HESI HEALTH ASSESSMENT 246
QUESTIONS AND CORRECT VERIFIED
ANSWERS
AA2clientA2withA2chestA2pain,A2dizziness,A2andA2vomitingA2forA2theA2lastA22A2hoursA2isA2adm
ittedA2forA2evaluationA2forA2AcuteA2CoronaryA2SyndromeA2(ACS).A2WhichA2cardiacA2bioma
rkerA2shouldA2theA2registeredA2nurseA2(RN)A2anticipateA2toA2beA2elevatedA2ifA2theA2clientA2
experiencedA2myocardialA2damage?
CreatineA2KinaseA2(CK-MB).
SerumA2troponin.
Myoglobin.
IschemiaA2modifiedA2albumin.A2-A2Ans--SerumA2troponin.
TroponinA2isA2theA2mostA2sensitiveA2andA2specificA2testA2forA2myocardialA2damage.A2Trop
oninA2elevationA2isA2moreA2specificA2thanA2CK-MB.
TheA2registeredA2nurseA2(RN)A2isA2developingA2theA2planA2ofA2careA2forA2aA2clientA2whoA2i
sA2admittedA2forA2alcoholA2detoxification.A2WhichA2goalA2shouldA2beA2mostA2importantA2for
A2theA2RNA2toA2primarilyA2focusA2theA2client'sA2care?
TheA2clientA2maintainsA2optimalA2nutritionalA2status.
TheA2clientA2willA2remainA2alertA2andA2oriented.
TheA2clientA2willA2remainA2freeA2fromA2injury.
TheA2clientA2willA2remainA2alcoholA2freeA2duringA2hospitalization.A2-A2Ans--
TheA2clientA2willA2remainA2freeA2fromA2injury.
Rationale
TheA2clientA2isA2atA2highestA2riskA2forA2injuryA2dueA2toA2alteredA2cognitiveA2andA2sensoryA2
disturbancesA2asA2wellA2asA2deliriumA2tremorsA2duringA2withdrawal.A2RemainingA2freeA2fro
mA2injuryA2isA2theA2mostA2importantA2goalA2forA2theA2acuteA2phaseA2ofA2alcoholA2withdraw
al.
TheA2registeredA2nurseA2(RN)A2isA2caringA2forA2aA2clientA2withA2aplasticA2anemiaA2whoA2isA
2hospitalizedA2forA2weightA2lossA2andA2generalizedA2weakness.A2LaboratoryA2valuesA2sho
wA2aA2whiteA2bloodA2countA2(WBC)A2ofA22,500/
mm3A2andA2aA2plateletA2countofA2160,000/
mm3.A2WhichA2interventionA2isA2theA2primaryA2focusA2inA2theA2client'sA2planA2ofA2careA2forA
2theA2RNA2toA2implement?
AssistA2withA2frequentA2ambulation.
EncourageA2visitorsA2toA2visit.
MaintainA2strictA2protectiveA2precautions.
AvoidA2peripheralA2injections.A2-A2Ans--MaintainA2strictA2protectiveA2precautions.
Rationale
TheA2clientA2shouldA2beA2underA2strictA2protectiveA2transmissionA2precautionsA2becauseA2
theA2WBCA2valuesA2areA2lowA2andA2normalA2WBCA2levelsA2areA24,000-10,000/
mm3,A2soA2theA2clientA2isA2anA2increasedA2highA2riskA2forA2infection.
,TheA2registeredA2nurseA2(RN)A2assessesA2aA2client'sA2resultsA2forA2arterialA2bloodA2gases
A2whoA2hasA2emphysema.A2WhichA2findingA2isA2consistentA2withA2respiratoryA2acidosis?
pHA27.32,A2pCO2A246A2mmHg,A2HCO3A224A2MEq/L.
pHA27.45A2,A2pCO2A237A2mmHg,A2HCO3A224A2mEq/L.
pHA27.34,A2pCO2A236A2mmHg,A2HCO3A221A2mEq/L.
pHA27.46,A2pCO2A235A2mmHg,A2HCO3A228A2mEq/L.A2-A2Ans--
pHA27.32,A2pCO2A246A2mmHg,A2HCO3A224A2MEq/L.
