NUR 240 Hesi Practice 1 Complete Solution 2022
1. the nurse is developing a teaching plan for a client with acute gastritis caused by drinking
contaminated water. The nurse should emphasize the need to report the onset of which
problem?
Bloody emesis
2. a client with multiple sclerosis is experiencing scotomas (blind spots), second which are limiting
peripheral vision. What intervention should the nurse include in the client's plan of care?
alternate and eye patch from eye to eye every two hours.
3. A client with diabetes mellitus tells the nurse that she uses cranberry juice to help prevent
urinary tract infections. What instructions should the nurse provide?
Drinking cranberry juice does not prevent infection.
4. the health care provider explains through an interpreter the risks and benefits of a scheduled
surgical procedure to a non-English speaking female client. The client gives verbal consent and
the health care provider leaves, instructing a nurse to witness the signature on the consent form.
The client and the interpreter then speak together in the foreign language for an additional 2
minutes until the interpreter concludes, she says it is OK. what action should the nurse take
next?
Ask for a full explanation from the interpreter of the witness discussion.
,5. second child with heart failure is taking digitalis. Which signs indicate to the nurse that the child
may be experiencing digitalis toxicity.
vomiting
6. the unlicensed assistive personnel reports that a client's blood pressure cannot be measured
because the client has casts on both arms and is unable to be turned to the prone position for
blood pressure measurement in the legs. What action should the nurse implement?
Demonstrate how to palpate the popliteal pulse with client supine and the knee flexed.
7. an older adult with known known cognitive impairment residing in a long-term care facility
suddenly comes disoriented and confused. There are no signs of extremity weakness or other
neurological changes. Which intervention should the nurse implement?
Assess the urine for cloudiness.
8. a public health nurse receives funding to initiate a primary prevention program in the
community. Which program best fits the nurse’s proposal?
Vitamin supplements for high-risk pregnant women
9. second is caring for newborn who arrives in a nursery following a precipitous birth on the way to
the hospital. Drug screen of the mother reveals the presence of cocaine metabolites. The infant
has a heart rate of 175 beats per minute, cries continuously, is irritable and is hyper reactive to
stimuli. Which intervention is most important for the nurse to include in the infant’s plan of
care?
Implement seizure precautions.
10. the nurse is assessing a first day postpartum client. Which finding is most indicative of a
postpartum infection?
Moderate amount of foul-smelling lochia
11. have a group of nurses implement a pilot study to evaluate a proposed evidence-based change
to providing client care period evaluation indicates successful outcomes and the nurses want to
integrate the change throughout the facility. What actions should be taken? Select all that apply.
obtain informed consent from clients who received care.
invite data review by the quality improvement department.
proposed clinical practice guidelines to the nursing committee.
, arrange in service training through the educational department.
12. the nurse is planning to assess a client's oxygen saturation in Sherman if additional oxygen is
needed via nasal cannula. The client has bilateral below the knee amputations and radial pulses
that are weak and thready. What action should the nurse take?
Place the oximeter clip on the earlobe to obtain the oxygen saturation reading.
13. second nurses screening students for spinal abnormalities and instructs each student to stand up
and then touch his toes. Which finding indicates a student should be referred for scoliosis
evaluation?
Asymmetry of the shoulders when standing upright.
14. when caring for a client with diabetes insipidus, it is most important for the nurse to include
frequent assessment for which condition and the client's plan of care.
Nausea and vomiting, muscle weakness
15. the nurse is preparing an older client for discharge following cataract extractions. Which
instruction should be included in the discharge teaching?
Avoid straining at stool, bending or lifting heavy objects.
16. an adult suffered burns to face and chest resulting from a grease fire. On admission, the client
has been intubated and a true leader bolus of normal saline was administered. Currently the
normal sailing is running at 250 milliliters per hour period the client's heart rate is 120 beats per
minute, blood pressure is , respirations are 12, over the ventilated 12 breaths for total of
24 breaths per minute, and the central venous pressure is 4 millimeters water. Which
intervention should the nurse implement?
Second fuse an additional bolus of normal saline
17. the nurse identifies the presence of clear fluid on a surgical dressing of a client who just returned
CD unit following lumbar surgery. Which action should the nurse implement immediately?
