Nurs 170 HESI Prep Exam Questions With
Complete Answers
A client becomes angry while waiting for a supervised break to smoke a
cigarette outside and states, "I want to go outside now and smoke. It takes
forever to get anything done here!" Which intervention is best for the nurse to
implement?
a. Encourage the client to use a nicotine patch.
b. Reassure the client that it is almost time for another break.
c. Have the client leave the unit with another staff.
d. Review the schedule of outdoor breaks with the client. - ANSWER Correct
Answer: D
Rationale: The best nursing action is to review the schedule of outdoor breaks
(D) and provide concrete information about the schedule. (A) is contraindicated
if the client wants to continue smoking. (B) is insufficient to encourage a trusting
relationship with the client. (C) is preferential for this client only and is
inconsistent with unit rules.
When the health care provider diagnoses metastatic cancer and recommends a
gastrostomy for an older female client in stable condition, the son tells the nurse
that his mother must not be told the reason for the surgery because she "can't
handle" the cancer diagnosis. Which legal principle is the court most likely to
uphold regarding this client's right to informed consent?
a. The family can provide the consent required in this situation because the
older adult is in no condition to make such decisions.
b. Because the client is mentally incompetent, the son has the right to waive
informed consent for her.
c. The court will allow the health care provider to make the decision to withhold
informed consent under therapeutic privilege.
d. If informed consent is withheld from a client, health care providers could be
found guilty of negligence. - ANSWER Correct Answer: D
Rationale: Health care providers may be found guilty of negligence (D),
specifically assault and battery, if they carry out a treatment without the client's
consent. The client's condition is stable, so (A) is not a valid rationale. Advanced
age does not automatically authorize the son to make all decisions for his
mother, and there is no evidence that the client is mentally incompetent (B).
,Although (C) may have been upheld in the past, when paternalistic medical
practice was common, today's courts are unlikely to accept it.
Urinary catheterization is prescribed for a postoperative female client who has
been unable to void for 8 hours. The nurse inserts the catheter, but no urine is
seen in the tubing. Which action will the nurse take next?
a. Clamp the catheter and recheck it in 60 minutes.
b. Pull the catheter back 3 inches and redirect upward.
c. Leave the catheter in place and reattempt with another catheter.
d. Notify the health care provider of a possible obstruction. - ANSWER Correct
Answer: C
Rationale: It is likely that the first catheter is in the vagina, rather than the
bladder. Leaving the first catheter in place will help locate the meatus when
attempting the second catheterization (C). The client should have at least 240
mL of urine after 8 hours. (A) does not resolve the problem. (B) will not change
the location of the catheter unless it is completely removed, in which case a new
catheter must be used. There is no evidence of a urinary tract obstruction if the
catheter could be easily inserted (D).
The nurse is using the Glasgow Coma Scale to perform a neurologic
assessment. A comatose client winces and pulls away from a painful stimulus.
Which action should the nurse take next?
a. Document that the client responds to painful stimulus.
b. Observe the client's response to verbal stimulation.
c. Place the client on seizure precautions for 24 hours.
d. Report decorticate posturing to the health care provider. - ANSWER Correct
Answer: A
Rationale: The client has demonstrated a purposeful response to pain, which
should be documented as such (A). Response to painful stimulus is assessed
after response to verbal stimulus, not before (B). There is no indication for
placing the client on seizure precautions (C). Reporting (D) is nonpurposeful
movement.
A female nurse is assigned to care for a close friend, who says, "I am worried
that friends will find out about my diagnosis." The nurse tells her friend that
legally she must protect a client's confidentiality. Which resource describes the
nurse's legal responsibilities?
a. Code of Ethics for Nurses
b. State Nurse Practice Acts
c. Patient's Bill of Rights
d. ANA Standards of Practice - ANSWER Correct Answer: B
,Rationale: The State Nurse Practice Act (B) contains legal requirements for the
protection of client confidentiality and the consequences for breaches in
confidentiality. (A) outlines ethical standards for nursing care but does not
include legal guidelines. (C and D) describe expectations for nursing practice
but do not address legal implications.