Rationale
NormalA2ABGA2rangesA2areA2pHA27.35A2toA27.45;A2pCO2A235A2toA245A2mmHg;A2HCO3A221
A2toA228A2mEq/
L,A2andA2pO2A280A2toA2100A2mmHg.A2AnA2ABGA2ofA2pHA27.32,A2pCO2A246A2mmHg,A2HCO
3A224A2MEq/
LA2representsA2aA2clientA2withA2respiratoryA2acidosisA2whichA2isA2characterizedA2by:A2lowA2
pH,A2pCO2higherA2thanA2normal,A2andA2HCO3A2withinA2normalA2limits.
TheA2registeredA2nurseA2(RN)A2isA2caringA2forA2aA2clientA2whoA2hasA2takenA2atenololA2forA2
2A2years.A2TheA2healthcareA2providerA2recentlyA2changedA2theA2medicationA2toA2enalaprilt
oA2manageA2theA2client'sA2bloodA2pressure.A2WhichA2instructionA2shouldA2theA2RNA2provid
eA2theA2clientA2regardingA2theA2newA2medication?
TakeA2theA2medicationA2atA2bedtime.
ReportA2presenceA2ofA2increasedA2bruising.
CheckA2pulseA2beforeA2takingA2medication.
RiseA2slowlyA2whenA2gettingA2outA2ofA2bedA2orA2chair.A2-A2Ans--
RiseA2slowlyA2whenA2gettingA2outA2ofA2bedA2orA2chair.
Rationale
TheA2client'sA2newA2medicationA2isA2anA2angiotensin-
convertingA2enzymeA2(ACE)A2inhibitor,A2whichA2hasA2theA2sideA2effectA2oforthostaticA2hyp
otension.A2InstructingA2theA2clientA2toA2riseA2slowlyA2fromA2aA2sittingA2orA2lyingA2downA2pos
itionA2isA2importantA2toA2teachA2theA2clientA2toA2avoidA2dizzinessA2andA2potentiallyA2falling.
TheA2registeredA2nurseA2(RN)A2placesA2anA2iceA2packA2onA2aA2middleA2schoolA2studentA2w
hoA2comesA2toA2theA2schoolA2clinicA2complainingA2ofA2aA2sprainedA2ankle.A2WhichA2therap
euticA2responseA2shouldA2theA2RNA2anticipate?
ReducedA2painA2andA2minimizedA2brusing.
LoweringA2ofA2bodyA2coreA2temperature.
IncreasedA2circulationA2aroundA2injury.
ReabsorptionA2ofA2edemaA2atA2injury.A2-A2Ans--ReducedA2painA2andA2minimizedA2brusing.
Rationale
ColdA2applicationsA2produceA2aA2topicalA2anestheticA2effectA2toA2reduceA2painA2asA2wellA2
asA2constrictsA2bloodA2vesselsA2toA2minimizeA2bruising.
WhichA2actionA2shouldA2theA2registeredA2nurseA2(RN)A2implementA2toA2completeA2anA2ass
essmentA2forA2aA2clientA2whileA2usingA2anA2interpreter?
AskA2closed-endedA2questionsA2withA2theA2assistanceA2ofA2theA2interpreter.
MaintainA2eyeA2contactA2withA2theA2clientA2whileA2listeningA2toA2theA2translation.
, InstructA2interpreterA2toA2answerA2questionsA2fromA2interpreter'sA2pointA2ofA2view.
ProtectA2theA2client'sA2privacyA2byA2askingA2aA2limitedA2numberA2ofA2questions.A2-A2Ans--
MaintainA2eyeA2contactA2withA2theA2clientA2whileA2listeningA2toA2theA2translation.
Rationale
WhenA2completingA2anA2assessment,A2theA2RNA2shouldA2maintainA2eyeA2contactA2withA2t
heA2clientA2toA2gatherA2additionalA2informationA2fromA2theA2client'sA2nonverbalA2cues.
TheA2registeredA2nurseA2(RN)A2isA2assessingA2commonA2complicationsA2relatedA2toA2aA2cl
ient'sA2recentA2diagnosis,A2systemicA2lupusA2erythematosusA2(SLE).A2WhichA2symptomA2
shouldA2theA2RNA2instructA2theA2clientA2toA2reportA2immediately?
FeverA2relatedA2toA2infection.
WeightA2lossA2andA2anorexia.
DepressedA2mood.
BreakA2inA2tissueA2integrity.A2-A2Ans--FeverA2relatedA2toA2infection.
