HESI 700
Following discharge teaching, a male client with duodenal ulcer tells the nurse the he
will drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What
is the best follow-up action by the nurse? - Answer Review with the client the need to
avoid foods that are rich in milk and cream
A male client with hypertension, who received new antihypertensive prescriptions at his
last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP
is 158/106 and he admits that he has not been taking the prescribed medication
because the drugs make him "feel bad". In explaining the need for hypertension control,
the nurse should stress that an elevated BP places the client at risk for which
pathophysiological condition? - Answer Stroke secondary to hemorrhage
The nurse observes an unlicensed assistive personnel (UAP) positioning a newly
admitted client who has a seizure disorder. The client is supine and the UAP is placing
soft pillows along the side rails. What action should the nurse implement? - Answer
Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows
An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for
the past 12 days. Which assessment finding requires immediate follow-up - Answer
Describes life without purpose
A 60-year-old female client with a positive family history of ovarian cancer has
developed an abdominal mass and is being evaluated for possible ovarian cancer. Her
Papanicolau (Pap) smear results are negative. What information should the nurse
include in the client's teaching plan - Answer Further evaluation involving surgery may
be needed
A client who recently underwent a tracheostomy is being prepared for discharge to
home. Which instructions is most important for the nurse to include in the discharge
plan? - Answer Teach tracheal suctioning techniques
In assessing an adult client with a partial rebreather mask, the nurse notes that the
oxygen reservoir bag does not deflate completely during inspiration and the client's
respiratory rate is 14 breaths / minute. What action should the nurse implement -
Answer Document the assessment data
Rational: reservoir bag should not deflate completely during inspiration and the client's
respiratory rate is within normal limits.
During shift report, the central electrocardiogram (EKG) monitoring system alarms.
Which client alarm should the nurse investigate first? - Answer Respiratory apnea of 30
seconds
During a home visit, the nurse observed an elderly client with diabetes slip and fall.
What action should the nurse take first? - Answer Check the client for lacerations or
fractures
,HESI 700
At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section),
the client tells the nurse that she drank a cup a coffee at 0400 because she wanted to
avoid getting a headache. Which action should the nurse take first? - Answer Inform the
anesthesia care provider
After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2
heart sounds. To determine if an S3 heart sound is present, what action should the
nurse take first - Answer Listen with the bell at the same location
A 66-year-old woman is retiring and will no longer have a health insurance through her
place of employment. Which agency should the client be referred to by the employee
health nurse for health insurance needs? - Answer Medicare
A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset.
What snack should the nurse instruct the client to take with the tetracycline? - Answer
Toasted wheat bread and jelly
Following a lumbar puncture, a client voices several complaints. What complaint
indicated to the nurse that the client is experiencing a complication? - Answer "I have a
headache that gets worse when I sit up"
An elderly client seems confused and reports the onset of nausea, dysuria, and urgency
with incontinence. Which action should the nurse implement - Answer Obtain a clean
catch mid-stream specimen
The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods
that are in keeping with the child's dietary restrictions. Which foods are contraindicated
for this child? - Answer Foods sweetened with aspartame
Before preparing a client for the first surgical case of the day, a part-time scrub nurse
asks the circulating nurse if a 3 minute surgical hand scrub is adequate preparation for
this client. Which response should the circulating nurse provide? - Answer Direct the
nurse to continue the surgical hand scrub for a 5 minute duration
Which breakfast selection indicates that the client understands the nurse's instructions
about the dietary management of osteoporosis? - Answer Bagel with jelly and skim milk
The charge nurse of a critical care unit is informed at the beginning of the shift that less
than the optimal number of registered nurses will be working that shift. In planning
assignments, which client should receive the most care hours by a registered nurse
(RN) - Answer An 82-year-old client with Alzheimer's disease newly-fractures femur who
has a Foley catheter and soft wrist restrains applied
A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the
pediatrician's office. Upon inspection, the nurse notes that the nail went through the
shoe and pierced the bottom of the child's foot. Which action should the nurse
,HESI 700
implement first? - Answer Cleanse the foot with soap and water and apply an antibiotic
ointment
The mother of an adolescent tells the clinic nurse, "My son has athlete's foot, I have
been applying triple antibiotic ointment for two days, but there has been no
improvement." What instruction should the nurse provide? - Answer Stop using the
ointment and encourage complete drying of the feet and wearing clean socks.
