Nurs 221 HESI Practice – Review
Questions & Answers |
Thorough Study Guide With
Solutions
Section 1: Foundations of Nursing Practice & Prioritization
Question 1: At what step in the procedure should the nurse don sterile gloves?
A. Prior to removing the dressing on the client's hip
B. Before opening the new sterile dressing package
C. Before cleansing the client's hip incision
D. After cleansing the client's hip incision
✔✔✔ANSW✔✔: C. Before cleansing the client's hip incision
Rationale: Sterile gloves are donned after the sterile field is prepared and just before
the actual procedure or contact with the sterile site begins. This ensures that the
sterile gloves remain uncontaminated for the cleansing and dressing change .
Question 2: On admission, a client presents a signed living will that includes a Do
Not Resuscitate (DNR) prescription. When the client stops breathing, the nurse
performs cardiopulmonary resuscitation (CPR) and successfully revives the client.
What legal issues could be brought against the nurse?
A. Assault
B. Battery
C. Malpractice
D. False imprisonment
,✔✔✔ANSW✔✔: B. Battery
Rationale: Battery is defined as the unlawful touching of another person without
consent. By performing CPR on a client with a valid DNR order, the nurse
committed an act of unwanted touching, which legally constitutes battery .
Question 3: A client who is in hospice care complains of increasing amounts of
pain. The healthcare provider prescribes an analgesic every four hours as needed.
Which action should the nurse implement?
A. Give an around-the-clock schedule for administration of analgesics.
B. Administer analgesic medication as needed when the pain is severe.
C. Provide medication to keep the client sedated and unaware of stimuli.
D. Offer a medication-free period so that the client can do daily activities.
✔✔✔ANSW✔✔: A. Give an around-the-clock schedule for administration of
analgesics.
Rationale: In hospice and for clients with chronic pain, analgesics are more
effective in maintaining comfort when given on a scheduled, around-the-clock
basis to prevent pain from returning, rather than waiting for pain to become severe
(PRN) .
Question 4: The nurse is working in the emergency department (ED) of a children's
medical center. Which client should the nurse assess first?
A. The 1-month-old infant who has developed colic and is crying.
B. The 2-year-old toddler who was bitten by another child at the day-care center.
C. The 6-year-old school-age child who was hit by a car while riding a bicycle.
D. The 14-year-old adolescent whose mother suspects her child is sexually active.
✔✔✔ANSW✔✔: C. The 6-year-old school-age child who was hit by a car while
riding a bicycle.
Rationale: Using the ABC (Airway, Breathing, Circulation) and safety principles, the
child who was hit by a car has the highest potential for life-threatening, multi-
system injuries and requires immediate assessment and intervention .
Question 5: The nurse is caring for clients on the pediatric medical unit. Which
client should the nurse assess first?
,A. The child diagnosed with type 1 diabetes who has a blood glucose level of 180
mg/dL.
B. The child diagnosed with pneumonia who is coughing and has a temperature of
100°F.
C. The child diagnosed with gastroenteritis who has a potassium (K+) level of 3.9
mEq/L.
D. The child diagnosed with cystic fibrosis who has a pulse oximeter reading of
90%.
✔✔✔ANSW✔✔: D. The child diagnosed with cystic fibrosis who has a pulse
oximeter reading of 90%.
Rationale: A pulse oximeter reading of 90% indicates significant hypoxia and is
potentially life-threatening, requiring immediate assessment. The other values are
within normal or near-normal ranges .
Question 6: The 8-year-old client diagnosed with a vaso-occlusive sickle cell crisis
is complaining of a severe headache. Which intervention should the nurse
implement first?
A. Administer 6 L of oxygen via nasal cannula.
B. Assess the client's neurological status.
C. Administer a narcotic analgesic by intravenous push (IVP).
D. Increase the client's intravenous (IV) rate.
✔✔✔ANSW✔✔: B. Assess the client's neurological status.
Rationale: In a child with sickle cell crisis, a severe headache could be an early sign
of a cerebrovascular accident (stroke). The nurse must first assess neurological
status to rule out this life-threatening complication before implementing comfort
measures .