Rationale
SecondaryA2infectionsA2areA2aA2majorA2concernA2withA2SLEA2clientsA2dueA2toA2theA2useA2o
fA2corticosteroidsA2andA2chemotherapeuticA2agents,A2whichA2suppressesA2theA2immuneA2
system,A2soA2reportingA2feverA2andA2infectionsA2shouldA2beA2reportedA2immediately.
AnA2olderA2clientA2isA2admittedA2toA2theA2hospitalA2withA2severeA2diarrhea.A2TheA2registere
dA2nurseA2(RN)A2isA2completingA2anA2assessmentA2andA2notesA2theA2clientA2hasA2dryA2mu
cousA2membranesA2andA2poorA2skinA2turgor.A2WhichA2assessmentA2dataA2shouldA2theA2R
NA2gatherA2toA2determineA2ifA2theA2clientA2hasA2aA2fluidA2volumeA2deficit?
LowerA2extremityA2edema.
OrthostaticA2hypotension.
ElevatedA2bloodA2pressure.
Cheyne-StokesA2respirations.A2-A2Ans--OrthostaticA2hypotension.
Rationale
OrthostaticA2hypotensionA2canA2beA2aA2signA2ofA2fluidA2volumeA2deficitA2inA2anA2olderA2clie
ntA2whoA2hasA2experiencedA2severeA2diarrhea.
TheA2registeredA2nurseA2(RN)A2isA2caringA2forA2anA2olderA2clientA2whoA2recentlyA2experien
cedA2aA2fracturedA2pelvisA2fromA2aA2fall.A2WhichA2assessmentA2findingA2isA2mostA2importa
ntA2forA2theA2RNA2toA2reportA2theA2healthcareA2provider?
LowerA2backA2pain.
HeadacheA2ofA27A2onA2scaleA21A2toA210.
BloodA2pressureA2ofA2140/98.
Dyspnea.A2-A2Ans--Dyspnea.
Rationale
AA2clientA2withA2aA2largeA2boneA2fractureA2isA2atA2riskA2forA2intramedullaryA2fatA2leakingA2in
toA2theA2bloodA2streamA2andA2becomingA2embolic.A2DyspneaA2isA2anA2indicationA2ofA2fatA2
embolismA2toA2theA2lungsA2andA2shouldA2beA2reportedA2toA2theA2healthcareA2providerA2im
mediately.
QUESTIONS AND CORRECT VERIFIED
ANSWERS
AA2clientA2withA2chestA2pain,A2dizziness,A2andA2vomitingA2forA2theA2lastA22A2hoursA2isA2adm
ittedA2forA2evaluationA2forA2AcuteA2CoronaryA2SyndromeA2(ACS).A2WhichA2cardiacA2bioma
rkerA2shouldA2theA2registeredA2nurseA2(RN)A2anticipateA2toA2beA2elevatedA2ifA2theA2clientA2
experiencedA2myocardialA2damage?
CreatineA2KinaseA2(CK-MB).
SerumA2troponin.
Myoglobin.
IschemiaA2modifiedA2albumin.A2-A2Ans--SerumA2troponin.
TroponinA2isA2theA2mostA2sensitiveA2andA2specificA2testA2forA2myocardialA2damage.A2Trop
oninA2elevationA2isA2moreA2specificA2thanA2CK-MB.
TheA2registeredA2nurseA2(RN)A2isA2developingA2theA2planA2ofA2careA2forA2aA2clientA2whoA2i
sA2admittedA2forA2alcoholA2detoxification.A2WhichA2goalA2shouldA2beA2mostA2importantA2for
A2theA2RNA2toA2primarilyA2focusA2theA2client'sA2care?
TheA2clientA2maintainsA2optimalA2nutritionalA2status.
TheA2clientA2willA2remainA2alertA2andA2oriented.
TheA2clientA2willA2remainA2freeA2fromA2injury.
TheA2clientA2willA2remainA2alcoholA2freeA2duringA2hospitalization.A2-A2Ans--
TheA2clientA2willA2remainA2freeA2fromA2injury.
Rationale
TheA2clientA2isA2atA2highestA2riskA2forA2injuryA2dueA2toA2alteredA2cognitiveA2andA2sensoryA2
disturbancesA2asA2wellA2asA2deliriumA2tremorsA2duringA2withdrawal.A2RemainingA2freeA2fro
mA2injuryA2isA2theA2mostA2importantA2goalA2forA2theA2acuteA2phaseA2ofA2alcoholA2withdraw
al.