A 26-year-old female client is admitted to the hospital for treatment of a simple goiter,
and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the
nurse that the prescribed dosage is too high for this client? The client experiences -
Answer Palpitations and shortness of breath
A client with a history of heart failure presents to the clinic with a nausea, vomiting,
yellow vision and palpitations. Which finding is most important for the nurse to assess to
the client? - Answer Obtain a list of medications taken for cardiac history
The healthcare provider prescribes an IV solution of isoproterenol (Isuprel) 1 mg in 250
ml of D5W at 300 mcg/hour. The nurse should program the infusion pump to deliver
how many ml/hour? (Enter numeric value only.) - Answer 75
Rationale: Convert mg to mcg and use the formula D/H x Q. 300 mcg/hour / 1,000 mcg
x 250 ml = 3/1 x 25 = 75 ml/hour
The pathophysiological mechanism are responsible for ascites related to liver failure?
(Select all that apply) - Answer -Fluid shifts from intravascular to interstitial area due to
decreased serum protein
-Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen
-Increased circulating aldosterone levels that increase sodium and water retention
The nurse is auscultating a client's heart sounds. Which description should the nurse
use to document this sound? (Please listen to the audio first to select the option that
applies) - Answer Murmur
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 -
Answer 0.4
rationale: 35mg/100mg x 1 = 0.35 = 0.4 ml
The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six
hours for four days. What assessment is most important for the nurse to complete? -
Answer Auscultate the client's bowel sounds
Rationale: hydromorphone is a potent opioid analgesic that slows peristalsis and
frequently causes constipation, so it is most important to Auscultate the client's bowel
sounds
, HESI 700
A female client is admitted with end stage pulmonary disease is alert, oriented, and
complaining of shortness of breath. The client tells the nurse that she wants "no heroic
measures" taken if she stops breathing, and she asks the nurse to document this in her
medical record. What action should the nurse implement - Answer Ask the client to
discuss "do not resuscitate" with her healthcare provider
A client is receiving a full strength continuous enteral tube feeding at 50 ml/hour and
has developed diarrhea. The client has a new prescription to change the feeding to half
strength. What intervention should the nurse implement? - Answer Add equal amounts
of water and feeding to a feeding bag and infuse at 50ml/hour
A female client reports that her hair is becoming coarse and breaking off, that the outer
part of her eyebrows have disappeared, and that her eyes are all puffy. Which follow-up
question is best for the nurse to ask? - Answer Have you noticed any changes in your
fingernails?
Rationale: The pattern of reported manifestations is suggestive of hypothyroidism
After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites
and malnutrition. The client is drowsy but responding to verbal stimuli and reports
recently spitting up blood. What assessment finding warrants immediate intervention by
the nurse? - Answer Capillary refill of 8 seconds
After the nurse witnesses a preoperative client sign the surgical consent form, the nurse
signs the form as a witness. What are the legal implications of the nurse's signature on
the client's surgical consent form? (Select all that apply) - Answer -The client voluntarily
grants permission for the procedure to be done -The client is competent to sign the
consent without impairment of judgment
-The client understands the risks and benefits associated with the procedure
Following surgery, a male client with antisocial personality disorder frequently requests
that a specific nurse be assigned to his care and is belligerent when another nurse is
assigned. What action should the charge nurse implement? - Answer Advise the client
that assignments are not based on clients requests
A client with cervical cancer is hospitalized for insertion of a sealed internal cervical
radiation implant. While providing care, the nurse finds the radiation implant in the bed.
What action should the nurse take? - Answer Place the implant in a lead container using
long-handled forceps
The client with which type of wound is most likely to need immediate intervention by the
nurse? - Answer Laceration
Rationale: A laceration is a wound that is produced by the tearing of soft body tissue.
