HESI 266 NIGHTINGALE EXAM
QUESTIONS & UPDATED DETAILED
ANSWERS PASSED ALREADY
GRADED A+ LATEST VERSION
The nurse assists a client with Parkinson's disease to ambulate
in the hallway. The client appears to "freeze" and then carefully lifts
on leg and steps forward. The client tells the nurse of pretending
to step over a crack on the floor. How should the nurse respond?
a. Assist the client to a carpeted area where he can walk more easily.
b. Re-orient the client to his present location and circumstance.
c. Confirm that this is an effective technique to help with ambulation.
d. Plan to assess the client's cognition after returning to his room.
c. Confirm that this is an effective technique to help with ambulation.
The nurse is teaching a client with glomerulonephritis about self
care. Which dietary recommendation should the nurse encourage
the client to follow?
a. Increase intake of high-fiber foods, such as bran cereal
b. Restrict protein intake by limiting meats and other high-protein foods
c. Limit oral fluid intake of 500 ml per day
d. Increase intake of potassium rich foods such as bananas and cantaloupe.
b. Restrict protein intake by limiting meats and other high-protein foods
a 37 year old female client reports to the preoperative area for herscheduled bariatric surgery.
The decision to have bariatric surgerycame after multiple attempts to lose weight by diet and
exercisewhich resulted in intial weight attempts were not sustained
Choose the most likely options for the information missing fromthe statement by selecting from
the lists of options provided?
The nurse recognizes that the most common serious complica-tion after having gastric bypass
,surgery is ___ as evidenced byincreased back, shoulder, or abdominal pain, restlessness, ___and
tachcardia.
First line - Anastomotic leak
Second line - Arrythmia (I think)
A client is diagnosed with chronic kidney disease and needsto begin dialysis. Which condition
entered on the client's medicalrecord should the nurse recognize as a contraindication for
peritoneal dialysis?
a. Nephrotic syndrom history
b. Crohn's disease with colectomy
c. Diabetes Mellitus
d. Latent Hepatitis C
b. Crohn's disease with colectomy
Rationale: Crohn's disease with colectomy. The nurse should recognize that clients with
extensive intra-abdominal surgical history are not candidates for peritoneal dialysis, as these
clients may have decreased peritoneal membrane surface areas and scar tissue formation,
which would make it insufficient for adequate dialysis exchange.
A client is admitted to the hospital for treatment of a simple
goiter, and levothyroxine sodium is prescribed. Which symptoms
indicate to the nurse that the prescribed dosage is too high for this
client?
a. Palpitations and shortness of breath
b. Bradycardia and constipation
c. Muscle cramping and dry, flushed skin
d. Lethargy and lack of appetite
a. Palpitations and shortness of breath
Rationales: Palpitations and shortness of breath are symptoms of thyrotoxicosis, indicating
excessive thyroid hormone levels, which could result from an overdose of Levothyroxine
Sodium.
The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and
massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis?
, a. Decreased portacaval pressure with greater collateral circulation.
b. Hyperaldosteronism causing an increased sodium reabsorption in renal tubules.
c. Decreased renin-angiotensin response related to an increase in renal bloodflow.
d. Hypoalbuminemia that results in a decreased colloidal oncotic pressure.
d. Hypoalbuminemia that results in a decreased colloidal oncotic pressure.
Rationale: In Cirrhosis, liver damaged leads to decreased synthesis of albumin. Albumin plays a
crucial role in maintaining colloidal oncotic pressure, and when it is decreased
(hypoalbuminemia), fluid is more likely to leak out of blood vessels, resulting in anemia. The
same mechanism contributes to the development of ascities in the abdominal cavity.
A client with a fracture of the right femur has had skeletal traction
applied. Which intervention should the nurse include in the client's
nursing care plan?
a. assess the pin sites for signs of infection.
b. administer pain medication at designated intervals around the clock.
c. assess the pulse proximal to the fracture site.
d. Remove traction every provide skin care.
a. assess the pin sites for signs of infection.
Rationale: Assessing the pin sites for sign of infection is in essential for clients with skeletal
traction to detect any early signs of infection such as redness, warmth, swelling, or purulent
drainage. Prompt identification and management of pin site infections can prevent
complications.
A client with a renal calculus reports severe right flank pain,
nausea, and vomiting. Which nursing problem has the highest
priority?
a. Acute pain related to renal calculus.
b. Nutritional deficit related to nausea.
c. Impaired renal function related to pain.
d. Risk for aspiration related to vomiting.
d. Risk for aspiration related to vomiting.