TheA2registeredA2nurseA2(RN)A2isA2caringA2forA2aA2clientA2withA2aplasticA2anemiaA2whoA2isA
2hospitalizedA2forA2weightA2lossA2andA2generalizedA2weakness.A2LaboratoryA2valuesA2sho
wA2aA2whiteA2bloodA2countA2(WBC)A2ofA22,500/
mm3A2andA2aA2plateletA2countofA2160,000/
mm3.A2WhichA2interventionA2isA2theA2primaryA2focusA2inA2theA2client'sA2planA2ofA2careA2forA
2theA2RNA2toA2implement?
AssistA2withA2frequentA2ambulation.
EncourageA2visitorsA2toA2visit.
MaintainA2strictA2protectiveA2precautions.
AvoidA2peripheralA2injections.A2-A2Ans--MaintainA2strictA2protectiveA2precautions.
Rationale
TheA2clientA2shouldA2beA2underA2strictA2protectiveA2transmissionA2precautionsA2becauseA2
theA2WBCA2valuesA2areA2lowA2andA2normalA2WBCA2levelsA2areA24,000-10,000/
mm3,A2soA2theA2clientA2isA2anA2increasedA2highA2riskA2forA2infection.
,TheA2registeredA2nurseA2(RN)A2assessesA2aA2client'sA2resultsA2forA2arterialA2bloodA2gases
A2whoA2hasA2emphysema.A2WhichA2findingA2isA2consistentA2withA2respiratoryA2acidosis?
pHA27.32,A2pCO2A246A2mmHg,A2HCO3A224A2MEq/L.
pHA27.45A2,A2pCO2A237A2mmHg,A2HCO3A224A2mEq/L.
pHA27.34,A2pCO2A236A2mmHg,A2HCO3A221A2mEq/L.
pHA27.46,A2pCO2A235A2mmHg,A2HCO3A228A2mEq/L.A2-A2Ans--
pHA27.32,A2pCO2A246A2mmHg,A2HCO3A224A2MEq/L.
Rationale
NormalA2ABGA2rangesA2areA2pHA27.35A2toA27.45;A2pCO2A235A2toA245A2mmHg;A2HCO3A221
A2toA228A2mEq/
L,A2andA2pO2A280A2toA2100A2mmHg.A2AnA2ABGA2ofA2pHA27.32,A2pCO2A246A2mmHg,A2HCO
3A224A2MEq/
LA2representsA2aA2clientA2withA2respiratoryA2acidosisA2whichA2isA2characterizedA2by:A2lowA2
pH,A2pCO2higherA2thanA2normal,A2andA2HCO3A2withinA2normalA2limits.
TheA2registeredA2nurseA2(RN)A2isA2caringA2forA2aA2clientA2whoA2hasA2takenA2atenololA2forA2
2A2years.A2TheA2healthcareA2providerA2recentlyA2changedA2theA2medicationA2toA2enalaprilt
oA2manageA2theA2client'sA2bloodA2pressure.A2WhichA2instructionA2shouldA2theA2RNA2provid
eA2theA2clientA2regardingA2theA2newA2medication?
TakeA2theA2medicationA2atA2bedtime.
ReportA2presenceA2ofA2increasedA2bruising.
CheckA2pulseA2beforeA2takingA2medication.
RiseA2slowlyA2whenA2gettingA2outA2ofA2bedA2orA2chair.A2-A2Ans--
RiseA2slowlyA2whenA2gettingA2outA2ofA2bedA2orA2chair.
Rationale
TheA2client'sA2newA2medicationA2isA2anA2angiotensin-
convertingA2enzymeA2(ACE)A2inhibitor,A2whichA2hasA2theA2sideA2effectA2oforthostaticA2hyp
otension.A2InstructingA2theA2clientA2toA2riseA2slowlyA2fromA2aA2sittingA2orA2lyingA2downA2pos
itionA2isA2importantA2toA2teachA2theA2clientA2toA2avoidA2dizzinessA2andA2potentiallyA2falling.
TheA2registeredA2nurseA2(RN)A2placesA2anA2iceA2packA2onA2aA2middleA2schoolA2studentA2w
hoA2comesA2toA2theA2schoolA2clinicA2complainingA2ofA2aA2sprainedA2ankle.A2WhichA2therap
euticA2responseA2shouldA2theA2RNA2anticipate?
ReducedA2painA2andA2minimizedA2brusing.
LoweringA2ofA2bodyA2coreA2temperature.
