 1
tablet PO PRN, for a client with chronic kidney disease (CKD) who is complaining of
indigestion. What intervention should the nurse implement?
A. Administer 30 minutes before eating.
B. Evaluate the effectiveness 1 hour after administration.
C. Instruct the client to swallow the tablet whole.
D. Question the healthcare provider's prescription. - Answer-D. Question the healthcare
provider's prescription.
Rationale
Magnesium agents are not usually used for clients with CKD due to the risk of
hypermagnesemia, so this prescription should be questioned by the nurse.
A postmenopausal client asks the nurse why she is experiencing discomfort during
intercourse. What response is best for the nurse to provide?
A. Estrogen deficiency causes the vaginal tissues to become dry and thinner.
B. Infrequent intercourse results in the vaginal tissues losing their elasticity.
C. Dehydration from inadequate fluid intake causes vulva tissue dryness.
D. Lack of adequate stimulation is the most common reason for dyspareunia. - Answer-
A. Estrogen deficiency causes the vaginal tissues to become dry and thinner.
Rationale
Estrogen deprivation decreases the moisture-secreting capacity of vaginal cells, so
vaginal tissues tend to become thinner, drier, and the rugae become smoother which
reduces vaginal stretching that contributes to dyspareunia. The discomfort during
intercourse, primary cause can be contributed to the decrease in estrogen hormone
levels.
,A client is admitted to the hospital with a medical diagnosis of pneumococcal
pneumonia. The nurse knows that the prognosis for gram-negative pneumonias (such
as E. coli, Klebsiella, Pseudomonas, and Proteus) is very poor because
A. they occur in the lower lobe alveoli which are more sensitive to infection.
B. gram-negative organisms are more resistant to antibiotic therapy.
C. they occur in healthy young adults who have recently been debilitated by an upper
respiratory infection.
D. gram-negative pneumonias usually affect infants and small children. - Answer-B.
gram-negative organisms are more resistant to antibiotic therapy.
Rationale
The gram-negative organisms are very resistant to drug therapy which makes recovery
very difficult and has become a world-wide concern in which the World Health
Organization is keeping a very close surveillance on these occurrences.
An 81-year-old male client has emphysema. He lives at home with his cat and manages
self-care with no difficulty. When making a home visit, the nurse notices that his tongue
is somewhat cracked and his eyeballs are sunken into his head. What nursing
intervention is indicated?
A. Help the client to determine ways to increase his fluid intake.
B. Obtain an appointment for the client to see an ear, nose, and throat specialist.
C. Schedule an appointment with an allergist to determine if the client is allergic to the
cat.
D. Encourage the client to slightly increase his use of oxygen at night and to always use
humidified oxygen. - Answer-A. Help the client to determine ways to increase his fluid
intake.
Rationale
The nurse should suggest creative methods to increase the intake of fluids, such as
having disposable fruit juices readily available. Clients with COPD should be
encouraged to have at least three liters of fluids a day to help keep their mucus thin. As
the disease progresses, these clients often reduce fluid intake because of shortness of
breath experience while drinking and due to the fact, they may be on diuretics related to
heart involvement with the disease and may purposely limit their fluid intake to decrease
the need for elimination.
When teaching diaphragmatic breathing to a client with chronic obstructive pulmonary
disease (COPD), which information should the nurse provide?
A. Place a small book or magazine on the abdomen and make it rise while inhaling
deeply.
B. Purse the lips while inhaling as deeply as possible and then exhale through the nose.
C. Wrap a towel around the abdomen and push against the towel while forcefully
exhaling.
D. Place one hand on the chest, one hand the abdomen and make both hands move
outward. - Answer-A. Place a small book or magazine on the abdomen and make it rise
while inhaling deeply.
Rationale
, Diaphragmatic or abdominal breathing uses the diaphragm instead of accessory
muscles to achieve maximum inhalation and to slow the respiratory rate. The client
should protrude the abdomen on inhalation and contract it with exhalation, so placing a
book or magazine, helps the client visualize the rise and fall of the abdomen.
The nurse is planning care for a client with newly diagnosed diabetes mellitus that
requires insulin. Which assessment should the nurse identify before beginning the
teaching session?
A. Present knowledge related to the skill of injection.
B. Intelligence and developmental level of the client.
C. Willingness of the client to learn the injection sites.
D. Financial resources available for the equipment. - Answer-C. Willingness of the client
to learn the injection sites.
Rationale
If a client is incapable or does not want to learn, it is unlikely that learning will occur, so
motivation is the first factor the nurse should assess before teaching.
A client with a 16-year history of diabetes mellitus is having renal function tests because
of recent fatigue, weakness, elevated blood urea nitrogen, and serum creatinine levels.
Which finding should the nurse conclude as an early symptom of renal insufficiency?
