NURS BS 1343: HESI 2015 VOLUME V Q & A
A client with a history of dementia has become increasingly confused at night and is picking at
an abdominal surgical dressing and the tape securing the intravenous (IV) line. The abdominal
dressing is no longer occlusive, and the IV insertion site is pink. What intervention should the
nurse implement?
Redress the abdominal incision
A male client’s laboratory results include a platelet count of 105,000/mm3. Based on this finding,
the nurse should include which action in the client’s plan of care?
Encourage the client to use an electric razor
A 13 year old client with non-union of a comminuted fracture of the tibia is admitted with
osteomyelitis. The healthcare provider collects bone aspirate specimens for culture and
sensitivity and applies a cast to the adolescent’s lower leg. What action should the nurse
implement next?
Begin parental antibiotic therapy
A male client receives a thrombolytic medication following a myocardial infarction. When the
client has a bowel movement, what action should the nurse implement?
Send a stool sample to the lab for a guaiac test
At 1615, prior to ambulating a postoperative client for the first time, the nurse reviews the
client’s medical record. Based on data contained on the record, what action should the nurse take
before assisting the client with ambulation?
Remove sequential compression devices
A client experiencing withdrawal from the benzodiazepines alprazolam (Xonax) is demonstrating
severe agitation and tremors. What is the best initial nursing action?
Initiate seizure precautions
An adult male client is admitted to the emergency room following an automobile collision in
which he sustained a head injury. What assessment data wound provide the earliest indication
, NURS BS 1343: HESI 2015 VOLUME V Q & A
that the client is experiencing increased intracranial pressure (ICP)?
Lethargy
In preparing a diabetes education program, which goal should the nurse identify as the primary
emphasis for a class on diabetes self-management?
Enable clients to become active participants in controlling the disease process
A client is schedules to receive an IV dose of onsansetron (Zofran) eight hours after receiving
chemotherapy. The client has a saline lock and is sleeping quietly without any restlessness. The
nurse caring for the client is not certified in chemotherapy administration. What action should
the nurse take?
Administer the Zofran after flushing the saline lock with saline
The development of atherosclerosis is a process of sequential events. Arrange the
pathophysiological events in orders of occurrence. (Place the first event on top and the last on the
bottom)
Arterial endothelium injury causes inflammation
Macrophages consume low density lipoprotein (LDL), creating foam cells
Foam cells release growth factors for smooth muscle cells
Smooth muscle grows over fatty streaks creating fibrous plaques
Vessel narrowing results in ischemia
The healthcare provider prescribes celtazidime (Fortax) 35 mg every 8 hours IM for an infant.
The 500 mg vial is labeled with the instruction to add 5.3 ml diluent to provide a concentration
of 100 mg/ml. How many ml should the nurse administered for each dose.(Enter numeric value
only. If rounding is required, round to the nearest tenth)
0.4
A 4 day postpartum client calls the clinic and reports that her nipples are so sore that she loves
breastfeed her infant. What instruction is best for the nurse to provide?
Let the nipple air dry toughly after each feeding
A client delivers a viable infant, but begins to have excessive uncontrolled vaginal
, NURS BS 1343: HESI 2015 VOLUME V Q & A
Notifying the health care provider of the clients’ condition, what information is most
Maternal blood pressure
An infant born to a heroin-addicted mother is admitted to the neonatal care, unit. What behaviors
can the to exhibit?
Irritability and a high-pitched cry
A multigravida, full-term laboring client complains of “back labor”. Vaginal examination reveals
that the client’s 3 cm with 50% effacement and the fetal head is at -1 station. What should the
nurse implement?
Apply counter-pressure to the sacral area
A client with gestational diabetes is undergoing a non-stress test (NST) at 34-week gestational is
144 beats/minute. The client is instructed to mark the fetal monitor by pressing a b each time
the baby moves. After 20 minutes, the nurse evaluates the fetal monitor strip. What
Two FHR accelerations of 15 beats/minute x 15 seconds are recorded
A postpartal client complaisn that she has the urge to urinate every hour but is only able to void a
small amount. What interventions provides the nurse with the most useful information?
Catheterize for residual urine after next voiding
During a 26-week gestation prenatal exam, a client reports occasional dizziness
What intervention is best for the nurse to recommend to this client?
Lie on the left or right side when sleeping or resting
Artificial rupture of the membrane of a laboring reveals meconium-stained fluid, what is the
priority?
Have a meconium aspirator available at delivery
A 6-year-old child with acute infectious diarrhea is placed on a rehydration therapy
Which action should the nurse instruct the parents to take if the child begins to vomit?