IncreasedA2circulationA2aroundA2injury.
ReabsorptionA2ofA2edemaA2atA2injury.A2-A2Ans--ReducedA2painA2andA2minimizedA2brusing.
Rationale
ColdA2applicationsA2produceA2aA2topicalA2anestheticA2effectA2toA2reduceA2painA2asA2wellA2
asA2constrictsA2bloodA2vesselsA2toA2minimizeA2bruising.
WhichA2actionA2shouldA2theA2registeredA2nurseA2(RN)A2implementA2toA2completeA2anA2ass
essmentA2forA2aA2clientA2whileA2usingA2anA2interpreter?
AskA2closed-endedA2questionsA2withA2theA2assistanceA2ofA2theA2interpreter.
MaintainA2eyeA2contactA2withA2theA2clientA2whileA2listeningA2toA2theA2translation.
, InstructA2interpreterA2toA2answerA2questionsA2fromA2interpreter'sA2pointA2ofA2view.
ProtectA2theA2client'sA2privacyA2byA2askingA2aA2limitedA2numberA2ofA2questions.A2-A2Ans--
MaintainA2eyeA2contactA2withA2theA2clientA2whileA2listeningA2toA2theA2translation.
Rationale
WhenA2completingA2anA2assessment,A2theA2RNA2shouldA2maintainA2eyeA2contactA2withA2t
heA2clientA2toA2gatherA2additionalA2informationA2fromA2theA2client'sA2nonverbalA2cues.
TheA2registeredA2nurseA2(RN)A2isA2assessingA2commonA2complicationsA2relatedA2toA2aA2cl
ient'sA2recentA2diagnosis,A2systemicA2lupusA2erythematosusA2(SLE).A2WhichA2symptomA2
shouldA2theA2RNA2instructA2theA2clientA2toA2reportA2immediately?
FeverA2relatedA2toA2infection.
WeightA2lossA2andA2anorexia.
DepressedA2mood.
BreakA2inA2tissueA2integrity.A2-A2Ans--FeverA2relatedA2toA2infection.
Rationale
SecondaryA2infectionsA2areA2aA2majorA2concernA2withA2SLEA2clientsA2dueA2toA2theA2useA2o
fA2corticosteroidsA2andA2chemotherapeuticA2agents,A2whichA2suppressesA2theA2immuneA2
system,A2soA2reportingA2feverA2andA2infectionsA2shouldA2beA2reportedA2immediately.
AnA2olderA2clientA2isA2admittedA2toA2theA2hospitalA2withA2severeA2diarrhea.A2TheA2registere
dA2nurseA2(RN)A2isA2completingA2anA2assessmentA2andA2notesA2theA2clientA2hasA2dryA2mu
cousA2membranesA2andA2poorA2skinA2turgor.A2WhichA2assessmentA2dataA2shouldA2theA2R
NA2gatherA2toA2determineA2ifA2theA2clientA2hasA2aA2fluidA2volumeA2deficit?
LowerA2extremityA2edema.
OrthostaticA2hypotension.
ElevatedA2bloodA2pressure.
Cheyne-StokesA2respirations.A2-A2Ans--OrthostaticA2hypotension.
Rationale
OrthostaticA2hypotensionA2canA2beA2aA2signA2ofA2fluidA2volumeA2deficitA2inA2anA2olderA2clie
ntA2whoA2hasA2experiencedA2severeA2diarrhea.
TheA2registeredA2nurseA2(RN)A2isA2caringA2forA2anA2olderA2clientA2whoA2recentlyA2experien
cedA2aA2fracturedA2pelvisA2fromA2aA2fall.A2WhichA2assessmentA2findingA2isA2mostA2importa
ntA2forA2theA2RNA2toA2reportA2theA2healthcareA2provider?
LowerA2backA2pain.
HeadacheA2ofA27A2onA2scaleA21A2toA210.
BloodA2pressureA2ofA2140/98.
Dyspnea.A2-A2Ans--Dyspnea.
Rationale
AA2clientA2withA2aA2largeA2boneA2fractureA2isA2atA2riskA2forA2intramedullaryA2fatA2leakingA2in
toA2theA2bloodA2streamA2andA2becomingA2embolic.A2DyspneaA2isA2anA2indicationA2ofA2fatA2
embolismA2toA2theA2lungsA2andA2shouldA2beA2reportedA2toA2theA2healthcareA2providerA2im
mediately.