This type of wound is often irregular and jagged. A laceration wound is often
contaminated with bacteria and debris from whatever object caused the cut
Following discharge teaching, a male client with duodenal ulcer tells the nurse the he
will drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What
is the best follow-up action by the nurse? - Answer Review with the client the need to
avoid foods that are rich in milk and cream
A male client with hypertension, who received new antihypertensive prescriptions at his
last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP
is 158/106 and he admits that he has not been taking the prescribed medication
because the drugs make him "feel bad". In explaining the need for hypertension control,
the nurse should stress that an elevated BP places the client at risk for which
pathophysiological condition? - Answer Stroke secondary to hemorrhage
The nurse observes an unlicensed assistive personnel (UAP) positioning a newly
admitted client who has a seizure disorder. The client is supine and the UAP is placing
soft pillows along the side rails. What action should the nurse implement? - Answer
Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows
An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for
the past 12 days. Which assessment finding requires immediate follow-up - Answer
Describes life without purpose
A 60-year-old female client with a positive family history of ovarian cancer has
developed an abdominal mass and is being evaluated for possible ovarian cancer. Her
Papanicolau (Pap) smear results are negative. What information should the nurse
include in the client's teaching plan - Answer Further evaluation involving surgery may
be needed
A client who recently underwent a tracheostomy is being prepared for discharge to
home. Which instructions is most important for the nurse to include in the discharge
plan? - Answer Teach tracheal suctioning techniques
In assessing an adult client with a partial rebreather mask, the nurse notes that the
oxygen reservoir bag does not deflate completely during inspiration and the client's
respiratory rate is 14 breaths / minute. What action should the nurse implement -
Answer Document the assessment data
Rational: reservoir bag should not deflate completely during inspiration and the client's
respiratory rate is within normal limits.
During shift report, the central electrocardiogram (EKG) monitoring system alarms.
Which client alarm should the nurse investigate first? - Answer Respiratory apnea of 30
seconds
During a home visit, the nurse observed an elderly client with diabetes slip and fall.
What action should the nurse take first? - Answer Check the client for lacerations or
fractures
,HESI 700
At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section),
the client tells the nurse that she drank a cup a coffee at 0400 because she wanted to
avoid getting a headache. Which action should the nurse take first? - Answer Inform the
anesthesia care provider
After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2
heart sounds. To determine if an S3 heart sound is present, what action should the
nurse take first - Answer Listen with the bell at the same location
A 66-year-old woman is retiring and will no longer have a health insurance through her
place of employment. Which agency should the client be referred to by the employee
health nurse for health insurance needs? - Answer Medicare
A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset.
What snack should the nurse instruct the client to take with the tetracycline? - Answer
Toasted wheat bread and jelly
Following a lumbar puncture, a client voices several complaints. What complaint
indicated to the nurse that the client is experiencing a complication? - Answer "I have a
headache that gets worse when I sit up"
An elderly client seems confused and reports the onset of nausea, dysuria, and urgency
with incontinence. Which action should the nurse implement - Answer Obtain a clean
catch mid-stream specimen
The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods
that are in keeping with the child's dietary restrictions. Which foods are contraindicated
for this child? - Answer Foods sweetened with aspartame
Before preparing a client for the first surgical case of the day, a part-time scrub nurse
asks the circulating nurse if a 3 minute surgical hand scrub is adequate preparation for
this client. Which response should the circulating nurse provide? - Answer Direct the
nurse to continue the surgical hand scrub for a 5 minute duration
Which breakfast selection indicates that the client understands the nurse's instructions
about the dietary management of osteoporosis? - Answer Bagel with jelly and skim milk
The charge nurse of a critical care unit is informed at the beginning of the shift that less
than the optimal number of registered nurses will be working that shift. In planning
assignments, which client should receive the most care hours by a registered nurse
(RN) - Answer An 82-year-old client with Alzheimer's disease newly-fractures femur who
has a Foley catheter and soft wrist restrains applied
A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the
pediatrician's office. Upon inspection, the nurse notes that the nail went through the
shoe and pierced the bottom of the child's foot. Which action should the nurse
,HESI 700
implement first? - Answer Cleanse the foot with soap and water and apply an antibiotic
ointment
The mother of an adolescent tells the clinic nurse, "My son has athlete's foot, I have
been applying triple antibiotic ointment for two days, but there has been no
improvement." What instruction should the nurse provide? - Answer Stop using the
ointment and encourage complete drying of the feet and wearing clean socks.