A. Dyspnea.
B. Nocturia.
C. Confusion.
D. Stomatitis. - Answer-B. Nocturia.
Rationale
As the glomerular filtration rate decreases in early renal insufficiency, metabolic waste
products, including urea, creatinine, and other substances, such phenols, hormones,
electrolytes, accumulate in the blood. In the early stage of renal insufficiency, polyuria
results from the inability of the kidneys to concentrate urine and contribute to nocturia.
A female client taking oral contraceptives reports to the nurse that she is experiencing
calf pain. What action should the nurse implement?
A. Determine if the client has also experienced breast tenderness and weight gain.
B. Encourage the client to begin a regular, daily program of walking and exercise.
C. Advise the client to notify the healthcare provider for immediate medical attention.
D. Tell the client to stop taking the medication for a week to see if symptoms subside. -
Answer-C. Advise the client to notify the healthcare provider for immediate medical
attention.
Rationale
Calf pain is indicative of thrombophlebitis, a serious, life-threatening complication
associated with the use of oral contraceptives which requires further assessment and
possibly immediate medical intervention.
A 58-year-old client who has been post-menopausal for five years is concerned about
the risk for osteoporosis because her mother has the condition. Which information
should the nurse offer?
QUESTIONS WITH CORRECT
ANSWERS
Which assessment finding by the nurse during a client's clinical breast examination
requires follow-up?
A. Newly retracted nipple.
B. A thickened area where the skin folds under the breast.
C. Whitish nipple discharge.
D. Tender lumpiness noted bilaterally throughout the breasts. - Answer-A. Newly
retracted nipple.
Rationale
A newly retracted nipple, compared to a life-long finding, may be an indication of breast
cancer and requires additional follow-up.
A client has been taking oral corticosteroids for the past five days because of seasonal
allergies. Which assessment finding is of most concern to the nurse?
A. White blood count of 10,000 mm3.
B. Serum glucose of 115 mg/dl.
C. Purulent sputum.
D. Excessive hunger. - Answer-C. Purulent sputum.
Rationale
Steroids cause immunosuppression, and a purulent sputum is an indication of infection,
so this symptom is of greatest concern.
The nurse is completing an admission interview and assessment on a client with a
history of Parkinson's disease. Which question provides information relevant to the
client's plan of care?
A. "Have you ever experienced any paralysis of your arms or legs?"
B. "Have you ever sustained a severe head injury?"
C. "Have you ever been 'frozen' in one spot, unable to move?"
D. "Do you have headaches, especially ones with throbbing pain?" - Answer-C. "Have
you ever been 'frozen' in one spot, unable to move?"
Rationale
Clients with Parkinson's disease frequently experience difficulty in initiating, maintaining,
and performing motor activities. They may even experience being rooted to a spot and
unable to move, refer to as being "frozen" in one spot.
The nurse working on a telemetry unit finds a client unconscious and in pulseless
ventricular tachycardia (VT). The client has an implanted automatic defibrillator. What
action should the nurse implement?
,A. Prepare the client for transcutaneous pacemaker.
B. Shock the client with 200 joules per hospital policy.
C. Use a magnet to deactivate the implanted pacemaker.
D. Observe the monitor until the onset of ventricular fibrillation. - Answer-B. Shock the
client with 200 joules per hospital policy.
Rationale
The client must be externally shocked 200 joules per hospital policy to restore an
effective cardiac rhythm. The automatic defibrillator is obviously malfunctioning.
In assessing a client diagnosed with primary hyperaldosteronism, the nurse expects the
laboratory test results to indicate a decreased serum level of which substance?
A. Sodium.
B. Antidiuretic hormone.
C. Potassium.
D. Glucose. - Answer-C. Potassium.
Rationale
Clients with primary hyperaldosteronism exhibit a profound decline in the serum levels
of potassium (hypokalemia). Hypertension, along with the hypokalemia are the most
prominent and universal signs for this condition. If both of these findings are present,
there is 50% likelihood the client to be diagnosed with hyperaldosteronism.
The healthcare provider prescribes aluminum and magnesium hydroxide (Maalox), 1
tablet PO PRN, for a client with chronic kidney disease (CKD) who is complaining of
indigestion. What intervention should the nurse implement?
A. Administer 30 minutes before eating.
B. Evaluate the effectiveness 1 hour after administration.
C. Instruct the client to swallow the tablet whole.
D. Question the healthcare provider's prescription. - Answer-D. Question the healthcare
provider's prescription.
Rationale
Magnesium agents are not usually used for clients with CKD due to the risk of
hypermagnesemia, so this prescription should be questioned by the nurse.
A postmenopausal client asks the nurse why she is experiencing discomfort during
intercourse. What response is best for the nurse to provide?
A. Estrogen deficiency causes the vaginal tissues to become dry and thinner.
B. Infrequent intercourse results in the vaginal tissues losing their elasticity.
C. Dehydration from inadequate fluid intake causes vulva tissue dryness.
D. Lack of adequate stimulation is the most common reason for dyspareunia. - Answer-
A. Estrogen deficiency causes the vaginal tissues to become dry and thinner.
Rationale
Estrogen deprivation decreases the moisture-secreting capacity of vaginal cells, so
vaginal tissues tend to become thinner, drier, and the rugae become smoother which
reduces vaginal stretching that contributes to dyspareunia. The discomfort during
intercourse, primary cause can be contributed to the decrease in estrogen hormone
levels.
