RNSG 2341 Adult Health Care Hesi. Over 800 Questions With Correct Answers
After a bronchoscopy with biopsy, the nurse assesses the client. The nurse should report which finding to the
health care provider?
laryngeal stridor
A client has a plural chest tube following removal of the lower lobe of the lung. Two days after surgery, the tubeis
accidentally pulled out of the chest wall. What should the nurse do first?
Apply an occlusive dressing such as petroleum jelly gauze.
The client asks the nurse, “Why won’t the health care provider tell me exactly how much of my leg he is going totake
off? Don’t you think I should know that?” On which information should the nurse base the response?
the adequacy of the blood supply to the tissues
An unlicensed assistive personnel (UAP) tells the nurse, “I think the client is confused. He keeps telling me hehas
to void, but that’s not possible because he has a catheter in place that is draining well.” What should the nurse tell
the UAP?
"The urge to void is usually created by the large catheter, and he may be having some bladder
spasms."
When assessing a client with advanced chronic obstructive pulmonary disease (COPD) which are expected
findings?
increased anteroposterior chest diameter
The nurse has placed the intubated client with acute respiratory distress syndrome (ARDS) in prone position for30
minutes. Which factors would require the nurse to discontinue prone positioning and return the client to the supine
position? Select all that apply.
The SpO2 and PO2 have decreased.
The client is tachycardic with drop in blood pressure.
The face has increased skin breakdown and edema.
The nurse is planning care for a client who has just returned to the medical-surgical unit following repair of an
aortic aneurysm. What is a priority assessment for this client?
decreased urinary output
Which is the most important initial postprocedure nursing assessment for a client who has had a cardiac
catheterization?
Observe the puncture site for swelling and bleeding.
A client has had a cerebrovascular accident, which has affected the left side of the client’s brain. The nurse
should assess the client for which symptom?
aphasia
The nurse is instructing an unlicensed assistive personnel (UAP) to collect a urine specimen from an indwelling
catheter. Which statement indicates that the UAP understands the instructions?
“I’ll get a sterile syringe and remove urine from the catheter through the collection port to place in
the specimen container.”
A client comes to the physician's office for a follow-up visit 4 weeks after suffering a myocardial infarction (MI).The
nurse takes this opportunity to evaluate the client's knowledge of the ordered cardiac rehabilitation program.Which
evaluation statement suggests that the client needs more instruction?
"Client walks 4 miles (6.4 kilometers) in 1 hour every day."
A client undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the first postoperative day,
the nurse notes the absence of a bone flap at the operative site. How should the nurse position the client's he
, ad?
elevated 30 degrees
After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive
isoniazid (INH) as prophylaxis against tuberculosis. The client's family asks the nurse how long the drug must be
taken. What is the usual duration of prophylactic isoniazid therapy?
6 to 12 months
The nurse is assisting a client with a stroke who has homonymous hemianopia. The nurse should understand thatthe
client will do which when eating?
Eat food on only half of the plate.
A client is arousing from a coma and keeps saying, “Just stop the pain.” The nurse responds based on the
knowledge that the client’s first response to pain will be to do what?
Escape the source of pain.
The nurse sees a client walking in the hallway who begins to have a seizure. What should the nurse do in order of
priority from first to last? All options must be used.
Ease the client to the floor.
Maintain a patent airway.
Obtain vital signs.
Record the seizure activity observed.
The nurse is teaching a client with multiple sclerosis about prevention of urinary tract infection (UTI) and renal
calculi. Which nutrition recommendations by the nurse would be the most likely to reduce the risk of these
conditions?
Increase fluids (2500 mL/day) and maintain urine acidity by drinking cranberry juice.
A nurse is assigned to care for a client with chest pain in the intensive care unit. The client is reading a book when
the nurse observes a flat line on the monitor and the alarm rings. What is the nurse's priority interventionat this
time?
assessing the client
A client with marked oliguria is ordered a test dose of 0.2 g/kg of 15% mannitol solution intravenously over 5
minutes. The client weighs 132 lb (60 kg). How many grams would the nurse administer? Record your answer asa
whole number.