A 26-year-old female client is admitted to the hospital for treatment of a simple goiter,
and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the
nurse that the prescribed dosage is too high for this client? The client experiences -
Answer Palpitations and shortness of breath
A client with a history of heart failure presents to the clinic with a nausea, vomiting,
yellow vision and palpitations. Which finding is most important for the nurse to assess to
the client? - Answer Obtain a list of medications taken for cardiac history
The healthcare provider prescribes an IV solution of isoproterenol (Isuprel) 1 mg in 250
ml of D5W at 300 mcg/hour. The nurse should program the infusion pump to deliver
how many ml/hour? (Enter numeric value only.) - Answer 75
Rationale: Convert mg to mcg and use the formula D/H x Q. 300 mcg/hour / 1,000 mcg
x 250 ml = 3/1 x 25 = 75 ml/hour
The pathophysiological mechanism are responsible for ascites related to liver failure?
(Select all that apply) - Answer -Fluid shifts from intravascular to interstitial area due to
decreased serum protein
-Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen
-Increased circulating aldosterone levels that increase sodium and water retention
The nurse is auscultating a client's heart sounds. Which description should the nurse
use to document this sound? (Please listen to the audio first to select the option that
applies) - Answer Murmur
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 -
Answer 0.4
rationale: 35mg/100mg x 1 = 0.35 = 0.4 ml
The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six
hours for four days. What assessment is most important for the nurse to complete? -
Answer Auscultate the client's bowel sounds
Rationale: hydromorphone is a potent opioid analgesic that slows peristalsis and
frequently causes constipation, so it is most important to Auscultate the client's bowel
sounds
, HESI 700
A female client is admitted with end stage pulmonary disease is alert, oriented, and
complaining of shortness of breath. The client tells the nurse that she wants "no heroic
measures" taken if she stops breathing, and she asks the nurse to document this in her
medical record. What action should the nurse implement - Answer Ask the client to
discuss "do not resuscitate" with her healthcare provider
A client is receiving a full strength continuous enteral tube feeding at 50 ml/hour and
has developed diarrhea. The client has a new prescription to change the feeding to half
strength. What intervention should the nurse implement? - Answer Add equal amounts
of water and feeding to a feeding bag and infuse at 50ml/hour
A female client reports that her hair is becoming coarse and breaking off, that the outer
part of her eyebrows have disappeared, and that her eyes are all puffy. Which follow-up
question is best for the nurse to ask? - Answer Have you noticed any changes in your
fingernails?
Rationale: The pattern of reported manifestations is suggestive of hypothyroidism
After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites
and malnutrition. The client is drowsy but responding to verbal stimuli and reports
recently spitting up blood. What assessment finding warrants immediate intervention by
the nurse? - Answer Capillary refill of 8 seconds
After the nurse witnesses a preoperative client sign the surgical consent form, the nurse
signs the form as a witness. What are the legal implications of the nurse's signature on
the client's surgical consent form? (Select all that apply) - Answer -The client voluntarily
grants permission for the procedure to be done -The client is competent to sign the
consent without impairment of judgment
-The client understands the risks and benefits associated with the procedure
Following surgery, a male client with antisocial personality disorder frequently requests
that a specific nurse be assigned to his care and is belligerent when another nurse is
assigned. What action should the charge nurse implement? - Answer Advise the client
that assignments are not based on clients requests
A client with cervical cancer is hospitalized for insertion of a sealed internal cervical
radiation implant. While providing care, the nurse finds the radiation implant in the bed.
What action should the nurse take? - Answer Place the implant in a lead container using
long-handled forceps
The client with which type of wound is most likely to need immediate intervention by the
nurse? - Answer Laceration
Rationale: A laceration is a wound that is produced by the tearing of soft body tissue.
This type of wound is often irregular and jagged. A laceration wound is often
contaminated with bacteria and debris from whatever object caused the cut