Section 2: Medical-Surgical Nursing
Question 7: During a visit to the outpatient clinic, the nurse assesses a client with
severe osteoarthritis using a goniometer. Which finding should the nurse expect to
measure?
A. Adequate venous blood flow to the lower extremities.
, B. Estimated amount of body fat by an underarm skinfold.
C. Degree of flexion and extension of the client's knee joint.
D. Change in the circumference of the joint in centimeters.
✔✔✔ANSW✔✔: C. Degree of flexion and extension of the client's knee joint.
Rationale: A goniometer is a specific instrument designed to measure the angle of
joints, thereby determining the range of motion, such as flexion and extension .
Question 8: The nurse is instructing a client with high cholesterol about diet and
lifestyle modification. What comment from the client indicates that the teaching
has been effective?
A. "If I exercise at least two times weekly for one hour, I will lower my cholesterol."
B. "I need to avoid eating proteins, including red meat."
C. "I will limit my intake of beef to 4 ounces per week."
D. "My blood level of low density lipoproteins needs to increase."
✔✔✔ANSW✔✔: C. "I will limit my intake of beef to 4 ounces per week."
Rationale: Limiting high-cholesterol foods like red meat is a specific and
measurable dietary modification. Exercise is important but is recommended more
frequently than twice a week. Protein should be chosen wisely, not avoided entirely.
LDL is the "bad" cholesterol and should decrease, not increase .
Question 9: An older client who is unresponsive following a cerebral vascular
accident (CVA) is receiving bolus enteral feedings through a gastrostomy tube. What
is the best position for the client for administration of the bolus tube feedings?
A. Prone
B. Fowler's
C. Sims'
D. Supine
✔✔✔ANSW✔✔: B. Fowler's
Rationale: Placing the client in Fowler's (semi-sitting) position uses gravity to help
move the feeding into the stomach and prevents reflux and aspiration of the formula
into the lungs, which is the primary risk during enteral feedings .
Questions & Answers |
Thorough Study Guide With
Solutions
Section 1: Foundations of Nursing Practice & Prioritization
Question 1: At what step in the procedure should the nurse don sterile gloves?
A. Prior to removing the dressing on the client's hip
B. Before opening the new sterile dressing package
C. Before cleansing the client's hip incision
D. After cleansing the client's hip incision
✔✔✔ANSW✔✔: C. Before cleansing the client's hip incision
Rationale: Sterile gloves are donned after the sterile field is prepared and just before
the actual procedure or contact with the sterile site begins. This ensures that the
sterile gloves remain uncontaminated for the cleansing and dressing change .
Question 2: On admission, a client presents a signed living will that includes a Do
Not Resuscitate (DNR) prescription. When the client stops breathing, the nurse
performs cardiopulmonary resuscitation (CPR) and successfully revives the client.
What legal issues could be brought against the nurse?
A. Assault
B. Battery
C. Malpractice
D. False imprisonment
,✔✔✔ANSW✔✔: B. Battery
Rationale: Battery is defined as the unlawful touching of another person without
consent. By performing CPR on a client with a valid DNR order, the nurse
committed an act of unwanted touching, which legally constitutes battery .
Question 3: A client who is in hospice care complains of increasing amounts of
pain. The healthcare provider prescribes an analgesic every four hours as needed.
Which action should the nurse implement?
A. Give an around-the-clock schedule for administration of analgesics.
B. Administer analgesic medication as needed when the pain is severe.
C. Provide medication to keep the client sedated and unaware of stimuli.
D. Offer a medication-free period so that the client can do daily activities.
✔✔✔ANSW✔✔: A. Give an around-the-clock schedule for administration of
analgesics.
Rationale: In hospice and for clients with chronic pain, analgesics are more
effective in maintaining comfort when given on a scheduled, around-the-clock
basis to prevent pain from returning, rather than waiting for pain to become severe
(PRN) .