12
A client with chronic renal failure receives hemodialysis treatments through a mature arteriovenous (AV) fistula.
What intervention will the nurse include in the care plan?
Auscultate the AV fistula for a bruit.
A client whose condition remains stable after a myocardial infarction is to gradually increase activity. Which sign
best indicates that the activity is appropriate for the client?
respiratory rate
A client with heart failure will take oral furosemide at home. To help the client evaluate the effectiveness of
furosemide therapy, the nurse should teach the client to:
weigh daily.
The client is on a fluid restriction of 500 mL/day plus replacement for urine output. Because the client’s 24-hour
urine output yesterday was 150 mL, the total fluid allotment for the next 24 hours is 650 mL. How should the
nurses distribute this fluid over the next 24 hours?
given in small amounts throughout each shift
,The nurse has given a client a nitroglycerin tablet sublingually for angina. Which vital signs should be assessed
following administration of nitroglycerin?
blood pressure
A client is returning from the operating room after inguinal hernia repair. The nurse notes that the client has fluid
volume excess from the operation and is at risk for left-sided heart failure. Which sign or symptom indicates left-
sided heart failure?
bibasilar crackles
A client is receiving captopril for heart failure. The nurse should notify the physician that the medication therapyis
ineffective if an assessment reveals
peripheral edema.
Which nursing diagnosis takes highest priority for a client with hyperthyroidism?
Imbalanced nutrition: Less than body requirements related to thyroid hormone excess
When teaching a client with Cushing's syndrome about dietary changes, the nurse should instruct the client to
increase intake of
fresh fruits.
A client develops decreased renal function and requires a change in antibiotic dosage. On which factor should the
physician base the dosage change?
creatinine clearance
A client developed cardiogenic shock after a severe myocardial infarction and has now developed acute renal failure.
The client’s family asks the nurse why the client has developed acute renal failure. What should the nursetell the
family?
“Because of the cardiogenic shock, there is:
a decrease in the blood flow through the kidneys.”
A sexually active male client has burning on urination and a milky discharge from the urethral meatus. What
documentation should be included on the client’s medical record? Select all that apply.
history of unprotected sex (sex without a condom)
length of time since symptoms presented
history of fever or chills
presence of any enlarged lymph nodes on examination
allergies to any medications
A client with type 1 diabetes mellitus asks the nurse about taking ginseng at home. What should the nurse tell the
client?
"Taking ginseng will increase the risk of hypoglycemia."
A client who had transurethral resection of the prostate (TURP) 2 days earlier has lower abdominal pain. What
should the nurse do first?
Assess the patency of the urethral catheter.
A 45-year-old client had a complete abdominal hysterectomy with bilateral salpingo-oophorectomy 2 days ago.The
client’s abdominal dressing is dry and intact. While sitting up in the chair, the client has severe pain and numbness
in her left leg. What should the nurse do first?
Assess color and temperature of the left leg.
A nurse is preparing a client for an intravenous pyelography. Which action is the priority?
Assess allergies to iodine.
, The nurse is caring for a client in the medical unit. The nurse receives a health care provider’s order for
hydrocortisone 100 mg intravenously at a rate of 10 cc/hour for a client in acute adrenal crisis. The nurse
understands that this treatment is common in clients with which disease process?
Addison’s disease
A client with a ventricular dysrhythmia is receiving intravenous lidocaine. For which assessment finding shouldthe
nurse suspect the client is experiencing toxicity from the medication?
confusion and restlessness
The nurse is teaching a client about levothyroxine. Which instruction should a nurse offer the client?
"Take the drug on an empty stomach."
A client is returned to the hospital room after a subtotal thyroidectomy. Which piece of equipment is most
important for the nurse to keep at the client's bedside?
tracheostomy set
A nurse records a client’s fingerstick blood glucose level and gives 2 units of regular insulin as ordered. At thenext
scheduled blood glucose assessment, the nurse realizes that the wrong client was tested and given insulin.What is
the nurse's priority action related to this incident?
