NURS4300 hesi EXAM QUESTIONS WITH ANSWERS GRADED A+ and
rationale 2022
A male client with bipolar disorder has not slept or eaten in four days. He paces and becomes increasingly agitated and
loud wile the nurse talks to his spouse. What intervention is best for the nurse to implement at this time?
A. Walk with the client to the cafeteria and stay as he eats lunch.
B. Encourage the spouse to eat lunch with the client.
C. Request a full tray from the dietary department.
D. Move to a quiet area and provide peanut butter with
crackers. Answer
D. Move to a quiet area and provide peanut butter with crackers.
Rationale
Both inadequate nutrition and inadequate sleep patterns plague clients with bipolar disorder and contribute to agitation,
hostility, and aggressiveness. Using a calm, confident manner, the client should be moved to a quiet area (D) to decrease
environmental stimuli and limit involvement with the spouse while nutritional needs, such as "finger foods", should be
provided. (A, B, and C) are less effective when the client is unable to sit long enough to eat.
To assess for the presence of egophony, what instruction should the nurse give the client who has a lung abscess?
A. Repeat vocalizing the letter E while the thorax is auscultated.
B. Breathe in and out while all lobes of both lungs are auscultated.
C. Repeat the number 99 during a systematic auscultation of the thorax.
D. Whisper "one, two, three" in a sequence during auscultation of the
thorax. Answer
A. Repeat vocalizing the letter E while the thorax is auscultated.
Rationale
Egophony is an abnormally enhanced vocal resonance with a high pitched, bleating, nasal quality that occurs in areas of
consolidation, pleural effusion, or abscess. To assess for egophony, the client should repeat the letter "E" while the nurse
auscultates the thorax (A) and if a flat, nasal sound of "A" is heard through the stethoscope, it indicates the existence of
,NURS4300 hesi EXAM QUESTIONS WITH ANSWERS GRADED A+ and
rationale 2022
egophony. To assess for brochophony, the client should repeat the number 99 while the nurse auscultates the thorax (C).
Asking the client to breathe in and out while auscultating all lobes of both lungs (B) is used to assess breath sounds. To
assess whispered pectoriloquy, the client whispers the number sequence "one, two, three" while the nurse auscultates
the lung fields (D).
When using a Yankauer oral-tip catheter to suction a client's oropharynx, which action should the nurse take before
inserting the catheter into the oropharynx?
A. Ask the client to begin swallowing.
B. Turn on the continuous suction device.
C. Assess the nares for a deviated septum.
D. Apply suction by occluding the
port. Answer
B. Turn on the continuous suction device.
Rationale
The continuous suction device should be turned on (B) prior to inserting the Yankauer tip or tonsillar tip catheter into the
client's mouth so that suction can be applied as soon as it is in place. (A) is an action implemented prior to nasogastric
tube (NGT) placement. (C) should be assessed prior to insertion of a nasal suction catheter or NGT. Suction should not be
applied while a catheter is inserted (D) because it can traumatize tissue and remove oxygen in the upper airways.
When assessing a 24-year-old bodybuilder, the nurse is unable to palpate an apical impulse. What action should the
nurse implement?
A. Dim the lights in the examination room.
B. Continue with the cardiac examination.
C. Question the client about steroid use.
D. Position the client in high Fowler's
position. Answer
B. Continue with the cardiac examination.
Rationale
,NURS4300 hesi EXAM QUESTIONS WITH ANSWERS GRADED A+ and
rationale 2022
An apical impulse, the point of maximal impulse (PMI), is not palpable in about 50% of adults, particularly in those
who are obese or those with thick chest walls, such as body-builders, so a continuation of the exam (B) is the best
course of action. (A, C, and D) are not indicated.
A postoperative client's respiratory rate decreased from 14/minute to 6/minute after administration of an opioid
analgesic. Thirty minutes later, the clients respiratory rate decreases to 4/minute, and the nurse caring for the client
notifies the healthcare provider and administers a dose of IV naloxone (Narcan). The charge nurse should counsel the
nurse regarding which intervention?
A. The initial administration of the analgesic.
B. The decision regarding when to call the healthcare provider.
C. The administration of naloxone (Narcan) via IV.
D. The documentation of the client's respiratory
rate. Answer
B. The decision regarding when to call the healthcare provider.
Rationale
The nurse should have called the healthcare provider when the respiratory rate decreased to 6/minute, rather than
waiting 30 minutes when the rate was 4/minute. This delay increased the risk for respiratory failure (B). The charge
nurse should initiate interventions such as completing an adverse occurrence report, and ensuring that the nurse
receives guidance to prevent further poor decision making. (A, C, and D) were all appropriate interventions by the nurse
and do not require further action by the charge nurse.