Question 4: The nurse is working in the emergency department (ED) of a children's
medical center. Which client should the nurse assess first?
A. The 1-month-old infant who has developed colic and is crying.
B. The 2-year-old toddler who was bitten by another child at the day-care center.
C. The 6-year-old school-age child who was hit by a car while riding a bicycle.
D. The 14-year-old adolescent whose mother suspects her child is sexually active.
✔✔✔ANSW✔✔: C. The 6-year-old school-age child who was hit by a car while
riding a bicycle.
Rationale: Using the ABC (Airway, Breathing, Circulation) and safety principles, the
child who was hit by a car has the highest potential for life-threatening, multi-
system injuries and requires immediate assessment and intervention .
Question 5: The nurse is caring for clients on the pediatric medical unit. Which
client should the nurse assess first?
,A. The child diagnosed with type 1 diabetes who has a blood glucose level of 180
mg/dL.
B. The child diagnosed with pneumonia who is coughing and has a temperature of
100°F.
C. The child diagnosed with gastroenteritis who has a potassium (K+) level of 3.9
mEq/L.
D. The child diagnosed with cystic fibrosis who has a pulse oximeter reading of
90%.
✔✔✔ANSW✔✔: D. The child diagnosed with cystic fibrosis who has a pulse
oximeter reading of 90%.
Rationale: A pulse oximeter reading of 90% indicates significant hypoxia and is
potentially life-threatening, requiring immediate assessment. The other values are
within normal or near-normal ranges .
Question 6: The 8-year-old client diagnosed with a vaso-occlusive sickle cell crisis
is complaining of a severe headache. Which intervention should the nurse
implement first?
A. Administer 6 L of oxygen via nasal cannula.
B. Assess the client's neurological status.
C. Administer a narcotic analgesic by intravenous push (IVP).
D. Increase the client's intravenous (IV) rate.
✔✔✔ANSW✔✔: B. Assess the client's neurological status.
Rationale: In a child with sickle cell crisis, a severe headache could be an early sign
of a cerebrovascular accident (stroke). The nurse must first assess neurological
status to rule out this life-threatening complication before implementing comfort
measures .
Section 2: Medical-Surgical Nursing
Question 7: During a visit to the outpatient clinic, the nurse assesses a client with
severe osteoarthritis using a goniometer. Which finding should the nurse expect to
measure?
A. Adequate venous blood flow to the lower extremities.
, B. Estimated amount of body fat by an underarm skinfold.
C. Degree of flexion and extension of the client's knee joint.
D. Change in the circumference of the joint in centimeters.
✔✔✔ANSW✔✔: C. Degree of flexion and extension of the client's knee joint.
Rationale: A goniometer is a specific instrument designed to measure the angle of
joints, thereby determining the range of motion, such as flexion and extension .
Question 8: The nurse is instructing a client with high cholesterol about diet and
lifestyle modification. What comment from the client indicates that the teaching
has been effective?
A. "If I exercise at least two times weekly for one hour, I will lower my cholesterol."
B. "I need to avoid eating proteins, including red meat."
C. "I will limit my intake of beef to 4 ounces per week."
D. "My blood level of low density lipoproteins needs to increase."
✔✔✔ANSW✔✔: C. "I will limit my intake of beef to 4 ounces per week."
Rationale: Limiting high-cholesterol foods like red meat is a specific and
measurable dietary modification. Exercise is important but is recommended more
frequently than twice a week. Protein should be chosen wisely, not avoided entirely.
LDL is the "bad" cholesterol and should decrease, not increase .
Question 9: An older client who is unresponsive following a cerebral vascular
accident (CVA) is receiving bolus enteral feedings through a gastrostomy tube. What
is the best position for the client for administration of the bolus tube feedings?
A. Prone
B. Fowler's
C. Sims'
D. Supine
✔✔✔ANSW✔✔: B. Fowler's
Rationale: Placing the client in Fowler's (semi-sitting) position uses gravity to help
move the feeding into the stomach and prevents reflux and aspiration of the formula
into the lungs, which is the primary risk during enteral feedings .