Test of fluid on addressing for glucose.
1. the nurse is developing a teaching plan for a client with acute gastritis caused by drinking
contaminated water. The nurse should emphasize the need to report the onset of which
problem?
Bloody emesis
2. a client with multiple sclerosis is experiencing scotomas (blind spots), second which are limiting
peripheral vision. What intervention should the nurse include in the client's plan of care?
alternate and eye patch from eye to eye every two hours.
3. A client with diabetes mellitus tells the nurse that she uses cranberry juice to help prevent
urinary tract infections. What instructions should the nurse provide?
Drinking cranberry juice does not prevent infection.
4. the health care provider explains through an interpreter the risks and benefits of a scheduled
surgical procedure to a non-English speaking female client. The client gives verbal consent and
the health care provider leaves, instructing a nurse to witness the signature on the consent form.
The client and the interpreter then speak together in the foreign language for an additional 2
minutes until the interpreter concludes, she says it is OK. what action should the nurse take
next?
Ask for a full explanation from the interpreter of the witness discussion.
,5. second child with heart failure is taking digitalis. Which signs indicate to the nurse that the child
may be experiencing digitalis toxicity.
vomiting
6. the unlicensed assistive personnel reports that a client's blood pressure cannot be measured
because the client has casts on both arms and is unable to be turned to the prone position for
blood pressure measurement in the legs. What action should the nurse implement?
Demonstrate how to palpate the popliteal pulse with client supine and the knee flexed.
7. an older adult with known known cognitive impairment residing in a long-term care facility
suddenly comes disoriented and confused. There are no signs of extremity weakness or other
neurological changes. Which intervention should the nurse implement?
Assess the urine for cloudiness.
8. a public health nurse receives funding to initiate a primary prevention program in the
community. Which program best fits the nurse’s proposal?
Vitamin supplements for high-risk pregnant women
9. second is caring for newborn who arrives in a nursery following a precipitous birth on the way to
the hospital. Drug screen of the mother reveals the presence of cocaine metabolites. The infant
has a heart rate of 175 beats per minute, cries continuously, is irritable and is hyper reactive to
stimuli. Which intervention is most important for the nurse to include in the infant’s plan of
care?
Implement seizure precautions.
10. the nurse is assessing a first day postpartum client. Which finding is most indicative of a
postpartum infection?
Moderate amount of foul-smelling lochia
11. have a group of nurses implement a pilot study to evaluate a proposed evidence-based change
to providing client care period evaluation indicates successful outcomes and the nurses want to
integrate the change throughout the facility. What actions should be taken? Select all that apply.
obtain informed consent from clients who received care.
invite data review by the quality improvement department.
proposed clinical practice guidelines to the nursing committee.
, arrange in service training through the educational department.
12. the nurse is planning to assess a client's oxygen saturation in Sherman if additional oxygen is
needed via nasal cannula. The client has bilateral below the knee amputations and radial pulses
that are weak and thready. What action should the nurse take?
Place the oximeter clip on the earlobe to obtain the oxygen saturation reading.
13. second nurses screening students for spinal abnormalities and instructs each student to stand up
and then touch his toes. Which finding indicates a student should be referred for scoliosis
evaluation?
Asymmetry of the shoulders when standing upright.
14. when caring for a client with diabetes insipidus, it is most important for the nurse to include
frequent assessment for which condition and the client's plan of care.
Nausea and vomiting, muscle weakness
15. the nurse is preparing an older client for discharge following cataract extractions. Which
instruction should be included in the discharge teaching?
Avoid straining at stool, bending or lifting heavy objects.
16. an adult suffered burns to face and chest resulting from a grease fire. On admission, the client
has been intubated and a true leader bolus of normal saline was administered. Currently the
normal sailing is running at 250 milliliters per hour period the client's heart rate is 120 beats per
minute, blood pressure is , respirations are 12, over the ventilated 12 breaths for total of
24 breaths per minute, and the central venous pressure is 4 millimeters water. Which
intervention should the nurse implement?
Second fuse an additional bolus of normal saline
17. the nurse identifies the presence of clear fluid on a surgical dressing of a client who just returned
CD unit following lumbar surgery. Which action should the nurse implement immediately?
Test of fluid on addressing for glucose.