Rationale: Risk for aspiration related to vomiting is the highest priority because it addresses the
QUESTIONS & UPDATED DETAILED
ANSWERS PASSED ALREADY
GRADED A+ LATEST VERSION
The nurse assists a client with Parkinson's disease to ambulate
in the hallway. The client appears to "freeze" and then carefully lifts
on leg and steps forward. The client tells the nurse of pretending
to step over a crack on the floor. How should the nurse respond?
a. Assist the client to a carpeted area where he can walk more easily.
b. Re-orient the client to his present location and circumstance.
c. Confirm that this is an effective technique to help with ambulation.
d. Plan to assess the client's cognition after returning to his room.
c. Confirm that this is an effective technique to help with ambulation.
The nurse is teaching a client with glomerulonephritis about self
care. Which dietary recommendation should the nurse encourage
the client to follow?
a. Increase intake of high-fiber foods, such as bran cereal
b. Restrict protein intake by limiting meats and other high-protein foods
c. Limit oral fluid intake of 500 ml per day
d. Increase intake of potassium rich foods such as bananas and cantaloupe.
b. Restrict protein intake by limiting meats and other high-protein foods
a 37 year old female client reports to the preoperative area for herscheduled bariatric surgery.
The decision to have bariatric surgerycame after multiple attempts to lose weight by diet and
exercisewhich resulted in intial weight attempts were not sustained
Choose the most likely options for the information missing fromthe statement by selecting from
the lists of options provided?
The nurse recognizes that the most common serious complica-tion after having gastric bypass
,surgery is ___ as evidenced byincreased back, shoulder, or abdominal pain, restlessness, ___and
tachcardia.
First line - Anastomotic leak
Second line - Arrythmia (I think)
A client is diagnosed with chronic kidney disease and needsto begin dialysis. Which condition
entered on the client's medicalrecord should the nurse recognize as a contraindication for
peritoneal dialysis?
a. Nephrotic syndrom history
b. Crohn's disease with colectomy
c. Diabetes Mellitus
d. Latent Hepatitis C
b. Crohn's disease with colectomy
Rationale: Crohn's disease with colectomy. The nurse should recognize that clients with
extensive intra-abdominal surgical history are not candidates for peritoneal dialysis, as these
clients may have decreased peritoneal membrane surface areas and scar tissue formation,
which would make it insufficient for adequate dialysis exchange.
A client is admitted to the hospital for treatment of a simple
goiter, and levothyroxine sodium is prescribed. Which symptoms
indicate to the nurse that the prescribed dosage is too high for this
client?
a. Palpitations and shortness of breath
b. Bradycardia and constipation
c. Muscle cramping and dry, flushed skin
d. Lethargy and lack of appetite
a. Palpitations and shortness of breath
Rationales: Palpitations and shortness of breath are symptoms of thyrotoxicosis, indicating
excessive thyroid hormone levels, which could result from an overdose of Levothyroxine
Sodium.
The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and
massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis?
, a. Decreased portacaval pressure with greater collateral circulation.
b. Hyperaldosteronism causing an increased sodium reabsorption in renal tubules.
c. Decreased renin-angiotensin response related to an increase in renal bloodflow.
d. Hypoalbuminemia that results in a decreased colloidal oncotic pressure.
d. Hypoalbuminemia that results in a decreased colloidal oncotic pressure.
Rationale: In Cirrhosis, liver damaged leads to decreased synthesis of albumin. Albumin plays a
crucial role in maintaining colloidal oncotic pressure, and when it is decreased
(hypoalbuminemia), fluid is more likely to leak out of blood vessels, resulting in anemia. The
same mechanism contributes to the development of ascities in the abdominal cavity.
A client with a fracture of the right femur has had skeletal traction
applied. Which intervention should the nurse include in the client's
nursing care plan?
a. assess the pin sites for signs of infection.
b. administer pain medication at designated intervals around the clock.
c. assess the pulse proximal to the fracture site.
d. Remove traction every provide skin care.
a. assess the pin sites for signs of infection.
Rationale: Assessing the pin sites for sign of infection is in essential for clients with skeletal
traction to detect any early signs of infection such as redness, warmth, swelling, or purulent
drainage. Prompt identification and management of pin site infections can prevent
complications.
A client with a renal calculus reports severe right flank pain,
nausea, and vomiting. Which nursing problem has the highest
priority?
a. Acute pain related to renal calculus.
b. Nutritional deficit related to nausea.
c. Impaired renal function related to pain.
d. Risk for aspiration related to vomiting.
d. Risk for aspiration related to vomiting.
Rationale: Risk for aspiration related to vomiting is the highest priority because it addresses the