The nurse assesses a 2-year-old who is admitted for dehydration and finds that
the peripheral IV rate by gravity has slowed, even though the venous access site
is healthy. What should the nurse do next?
a. Apply a warm compress proximal to the site.
b. Check for kinks in the tubing and raise the IV pole.
c. Adjust the tape that stabilizes the needle.
d. Flush with normal saline and recount the drop rate. - ANSWER Correct
Answer: B
Rationale: The nurse should first check the tubing and height of the bag on the
IV pole (B), which are common factors that may slow the rate. Gravity infusion
rates are influenced by the height of the bag, tubing clamp closure or kinks,
needle size or position, fluid viscosity, client blood pressure (crying in the
pediatric client), and infiltration. Venospasm can slow the rate and often
responds to warmth over the vessel (A), but the nurse should first adjust the IV
pole height. The nurse may need to adjust the stabilizing tape on a positional
needle (C) or flush the venous access with normal saline (D), but less invasive
actions should be implemented first.
The nurse is instructing a client in the proper use of a metered-dose inhaler.
Which instruction should the nurse provide the client to ensure the optimal
benefits from the drug?
a. "Fill your lungs with air through your mouth and then compress the inhaler."
b. "Compress the inhaler while slowly breathing in through your mouth."
c. "Compress the inhaler while inhaling quickly through your nose."
d. "Exhale completely after compressing the inhaler and then inhale." - ANSWER
Correct Answer: B
Rationale: The medication should be inhaled through the mouth simultaneously
with compression of the inhaler (B). This will facilitate the desired destination of
the aerosol medication deep in the lungs for an optimal bronchodilation effect.
(A, C, and D) do not allow for deep lung penetration.
Which nonverbal action should the nurse implement to demonstrate active
listening?
a. Sit facing the client.
, b. Cross arms and legs.
c. Avoid eye contact.
d. Lean back in the chair. - ANSWER Correct Answer: A
Rationale: Active listening is conveyed using attentive verbal and nonverbal
communication techniques. To facilitate therapeutic communication and
attentiveness, the nurse should sit facing the client (A), which lets the client
know that the nurse is there to listen. Active listening skills include postures that
are open to the client, such as keeping the arms open and relaxed, not (B), and
leaning toward the client, not (D). To communicate involvement and willingness
to listen to the client, eye contact should be established and maintained (C).
The health care provider has changed a client's prescription from the PO to the
IV route of administration. The nurse should anticipate which change in the
pharmacokinetic properties of the medication?
a. The client will experience increased tolerance to the drug's effects and may
need a higher dose.
b. The onset of action of the drug will occur more rapidly, resulting in a more
rapid effect.
c. The medication will be more highly protein-bound, increasing the duration of
action.
d. The therapeutic index will be increased, placing the client at greater risk for
toxicity. - ANSWER Correct Answer: B
Rationale: Because the absorptive process is eliminated when medications are
administered via the IV route, the onset of action is more rapid, resulting in a
more immediate effect (B). Drug tolerance (A), protein binding (C), and the
drug's therapeutic index (D) are not affected by the change in route from PO to
IV. In addition, an increased therapeutic index reduces the risk of drug toxicity.
Which client is most likely to be at risk for spiritual distress?
a. Roman Catholic woman considering an abortion.
b. Jewish man considering hospice care for his wife.
c. Seventh-Day Adventist who needs a blood transfusion.
d. Muslim man who needs a total knee replacement. - ANSWER Correct Answer:
A
Rationale: In the Roman Catholic religion, any type of abortion is prohibited (A),
so facing this decision may place the client at risk for spiritual distress. There is
no prohibition of hospice care for members of the Jewish faith (B). Jehovah's
Witnesses prohibit blood transfusions, not Seventh-Day Adventists (C). There is
no conflict in the Muslim faith with regard to joint replacement (D).