Assess both clients, and call the appropriate healthcare providers to notify them of the errors.
Which statement would lead the nurse to determine that a client lacks understanding of the client’s acute cardiac
illness and the ability to make lifestyle changes?
“I already have my airline ticket, so I won’t miss my meeting tomorrow.”
A client is scheduled for an arteriogram. The nurse should explain to the client that the arteriogram will confirmthe
diagnosis of occlusive arterial disease by:
showing the location of the obstruction and the collateral circulation.
A client with peripheral artery disease has femoral-popliteal bypass surgery. What goal should the nurse establish
with the client immediately after surgery?
Maintain circulation.
A client with heart failure is taking furosemide, digoxin, and potassium chloride. The client has nausea, blurred
vision, headache, and weakness. The nurse notes that the client is confused. The telemetry strip shows first-
degree atrioventricular block. What other sign should the nurse assess next?
digoxin toxicity.
A client is scheduled to undergo percutaneous transluminal coronary angioplasty (PTCA). Which statement bythe
nurse best explains the procedure to the client?
”PTCA involves opening a blocked artery with an inflatable balloon located on the end of a
catheter.”
A nurse is caring for a client who had a three-vessel coronary bypass graft 4 days earlier. The client's cholesterol
profile is as follows: total cholesterol 265 mg/dl (6.845 mmol/L), low-density lipoprotein (LDL) 139 mg/dl (3.603
mmol/L), and high-density lipoprotein (HDL) 32 mg/dl (0.829 mmol/L). The client asks the nurse how tolower their
cholesterol. The nurse should tell the client that
the nurse willll ask the dietitian to talk with the client about modifying their diet.
Following a percutaneous transluminal coronary angioplasty, a client is monitored in the postprocedure unit. The
client's heparin infusion was stopped 2 hours earlier. There is no evidence of bleeding or hematoma at the insertion
site, and the pressure device is removed. The nurse should plan to safely remove the femoral sheath when the partial
thromboplastin time (PTT) is:
After a bronchoscopy with biopsy, the nurse assesses the client. The nurse should report which finding to the
health care provider?
laryngeal stridor
A client has a plural chest tube following removal of the lower lobe of the lung. Two days after surgery, the tubeis
accidentally pulled out of the chest wall. What should the nurse do first?
Apply an occlusive dressing such as petroleum jelly gauze.
The client asks the nurse, “Why won’t the health care provider tell me exactly how much of my leg he is going totake
off? Don’t you think I should know that?” On which information should the nurse base the response?
the adequacy of the blood supply to the tissues
An unlicensed assistive personnel (UAP) tells the nurse, “I think the client is confused. He keeps telling me hehas
to void, but that’s not possible because he has a catheter in place that is draining well.” What should the nurse tell
the UAP?
"The urge to void is usually created by the large catheter, and he may be having some bladder
spasms."
When assessing a client with advanced chronic obstructive pulmonary disease (COPD) which are expected
findings?
increased anteroposterior chest diameter
The nurse has placed the intubated client with acute respiratory distress syndrome (ARDS) in prone position for30
minutes. Which factors would require the nurse to discontinue prone positioning and return the client to the supine
position? Select all that apply.
The SpO2 and PO2 have decreased.
The client is tachycardic with drop in blood pressure.
The face has increased skin breakdown and edema.
The nurse is planning care for a client who has just returned to the medical-surgical unit following repair of an
aortic aneurysm. What is a priority assessment for this client?
decreased urinary output
Which is the most important initial postprocedure nursing assessment for a client who has had a cardiac
catheterization?
Observe the puncture site for swelling and bleeding.
A client has had a cerebrovascular accident, which has affected the left side of the client’s brain. The nurse
should assess the client for which symptom?
aphasia
The nurse is instructing an unlicensed assistive personnel (UAP) to collect a urine specimen from an indwelling
catheter. Which statement indicates that the UAP understands the instructions?
