HESI-FINAL NURSING CONCEPT 2
1) A postoperative client reports incisional pain. The client has two
prescriptions for PRN analgesia that accompanied the client from the post
anesthesia unit. Before selecting which medication to administer, which action
should the nurse implement?
a. Compare the client’s pain scale rating with the prescribed dosing
b. Determine which prescription will have the quickest onset of action.
c. Ask the client to choose which medication is needed for the pain
d. Document the client’s report of pain in the electronic medical record
2) A client who is experiencing respiratory distress is admitted with
respiratory acidosis. Which pathophysiological process supports the client’s
respiratory acidosis?
B. High levels of carbon dioxide have accumulated in the blood
3) A client with a history of chronic pain requests a nonopioid analgesic. The
client is Alert but has difficulty describing the exact nature and location of the
pain to the nurse. What action should the nurse implement next?
D. Administer the analgesic as requested
4) An adult client is admitted with AIDS and oral candidiasis manifested by
several painful mouth ulcers. The nurse delegate oral care to the unlicensed
assistive personnel (UAP) and discusses how to assist the client. Which
instruction should the nurse provide the UAP?.
a. Assist with personal care, but leave oral care for the nurse to complete
b. Provide a soft bristle brush for the client to use during oral care
5) A unlicensed assistive personnel (UAP) reports to the nurse that a client with
a postoperative wound infection has a temperature of 103.8 f, blood pressure
90/70, pulse 124 beats/min, and respirations of 28 breaths/min. When the nurse
assess the clients finding include mottled skin appearance and confusions.
Which actions should the nurse take first?
a. Obtain wound specimen for culture.
b. Initiate an infusion of intravenous (iv) fluids)
,c. Transfer client to ICU
d. assess the client core temperature.
6) Which intervention should the nurse include in the plan of care for a client
who has a chest tube due to hemothorax
1. Keep the arm and shoulder of the affected side immobile at all times???
2. Encourage the client to breath deeply and cough at frequent intervals
3. Maintain pleura vac slightly above the chest level
4. Ensure there is no fluctuation in the water seal
7) The nurse is evaluating teaching about drug therapy to treat gout. Which
statement by the client demonstrates an understanding of the use of
allopurinol to treat Gout?
a. I need to take the prescribed amount of the drug to get rid of my gout
b. I need to take this drug every day to keep from having any flares up.
c. I should take this drug when I have gout attacks to reduce symptoms
d. The pain and swelling can be controlled by taking this drug everyday
8) A client reports new onset hearing loss bilaterally after taking a medication
with known ototoxic effects. Which type of hearing loss should the nurse
suspect?
B. Sensorineural
9) A young adult client, admitted to the emergency department following a
motor vehicle collision, is transfused with 4 units of PRBCs. The client’s
pretransfusion hematocrit is 17%. Which hematocrit value should the nurse
expect the client to have after of all PRBCs have been transfused?
Rationale: One unit of pRBCs should raise the hemoglobin of an average adult by 1
g/dL and the hematocrit by 3%.
4 x 3%= 0.12
17 +12= 29
D. 29%
10) A client is receiving a continuous infusion of normal saline at 125 ml/hour
post abdominal surgery. The client is drowsy and complaining of constant
abdominal
, pain and a headache. Urine output is 800ml over the past 24h with a centra
venous pressure of 15mmHg. The nurse notes respiratory crackle and bounding
central pulses. Vital signs: temperature 101.2 F, Heart rate 96 beats/min,
Respirations 24 breaths/min, and Blood pressure 160/90mmHg. Which
interventions should the nurse implement first?
a. Review last administration of IV pan medication
b. Administer PRN dose of acetaminophen
c. Decrease iv fluids to keep vein open (KVO) rate
d. Calculate total I& O
11) Which instruction should the nurse include in the discharge teaching plan for
a client who has had a cataract extraction today?
A. Use metal eye shield on operative eye during the day
B. Administer eye ointment prior to applying wye drops
C. Light housekeeping is safe to do, but avoid heavy lifting.
D. Sexual activities may resume upon return home
12) An older male client with obesity and diabetes develops intermittent
claudication. Which additional information, obtained by the nurse during
the client’s initial assessment, is most significant?
A. Smokes 1.5 packs of cigarettes daily
13) The healthcare provider writes several prescriptions for a client
diagnosed with hospital-acquired pneumonia (HAP) that include a
combination of broad- spectrum antibiotics. Which intervention should the
nurse implement first?
D. Collect blood specimens for culture prior to starting antibiotic therapy
14) To assess the quality of an adult client’s pain, what approach should the
nurse use?
A. Ask the client to describe the pain
15) A client with fluid volume excess has gained 6.6 pounds. The nurse
recognizes that this is equivalent to what volume of fluid?
B. Three liters
1) A postoperative client reports incisional pain. The client has two
prescriptions for PRN analgesia that accompanied the client from the post
anesthesia unit. Before selecting which medication to administer, which action
should the nurse implement?
a. Compare the client’s pain scale rating with the prescribed dosing
b. Determine which prescription will have the quickest onset of action.
c. Ask the client to choose which medication is needed for the pain
d. Document the client’s report of pain in the electronic medical record
2) A client who is experiencing respiratory distress is admitted with
respiratory acidosis. Which pathophysiological process supports the client’s
respiratory acidosis?
B. High levels of carbon dioxide have accumulated in the blood
3) A client with a history of chronic pain requests a nonopioid analgesic. The
client is Alert but has difficulty describing the exact nature and location of the
pain to the nurse. What action should the nurse implement next?
D. Administer the analgesic as requested
4) An adult client is admitted with AIDS and oral candidiasis manifested by
several painful mouth ulcers. The nurse delegate oral care to the unlicensed
assistive personnel (UAP) and discusses how to assist the client. Which
instruction should the nurse provide the UAP?.
a. Assist with personal care, but leave oral care for the nurse to complete
b. Provide a soft bristle brush for the client to use during oral care
5) A unlicensed assistive personnel (UAP) reports to the nurse that a client with
a postoperative wound infection has a temperature of 103.8 f, blood pressure
90/70, pulse 124 beats/min, and respirations of 28 breaths/min. When the nurse
assess the clients finding include mottled skin appearance and confusions.
Which actions should the nurse take first?
a. Obtain wound specimen for culture.
b. Initiate an infusion of intravenous (iv) fluids)
,c. Transfer client to ICU
d. assess the client core temperature.
6) Which intervention should the nurse include in the plan of care for a client
who has a chest tube due to hemothorax
1. Keep the arm and shoulder of the affected side immobile at all times???
2. Encourage the client to breath deeply and cough at frequent intervals
3. Maintain pleura vac slightly above the chest level
4. Ensure there is no fluctuation in the water seal
7) The nurse is evaluating teaching about drug therapy to treat gout. Which
statement by the client demonstrates an understanding of the use of
allopurinol to treat Gout?
a. I need to take the prescribed amount of the drug to get rid of my gout
b. I need to take this drug every day to keep from having any flares up.
c. I should take this drug when I have gout attacks to reduce symptoms
d. The pain and swelling can be controlled by taking this drug everyday
8) A client reports new onset hearing loss bilaterally after taking a medication
with known ototoxic effects. Which type of hearing loss should the nurse
suspect?
B. Sensorineural
9) A young adult client, admitted to the emergency department following a
motor vehicle collision, is transfused with 4 units of PRBCs. The client’s
pretransfusion hematocrit is 17%. Which hematocrit value should the nurse
expect the client to have after of all PRBCs have been transfused?
Rationale: One unit of pRBCs should raise the hemoglobin of an average adult by 1
g/dL and the hematocrit by 3%.
4 x 3%= 0.12
17 +12= 29
D. 29%
10) A client is receiving a continuous infusion of normal saline at 125 ml/hour
post abdominal surgery. The client is drowsy and complaining of constant
abdominal
, pain and a headache. Urine output is 800ml over the past 24h with a centra
venous pressure of 15mmHg. The nurse notes respiratory crackle and bounding
central pulses. Vital signs: temperature 101.2 F, Heart rate 96 beats/min,
Respirations 24 breaths/min, and Blood pressure 160/90mmHg. Which
interventions should the nurse implement first?
a. Review last administration of IV pan medication
b. Administer PRN dose of acetaminophen
c. Decrease iv fluids to keep vein open (KVO) rate
d. Calculate total I& O
11) Which instruction should the nurse include in the discharge teaching plan for
a client who has had a cataract extraction today?
A. Use metal eye shield on operative eye during the day
B. Administer eye ointment prior to applying wye drops
C. Light housekeeping is safe to do, but avoid heavy lifting.
D. Sexual activities may resume upon return home
12) An older male client with obesity and diabetes develops intermittent
claudication. Which additional information, obtained by the nurse during
the client’s initial assessment, is most significant?
A. Smokes 1.5 packs of cigarettes daily
13) The healthcare provider writes several prescriptions for a client
diagnosed with hospital-acquired pneumonia (HAP) that include a
combination of broad- spectrum antibiotics. Which intervention should the
nurse implement first?
D. Collect blood specimens for culture prior to starting antibiotic therapy
14) To assess the quality of an adult client’s pain, what approach should the
nurse use?
A. Ask the client to describe the pain
15) A client with fluid volume excess has gained 6.6 pounds. The nurse
recognizes that this is equivalent to what volume of fluid?
B. Three liters