Complete Answers
A client becomes angry while waiting for a supervised break to smoke a
cigarette outside and states, "I want to go outside now and smoke. It takes
forever to get anything done here!" Which intervention is best for the nurse to
implement?
a. Encourage the client to use a nicotine patch.
b. Reassure the client that it is almost time for another break.
c. Have the client leave the unit with another staff.
d. Review the schedule of outdoor breaks with the client. - ANSWER Correct
Answer: D
Rationale: The best nursing action is to review the schedule of outdoor breaks
(D) and provide concrete information about the schedule. (A) is contraindicated
if the client wants to continue smoking. (B) is insufficient to encourage a trusting
relationship with the client. (C) is preferential for this client only and is
inconsistent with unit rules.
When the health care provider diagnoses metastatic cancer and recommends a
gastrostomy for an older female client in stable condition, the son tells the nurse
that his mother must not be told the reason for the surgery because she "can't
handle" the cancer diagnosis. Which legal principle is the court most likely to
uphold regarding this client's right to informed consent?
a. The family can provide the consent required in this situation because the
older adult is in no condition to make such decisions.
b. Because the client is mentally incompetent, the son has the right to waive
informed consent for her.
c. The court will allow the health care provider to make the decision to withhold
informed consent under therapeutic privilege.
d. If informed consent is withheld from a client, health care providers could be
found guilty of negligence. - ANSWER Correct Answer: D
Rationale: Health care providers may be found guilty of negligence (D),
specifically assault and battery, if they carry out a treatment without the client's
consent. The client's condition is stable, so (A) is not a valid rationale. Advanced
age does not automatically authorize the son to make all decisions for his
mother, and there is no evidence that the client is mentally incompetent (B).
,Although (C) may have been upheld in the past, when paternalistic medical
practice was common, today's courts are unlikely to accept it.
Urinary catheterization is prescribed for a postoperative female client who has
been unable to void for 8 hours. The nurse inserts the catheter, but no urine is
seen in the tubing. Which action will the nurse take next?
a. Clamp the catheter and recheck it in 60 minutes.
b. Pull the catheter back 3 inches and redirect upward.
c. Leave the catheter in place and reattempt with another catheter.
d. Notify the health care provider of a possible obstruction. - ANSWER Correct
Answer: C
Rationale: It is likely that the first catheter is in the vagina, rather than the
bladder. Leaving the first catheter in place will help locate the meatus when
attempting the second catheterization (C). The client should have at least 240
mL of urine after 8 hours. (A) does not resolve the problem. (B) will not change
the location of the catheter unless it is completely removed, in which case a new
catheter must be used. There is no evidence of a urinary tract obstruction if the
catheter could be easily inserted (D).
The nurse is using the Glasgow Coma Scale to perform a neurologic
assessment. A comatose client winces and pulls away from a painful stimulus.
Which action should the nurse take next?
a. Document that the client responds to painful stimulus.
b. Observe the client's response to verbal stimulation.
c. Place the client on seizure precautions for 24 hours.
d. Report decorticate posturing to the health care provider. - ANSWER Correct
Answer: A
Rationale: The client has demonstrated a purposeful response to pain, which
should be documented as such (A). Response to painful stimulus is assessed
after response to verbal stimulus, not before (B). There is no indication for
placing the client on seizure precautions (C). Reporting (D) is nonpurposeful
movement.
A female nurse is assigned to care for a close friend, who says, "I am worried
that friends will find out about my diagnosis." The nurse tells her friend that
legally she must protect a client's confidentiality. Which resource describes the
nurse's legal responsibilities?
a. Code of Ethics for Nurses
b. State Nurse Practice Acts
c. Patient's Bill of Rights
d. ANA Standards of Practice - ANSWER Correct Answer: B
,Rationale: The State Nurse Practice Act (B) contains legal requirements for the
protection of client confidentiality and the consequences for breaches in
confidentiality. (A) outlines ethical standards for nursing care but does not
include legal guidelines. (C and D) describe expectations for nursing practice
but do not address legal implications.