“I’ll get a sterile syringe and remove urine from the catheter through the collection port to place in
the specimen container.”
A client comes to the physician's office for a follow-up visit 4 weeks after suffering a myocardial infarction (MI).The
nurse takes this opportunity to evaluate the client's knowledge of the ordered cardiac rehabilitation program.Which
evaluation statement suggests that the client needs more instruction?
"Client walks 4 miles (6.4 kilometers) in 1 hour every day."
A client undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the first postoperative day,
the nurse notes the absence of a bone flap at the operative site. How should the nurse position the client's he
, ad?
elevated 30 degrees
After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive
isoniazid (INH) as prophylaxis against tuberculosis. The client's family asks the nurse how long the drug must be
taken. What is the usual duration of prophylactic isoniazid therapy?
6 to 12 months
The nurse is assisting a client with a stroke who has homonymous hemianopia. The nurse should understand thatthe
client will do which when eating?
Eat food on only half of the plate.
A client is arousing from a coma and keeps saying, “Just stop the pain.” The nurse responds based on the
knowledge that the client’s first response to pain will be to do what?
Escape the source of pain.
The nurse sees a client walking in the hallway who begins to have a seizure. What should the nurse do in order of
priority from first to last? All options must be used.
Ease the client to the floor.
Maintain a patent airway.
Obtain vital signs.
Record the seizure activity observed.
The nurse is teaching a client with multiple sclerosis about prevention of urinary tract infection (UTI) and renal
calculi. Which nutrition recommendations by the nurse would be the most likely to reduce the risk of these
conditions?
Increase fluids (2500 mL/day) and maintain urine acidity by drinking cranberry juice.
A nurse is assigned to care for a client with chest pain in the intensive care unit. The client is reading a book when
the nurse observes a flat line on the monitor and the alarm rings. What is the nurse's priority interventionat this
time?
assessing the client
A client with marked oliguria is ordered a test dose of 0.2 g/kg of 15% mannitol solution intravenously over 5
minutes. The client weighs 132 lb (60 kg). How many grams would the nurse administer? Record your answer asa
whole number.
12
A client with chronic renal failure receives hemodialysis treatments through a mature arteriovenous (AV) fistula.
What intervention will the nurse include in the care plan?
Auscultate the AV fistula for a bruit.
A client whose condition remains stable after a myocardial infarction is to gradually increase activity. Which sign
best indicates that the activity is appropriate for the client?
respiratory rate
A client with heart failure will take oral furosemide at home. To help the client evaluate the effectiveness of
furosemide therapy, the nurse should teach the client to:
weigh daily.
The client is on a fluid restriction of 500 mL/day plus replacement for urine output. Because the client’s 24-hour
urine output yesterday was 150 mL, the total fluid allotment for the next 24 hours is 650 mL. How should the
nurses distribute this fluid over the next 24 hours?
given in small amounts throughout each shift
,The nurse has given a client a nitroglycerin tablet sublingually for angina. Which vital signs should be assessed
following administration of nitroglycerin?
blood pressure
A client is returning from the operating room after inguinal hernia repair. The nurse notes that the client has fluid
volume excess from the operation and is at risk for left-sided heart failure. Which sign or symptom indicates left-
sided heart failure?
bibasilar crackles
A client is receiving captopril for heart failure. The nurse should notify the physician that the medication therapyis
ineffective if an assessment reveals
peripheral edema.
Which nursing diagnosis takes highest priority for a client with hyperthyroidism?
Imbalanced nutrition: Less than body requirements related to thyroid hormone excess
When teaching a client with Cushing's syndrome about dietary changes, the nurse should instruct the client to
increase intake of
fresh fruits.
A client develops decreased renal function and requires a change in antibiotic dosage. On which factor should the
physician base the dosage change?
creatinine clearance
A client developed cardiogenic shock after a severe myocardial infarction and has now developed acute renal failure.
The client’s family asks the nurse why the client has developed acute renal failure. What should the nursetell the
family?
“Because of the cardiogenic shock, there is:
a decrease in the blood flow through the kidneys.”