A client with a history of dementia has become increasingly confused at night and is picking at
an abdominal surgical dressing and the tape securing the intravenous (IV) line. The abdominal
dressing is no longer occlusive, and the IV insertion site is pink. What intervention should the
nurse implement?
Redress the abdominal incision
A male client’s laboratory results include a platelet count of 105,000/mm3. Based on this finding,
the nurse should include which action in the client’s plan of care?
Encourage the client to use an electric razor
A 13 year old client with non-union of a comminuted fracture of the tibia is admitted with
osteomyelitis. The healthcare provider collects bone aspirate specimens for culture and
sensitivity and applies a cast to the adolescent’s lower leg. What action should the nurse
implement next?
Begin parental antibiotic therapy
A male client receives a thrombolytic medication following a myocardial infarction. When the
client has a bowel movement, what action should the nurse implement?
Send a stool sample to the lab for a guaiac test
At 1615, prior to ambulating a postoperative client for the first time, the nurse reviews the
client’s medical record. Based on data contained on the record, what action should the nurse take
before assisting the client with ambulation?
Remove sequential compression devices
A client experiencing withdrawal from the benzodiazepines alprazolam (Xonax) is demonstrating
severe agitation and tremors. What is the best initial nursing action?
Initiate seizure precautions
An adult male client is admitted to the emergency room following an automobile collision in
which he sustained a head injury. What assessment data wound provide the earliest indication
, NURS BS 1343: HESI 2015 VOLUME V Q & A
that the client is experiencing increased intracranial pressure (ICP)?
Lethargy
In preparing a diabetes education program, which goal should the nurse identify as the primary
emphasis for a class on diabetes self-management?
Enable clients to become active participants in controlling the disease process
A client is schedules to receive an IV dose of onsansetron (Zofran) eight hours after receiving
chemotherapy. The client has a saline lock and is sleeping quietly without any restlessness. The
nurse caring for the client is not certified in chemotherapy administration. What action should
the nurse take?
Administer the Zofran after flushing the saline lock with saline
The development of atherosclerosis is a process of sequential events. Arrange the
pathophysiological events in orders of occurrence. (Place the first event on top and the last on the
bottom)
Arterial endothelium injury causes inflammation
Macrophages consume low density lipoprotein (LDL), creating foam cells
Foam cells release growth factors for smooth muscle cells
Smooth muscle grows over fatty streaks creating fibrous plaques
Vessel narrowing results in ischemia
The healthcare provider prescribes celtazidime (Fortax) 35 mg every 8 hours IM for an infant.
The 500 mg vial is labeled with the instruction to add 5.3 ml diluent to provide a concentration
of 100 mg/ml. How many ml should the nurse administered for each dose.(Enter numeric value
only. If rounding is required, round to the nearest tenth)
0.4
A 4 day postpartum client calls the clinic and reports that her nipples are so sore that she loves
breastfeed her infant. What instruction is best for the nurse to provide?
Let the nipple air dry toughly after each feeding
A client delivers a viable infant, but begins to have excessive uncontrolled vaginal
, NURS BS 1343: HESI 2015 VOLUME V Q & A
Notifying the health care provider of the clients’ condition, what information is most
Maternal blood pressure
An infant born to a heroin-addicted mother is admitted to the neonatal care, unit. What behaviors
can the to exhibit?
Irritability and a high-pitched cry
A multigravida, full-term laboring client complains of “back labor”. Vaginal examination reveals
that the client’s 3 cm with 50% effacement and the fetal head is at -1 station. What should the
nurse implement?
Apply counter-pressure to the sacral area
A client with gestational diabetes is undergoing a non-stress test (NST) at 34-week gestational is
144 beats/minute. The client is instructed to mark the fetal monitor by pressing a b each time
the baby moves. After 20 minutes, the nurse evaluates the fetal monitor strip. What
Two FHR accelerations of 15 beats/minute x 15 seconds are recorded
A postpartal client complaisn that she has the urge to urinate every hour but is only able to void a
small amount. What interventions provides the nurse with the most useful information?
Catheterize for residual urine after next voiding
During a 26-week gestation prenatal exam, a client reports occasional dizziness
What intervention is best for the nurse to recommend to this client?
Lie on the left or right side when sleeping or resting
Artificial rupture of the membrane of a laboring reveals meconium-stained fluid, what is the
priority?
Have a meconium aspirator available at delivery
A 6-year-old child with acute infectious diarrhea is placed on a rehydration therapy
Which action should the nurse instruct the parents to take if the child begins to vomit?