,A client is admitted to the hospital with a medical diagnosis of pneumococcal
pneumonia. The nurse knows that the prognosis for gram-negative pneumonias (such
as E. coli, Klebsiella, Pseudomonas, and Proteus) is very poor because
A. they occur in the lower lobe alveoli which are more sensitive to infection.
B. gram-negative organisms are more resistant to antibiotic therapy.
C. they occur in healthy young adults who have recently been debilitated by an upper
respiratory infection.
D. gram-negative pneumonias usually affect infants and small children. - Answer-B.
gram-negative organisms are more resistant to antibiotic therapy.
Rationale
The gram-negative organisms are very resistant to drug therapy which makes recovery
very difficult and has become a world-wide concern in which the World Health
Organization is keeping a very close surveillance on these occurrences.
An 81-year-old male client has emphysema. He lives at home with his cat and manages
self-care with no difficulty. When making a home visit, the nurse notices that his tongue
is somewhat cracked and his eyeballs are sunken into his head. What nursing
intervention is indicated?
A. Help the client to determine ways to increase his fluid intake.
B. Obtain an appointment for the client to see an ear, nose, and throat specialist.
C. Schedule an appointment with an allergist to determine if the client is allergic to the
cat.
D. Encourage the client to slightly increase his use of oxygen at night and to always use
humidified oxygen. - Answer-A. Help the client to determine ways to increase his fluid
intake.
Rationale
The nurse should suggest creative methods to increase the intake of fluids, such as
having disposable fruit juices readily available. Clients with COPD should be
encouraged to have at least three liters of fluids a day to help keep their mucus thin. As
the disease progresses, these clients often reduce fluid intake because of shortness of
breath experience while drinking and due to the fact, they may be on diuretics related to
heart involvement with the disease and may purposely limit their fluid intake to decrease
the need for elimination.
When teaching diaphragmatic breathing to a client with chronic obstructive pulmonary
disease (COPD), which information should the nurse provide?
A. Place a small book or magazine on the abdomen and make it rise while inhaling
deeply.
B. Purse the lips while inhaling as deeply as possible and then exhale through the nose.
C. Wrap a towel around the abdomen and push against the towel while forcefully
exhaling.
D. Place one hand on the chest, one hand the abdomen and make both hands move
outward. - Answer-A. Place a small book or magazine on the abdomen and make it rise
while inhaling deeply.
Rationale
, Diaphragmatic or abdominal breathing uses the diaphragm instead of accessory
muscles to achieve maximum inhalation and to slow the respiratory rate. The client
should protrude the abdomen on inhalation and contract it with exhalation, so placing a
book or magazine, helps the client visualize the rise and fall of the abdomen.
The nurse is planning care for a client with newly diagnosed diabetes mellitus that
requires insulin. Which assessment should the nurse identify before beginning the
teaching session?
A. Present knowledge related to the skill of injection.
B. Intelligence and developmental level of the client.
C. Willingness of the client to learn the injection sites.
D. Financial resources available for the equipment. - Answer-C. Willingness of the client
to learn the injection sites.
Rationale
If a client is incapable or does not want to learn, it is unlikely that learning will occur, so
motivation is the first factor the nurse should assess before teaching.
A client with a 16-year history of diabetes mellitus is having renal function tests because
of recent fatigue, weakness, elevated blood urea nitrogen, and serum creatinine levels.
Which finding should the nurse conclude as an early symptom of renal insufficiency?
A. Dyspnea.
B. Nocturia.
C. Confusion.
D. Stomatitis. - Answer-B. Nocturia.
Rationale
As the glomerular filtration rate decreases in early renal insufficiency, metabolic waste
products, including urea, creatinine, and other substances, such phenols, hormones,
electrolytes, accumulate in the blood. In the early stage of renal insufficiency, polyuria
results from the inability of the kidneys to concentrate urine and contribute to nocturia.
A female client taking oral contraceptives reports to the nurse that she is experiencing
calf pain. What action should the nurse implement?
A. Determine if the client has also experienced breast tenderness and weight gain.
B. Encourage the client to begin a regular, daily program of walking and exercise.
C. Advise the client to notify the healthcare provider for immediate medical attention.
D. Tell the client to stop taking the medication for a week to see if symptoms subside. -
Answer-C. Advise the client to notify the healthcare provider for immediate medical
attention.
Rationale
Calf pain is indicative of thrombophlebitis, a serious, life-threatening complication
associated with the use of oral contraceptives which requires further assessment and
possibly immediate medical intervention.
A 58-year-old client who has been post-menopausal for five years is concerned about
the risk for osteoporosis because her mother has the condition. Which information
should the nurse offer?