The nurse assesses a 2-year-old who is admitted for dehydration and finds that
the peripheral IV rate by gravity has slowed, even though the venous access site
is healthy. What should the nurse do next?
a. Apply a warm compress proximal to the site.
b. Check for kinks in the tubing and raise the IV pole.
c. Adjust the tape that stabilizes the needle.
d. Flush with normal saline and recount the drop rate. - ANSWER Correct
Answer: B
Rationale: The nurse should first check the tubing and height of the bag on the
IV pole (B), which are common factors that may slow the rate. Gravity infusion
rates are influenced by the height of the bag, tubing clamp closure or kinks,
needle size or position, fluid viscosity, client blood pressure (crying in the
pediatric client), and infiltration. Venospasm can slow the rate and often
responds to warmth over the vessel (A), but the nurse should first adjust the IV
pole height. The nurse may need to adjust the stabilizing tape on a positional
needle (C) or flush the venous access with normal saline (D), but less invasive
actions should be implemented first.
The nurse is instructing a client in the proper use of a metered-dose inhaler.
Which instruction should the nurse provide the client to ensure the optimal
benefits from the drug?
a. "Fill your lungs with air through your mouth and then compress the inhaler."
b. "Compress the inhaler while slowly breathing in through your mouth."
c. "Compress the inhaler while inhaling quickly through your nose."
d. "Exhale completely after compressing the inhaler and then inhale." - ANSWER
Correct Answer: B
Rationale: The medication should be inhaled through the mouth simultaneously
with compression of the inhaler (B). This will facilitate the desired destination of
the aerosol medication deep in the lungs for an optimal bronchodilation effect.
(A, C, and D) do not allow for deep lung penetration.
Which nonverbal action should the nurse implement to demonstrate active
listening?
a. Sit facing the client.
, b. Cross arms and legs.
c. Avoid eye contact.
d. Lean back in the chair. - ANSWER Correct Answer: A
Rationale: Active listening is conveyed using attentive verbal and nonverbal
communication techniques. To facilitate therapeutic communication and
attentiveness, the nurse should sit facing the client (A), which lets the client
know that the nurse is there to listen. Active listening skills include postures that
are open to the client, such as keeping the arms open and relaxed, not (B), and
leaning toward the client, not (D). To communicate involvement and willingness
to listen to the client, eye contact should be established and maintained (C).
The health care provider has changed a client's prescription from the PO to the
IV route of administration. The nurse should anticipate which change in the
pharmacokinetic properties of the medication?
a. The client will experience increased tolerance to the drug's effects and may
need a higher dose.
b. The onset of action of the drug will occur more rapidly, resulting in a more
rapid effect.
c. The medication will be more highly protein-bound, increasing the duration of
action.
d. The therapeutic index will be increased, placing the client at greater risk for
toxicity. - ANSWER Correct Answer: B
Rationale: Because the absorptive process is eliminated when medications are
administered via the IV route, the onset of action is more rapid, resulting in a
more immediate effect (B). Drug tolerance (A), protein binding (C), and the
drug's therapeutic index (D) are not affected by the change in route from PO to
IV. In addition, an increased therapeutic index reduces the risk of drug toxicity.
Which client is most likely to be at risk for spiritual distress?
a. Roman Catholic woman considering an abortion.
b. Jewish man considering hospice care for his wife.
c. Seventh-Day Adventist who needs a blood transfusion.
d. Muslim man who needs a total knee replacement. - ANSWER Correct Answer:
A
Rationale: In the Roman Catholic religion, any type of abortion is prohibited (A),
so facing this decision may place the client at risk for spiritual distress. There is
no prohibition of hospice care for members of the Jewish faith (B). Jehovah's
Witnesses prohibit blood transfusions, not Seventh-Day Adventists (C). There is
no conflict in the Muslim faith with regard to joint replacement (D).