A sexually active male client has burning on urination and a milky discharge from the urethral meatus. What
documentation should be included on the client’s medical record? Select all that apply.
history of unprotected sex (sex without a condom)
length of time since symptoms presented
history of fever or chills
presence of any enlarged lymph nodes on examination
allergies to any medications
A client with type 1 diabetes mellitus asks the nurse about taking ginseng at home. What should the nurse tell the
client?
"Taking ginseng will increase the risk of hypoglycemia."
A client who had transurethral resection of the prostate (TURP) 2 days earlier has lower abdominal pain. What
should the nurse do first?
Assess the patency of the urethral catheter.
A 45-year-old client had a complete abdominal hysterectomy with bilateral salpingo-oophorectomy 2 days ago.The
client’s abdominal dressing is dry and intact. While sitting up in the chair, the client has severe pain and numbness
in her left leg. What should the nurse do first?
Assess color and temperature of the left leg.
A nurse is preparing a client for an intravenous pyelography. Which action is the priority?
Assess allergies to iodine.
, The nurse is caring for a client in the medical unit. The nurse receives a health care provider’s order for
hydrocortisone 100 mg intravenously at a rate of 10 cc/hour for a client in acute adrenal crisis. The nurse
understands that this treatment is common in clients with which disease process?
Addison’s disease
A client with a ventricular dysrhythmia is receiving intravenous lidocaine. For which assessment finding shouldthe
nurse suspect the client is experiencing toxicity from the medication?
confusion and restlessness
The nurse is teaching a client about levothyroxine. Which instruction should a nurse offer the client?
"Take the drug on an empty stomach."
A client is returned to the hospital room after a subtotal thyroidectomy. Which piece of equipment is most
important for the nurse to keep at the client's bedside?
tracheostomy set
A nurse records a client’s fingerstick blood glucose level and gives 2 units of regular insulin as ordered. At thenext
scheduled blood glucose assessment, the nurse realizes that the wrong client was tested and given insulin.What is
the nurse's priority action related to this incident?
Assess both clients, and call the appropriate healthcare providers to notify them of the errors.
Which statement would lead the nurse to determine that a client lacks understanding of the client’s acute cardiac
illness and the ability to make lifestyle changes?
“I already have my airline ticket, so I won’t miss my meeting tomorrow.”
A client is scheduled for an arteriogram. The nurse should explain to the client that the arteriogram will confirmthe
diagnosis of occlusive arterial disease by:
showing the location of the obstruction and the collateral circulation.
A client with peripheral artery disease has femoral-popliteal bypass surgery. What goal should the nurse establish
with the client immediately after surgery?
Maintain circulation.
A client with heart failure is taking furosemide, digoxin, and potassium chloride. The client has nausea, blurred
vision, headache, and weakness. The nurse notes that the client is confused. The telemetry strip shows first-
degree atrioventricular block. What other sign should the nurse assess next?
digoxin toxicity.
A client is scheduled to undergo percutaneous transluminal coronary angioplasty (PTCA). Which statement bythe
nurse best explains the procedure to the client?
”PTCA involves opening a blocked artery with an inflatable balloon located on the end of a
catheter.”
A nurse is caring for a client who had a three-vessel coronary bypass graft 4 days earlier. The client's cholesterol
profile is as follows: total cholesterol 265 mg/dl (6.845 mmol/L), low-density lipoprotein (LDL) 139 mg/dl (3.603
mmol/L), and high-density lipoprotein (HDL) 32 mg/dl (0.829 mmol/L). The client asks the nurse how tolower their
cholesterol. The nurse should tell the client that
the nurse willll ask the dietitian to talk with the client about modifying their diet.
Following a percutaneous transluminal coronary angioplasty, a client is monitored in the postprocedure unit. The
client's heparin infusion was stopped 2 hours earlier. There is no evidence of bleeding or hematoma at the insertion
site, and the pressure device is removed. The nurse should plan to safely remove the femoral sheath when the partial
thromboplastin time (PTT) is:
