HESI MIDTERM EXAM (160 QUESTIONS AND CORRECT ANSWERS) GRADED A+
1.The nurse is aware that intimate partner violence (IPV) screening should occur with which
situation?
A. As soon as the clinician suspects a problem.
B. As a routine part of each health care encounter
C. Once the clinician confirms a history of abuse
D. Only when the client presents with an unexpected injury.
2.A client is admitted with diagnosis of Wernicke’s syndrome. Which assessment finding should
the nurse….?
A. Confusion
B. Right lower abdominal pain
C. Peripheral neuropathy
D. Depression
3. A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values
indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most
important following the procedure?
A. Measure urine output
B. Assess body temperature.
C. Monitor skin elasticity.
D. Observe the aspiration site.
4. A client who had a small bowel resection acquired methicillin resistant staphylococcus aureus
(MRSA) while hospitalized. He was treated and released but is readmitted today because of
diarrhea and dehydration. It is most important for the nurse to implement which intervention.
A. Instruct visitors to gown and wash hands.
B. Maintain contact transmission precaution.
C. Review WBC count daily.
D. Collect serial stool specimens for culture.
,5. After an elderly female client receives treatment for drug toxicity, the healthcare provider
prescribes a 24 hour creatinine clearance test. Prior to starting the urine collection, the nurse
notes that the client's serum creatinine is 0.3 mg/dl (22.9 micromol/L). What action should the
nurse implement?
A. Notify HCP of the results.
B. Assess the client for signs of hypokalemia.
C. Evaluate client’s serum BUN level.
D. Initiate the urine collection as prescribed.
6. Prior to insertion of an indwelling urinary catheter, what client information is most important
for the nurse to obtain?
A. Color, clarity, and odor of urine.
B. Client allergies to antiseptic solution.
C. Previous history of UTI
D. Client’s ability to increase fluid intake.
7. An adult is admitted to the emergency department following ingestion of a bottle of
antidepressants secondary to chronic pain. A nasogastric tube and a left subclavian venous
catheter are placed. The nurse auscultates audible breath sounds on the right side, faint sounds
procedure, and chest movement on the right side of the thorax. Which procedure should the
nurse prepare for first:
A. Insertion of a left- sided chest tube
B. Setup of PCA
C. Retraction of the nasogastric tube
D. Placement of endotracheal tube
8. The nurse is preparing to mix two medications from two different multidose vials, A and
B. In which order should these actions be implemented when drawing the solutions from the
vials?
1. Verify the drug and dose with the label on the vial.
2. Inject the volume of air to be aspirated from each vial.
, 3. Aspirate from vial A
4. Aspirate from vial B
9. In assessing a client 48 hours following a fracture, the nurse observes ecchymosis at the
fracture site, and recognizes that hematoma formation at the bone fragment site has occurred.
What action should the nurse implement?
A. Assign UAP to take vitals every hour.
B. Advise the client that anticoagulant therapy may be needed.
C. Call the lab to obtain a stat APTT and prothrombin time.
D. Document the extent of the bruising in the medical record.
10. The nurse is planning care for a client who admits having suicidal thoughts. Which client
behavior indicates the highest risk for the client acting on these suicidal thoughts?
A. Begin to show signs of improvement in affect.
B. Lacks interest in the activities of family and friends
C. Expresses feelings of sadness and loneliness.
D. Neglects personal hygiene and has no appetite.
11. A 3 year-old boy is brought to the emergency department after the mother found the child in
the backyard holding a piece of a toy in his hand and in respiratory distress. The child is dusky
with a loud, inspiratory stridor and weak attempts to cough. Which actions should the nurse
implement?
A. Obtain a pulse oximetry reading and arterial blood gases.
B. Determine if the child ingested a toxic substance and if vomiting occurred.
C. Request a stat chest x-ray and prepare medications for asthmatic episodes.
D. Auscultate all pulmonary lung fields and attempt a Heimlich maneuver.
12. While moving stables from the client's postoperative wound site, the nurse observes that the
client's eyes closed and his face and hands are clenched. The client states, "I just hate having
staples removed." Acknowledge the client’s anxiety, which action should the nurse implement?
A. Attempt to distract the client with general conservation.
B. Reassure the client that this is a simple nursing procedure.
, C. Explain the procedure in detail while removing stables.
D. Encourage the client to continue to verbalize anxiety.
13. HCP prescribes cephalexin 125mg/5ml oral suspension. Client weighs 77 lbs. The
recommended safe dose 25 mg/kg/24hrs
35 mL
14. What is the primary purpose for initiating nursing interventions that promote good nutrition,
rest, exercise, and stress reduction for a client diagnosed with HIV?
A. Improve function of the immune system.
B. Promote a feeling of general well-being
C. Increase ability to carry out activities of daily living
D. Prevent spread of infection to others
15. A client with chronic obstructive lung disease who is receiving oxygen at 1.5 liters per
minute by nasal cannula is currently short of breath. What should the nurse do?
A. Instruct the client in pursed lip breathing
B. Increase oxygen to three liters/ per minute
C. Ask client to take short rapid breaths
D. Have the client breathe into a paper bag
16. The nurse is caring for a child who takes methylphenidate extended release for the
treatment of attention deficit hyperactivity disorder (ADHD). Which assessment finding is an
expected side effect of this medication?
A. Flat affect
B. Decrease Focus
C. Weight loss of 5lbs in 1 month
D. Muscle weakness
1.The nurse is aware that intimate partner violence (IPV) screening should occur with which
situation?
A. As soon as the clinician suspects a problem.
B. As a routine part of each health care encounter
C. Once the clinician confirms a history of abuse
D. Only when the client presents with an unexpected injury.
2.A client is admitted with diagnosis of Wernicke’s syndrome. Which assessment finding should
the nurse….?
A. Confusion
B. Right lower abdominal pain
C. Peripheral neuropathy
D. Depression
3. A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values
indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most
important following the procedure?
A. Measure urine output
B. Assess body temperature.
C. Monitor skin elasticity.
D. Observe the aspiration site.
4. A client who had a small bowel resection acquired methicillin resistant staphylococcus aureus
(MRSA) while hospitalized. He was treated and released but is readmitted today because of
diarrhea and dehydration. It is most important for the nurse to implement which intervention.
A. Instruct visitors to gown and wash hands.
B. Maintain contact transmission precaution.
C. Review WBC count daily.
D. Collect serial stool specimens for culture.
,5. After an elderly female client receives treatment for drug toxicity, the healthcare provider
prescribes a 24 hour creatinine clearance test. Prior to starting the urine collection, the nurse
notes that the client's serum creatinine is 0.3 mg/dl (22.9 micromol/L). What action should the
nurse implement?
A. Notify HCP of the results.
B. Assess the client for signs of hypokalemia.
C. Evaluate client’s serum BUN level.
D. Initiate the urine collection as prescribed.
6. Prior to insertion of an indwelling urinary catheter, what client information is most important
for the nurse to obtain?
A. Color, clarity, and odor of urine.
B. Client allergies to antiseptic solution.
C. Previous history of UTI
D. Client’s ability to increase fluid intake.
7. An adult is admitted to the emergency department following ingestion of a bottle of
antidepressants secondary to chronic pain. A nasogastric tube and a left subclavian venous
catheter are placed. The nurse auscultates audible breath sounds on the right side, faint sounds
procedure, and chest movement on the right side of the thorax. Which procedure should the
nurse prepare for first:
A. Insertion of a left- sided chest tube
B. Setup of PCA
C. Retraction of the nasogastric tube
D. Placement of endotracheal tube
8. The nurse is preparing to mix two medications from two different multidose vials, A and
B. In which order should these actions be implemented when drawing the solutions from the
vials?
1. Verify the drug and dose with the label on the vial.
2. Inject the volume of air to be aspirated from each vial.
, 3. Aspirate from vial A
4. Aspirate from vial B
9. In assessing a client 48 hours following a fracture, the nurse observes ecchymosis at the
fracture site, and recognizes that hematoma formation at the bone fragment site has occurred.
What action should the nurse implement?
A. Assign UAP to take vitals every hour.
B. Advise the client that anticoagulant therapy may be needed.
C. Call the lab to obtain a stat APTT and prothrombin time.
D. Document the extent of the bruising in the medical record.
10. The nurse is planning care for a client who admits having suicidal thoughts. Which client
behavior indicates the highest risk for the client acting on these suicidal thoughts?
A. Begin to show signs of improvement in affect.
B. Lacks interest in the activities of family and friends
C. Expresses feelings of sadness and loneliness.
D. Neglects personal hygiene and has no appetite.
11. A 3 year-old boy is brought to the emergency department after the mother found the child in
the backyard holding a piece of a toy in his hand and in respiratory distress. The child is dusky
with a loud, inspiratory stridor and weak attempts to cough. Which actions should the nurse
implement?
A. Obtain a pulse oximetry reading and arterial blood gases.
B. Determine if the child ingested a toxic substance and if vomiting occurred.
C. Request a stat chest x-ray and prepare medications for asthmatic episodes.
D. Auscultate all pulmonary lung fields and attempt a Heimlich maneuver.
12. While moving stables from the client's postoperative wound site, the nurse observes that the
client's eyes closed and his face and hands are clenched. The client states, "I just hate having
staples removed." Acknowledge the client’s anxiety, which action should the nurse implement?
A. Attempt to distract the client with general conservation.
B. Reassure the client that this is a simple nursing procedure.
, C. Explain the procedure in detail while removing stables.
D. Encourage the client to continue to verbalize anxiety.
13. HCP prescribes cephalexin 125mg/5ml oral suspension. Client weighs 77 lbs. The
recommended safe dose 25 mg/kg/24hrs
35 mL
14. What is the primary purpose for initiating nursing interventions that promote good nutrition,
rest, exercise, and stress reduction for a client diagnosed with HIV?
A. Improve function of the immune system.
B. Promote a feeling of general well-being
C. Increase ability to carry out activities of daily living
D. Prevent spread of infection to others
15. A client with chronic obstructive lung disease who is receiving oxygen at 1.5 liters per
minute by nasal cannula is currently short of breath. What should the nurse do?
A. Instruct the client in pursed lip breathing
B. Increase oxygen to three liters/ per minute
C. Ask client to take short rapid breaths
D. Have the client breathe into a paper bag
16. The nurse is caring for a child who takes methylphenidate extended release for the
treatment of attention deficit hyperactivity disorder (ADHD). Which assessment finding is an
expected side effect of this medication?
A. Flat affect
B. Decrease Focus
C. Weight loss of 5lbs in 1 month
D. Muscle weakness