An adolescent is admitted to the hospital because of a suicide attempt with an overdose of acetaminophen (Tylenol).
Which blood values are most important for the nurse to monitor during the first 72 hours following ingestion of this
overdose?
A. LDH or LD, SGOT or ALT, SGPT or AST.
B. White blood count, hemoglobin, hematocrit.
C. BUN, creatinine, specific gravity.
D. pH, PCO2,
HCO3. Answer
A. LDH or LD, SGOT or ALT, SGPT or AST.
, NURS4300 hesi EXAM QUESTIONS WITH ANSWERS GRADED A+ and
rationale 2022
Rationale
All of these blood values should be monitored, but (A) it is most important for this particular client, because
acetaminophen (Tylenol) is extremely hepatotoxic. (B) might be an indication of infection or bleeding, (C) of renal
functioning, and (D) of gas exchange.
rationale 2022
A male client with bipolar disorder has not slept or eaten in four days. He paces and becomes increasingly agitated and
loud wile the nurse talks to his spouse. What intervention is best for the nurse to implement at this time?
A. Walk with the client to the cafeteria and stay as he eats lunch.
B. Encourage the spouse to eat lunch with the client.
C. Request a full tray from the dietary department.
D. Move to a quiet area and provide peanut butter with
crackers. Answer
D. Move to a quiet area and provide peanut butter with crackers.
Rationale
Both inadequate nutrition and inadequate sleep patterns plague clients with bipolar disorder and contribute to agitation,
hostility, and aggressiveness. Using a calm, confident manner, the client should be moved to a quiet area (D) to decrease
environmental stimuli and limit involvement with the spouse while nutritional needs, such as "finger foods", should be
provided. (A, B, and C) are less effective when the client is unable to sit long enough to eat.
To assess for the presence of egophony, what instruction should the nurse give the client who has a lung abscess?
A. Repeat vocalizing the letter E while the thorax is auscultated.
B. Breathe in and out while all lobes of both lungs are auscultated.
C. Repeat the number 99 during a systematic auscultation of the thorax.
D. Whisper "one, two, three" in a sequence during auscultation of the
thorax. Answer
A. Repeat vocalizing the letter E while the thorax is auscultated.
Rationale
Egophony is an abnormally enhanced vocal resonance with a high pitched, bleating, nasal quality that occurs in areas of
consolidation, pleural effusion, or abscess. To assess for egophony, the client should repeat the letter "E" while the nurse
auscultates the thorax (A) and if a flat, nasal sound of "A" is heard through the stethoscope, it indicates the existence of
,NURS4300 hesi EXAM QUESTIONS WITH ANSWERS GRADED A+ and
rationale 2022
egophony. To assess for brochophony, the client should repeat the number 99 while the nurse auscultates the thorax (C).
Asking the client to breathe in and out while auscultating all lobes of both lungs (B) is used to assess breath sounds. To
assess whispered pectoriloquy, the client whispers the number sequence "one, two, three" while the nurse auscultates
the lung fields (D).
When using a Yankauer oral-tip catheter to suction a client's oropharynx, which action should the nurse take before
inserting the catheter into the oropharynx?
A. Ask the client to begin swallowing.
B. Turn on the continuous suction device.
C. Assess the nares for a deviated septum.
D. Apply suction by occluding the
port. Answer
B. Turn on the continuous suction device.
Rationale
The continuous suction device should be turned on (B) prior to inserting the Yankauer tip or tonsillar tip catheter into the
client's mouth so that suction can be applied as soon as it is in place. (A) is an action implemented prior to nasogastric
tube (NGT) placement. (C) should be assessed prior to insertion of a nasal suction catheter or NGT. Suction should not be
applied while a catheter is inserted (D) because it can traumatize tissue and remove oxygen in the upper airways.
When assessing a 24-year-old bodybuilder, the nurse is unable to palpate an apical impulse. What action should the
nurse implement?
A. Dim the lights in the examination room.
B. Continue with the cardiac examination.
C. Question the client about steroid use.
D. Position the client in high Fowler's
position. Answer
B. Continue with the cardiac examination.
Rationale
,NURS4300 hesi EXAM QUESTIONS WITH ANSWERS GRADED A+ and
rationale 2022
An apical impulse, the point of maximal impulse (PMI), is not palpable in about 50% of adults, particularly in those
who are obese or those with thick chest walls, such as body-builders, so a continuation of the exam (B) is the best
course of action. (A, C, and D) are not indicated.
A postoperative client's respiratory rate decreased from 14/minute to 6/minute after administration of an opioid
analgesic. Thirty minutes later, the clients respiratory rate decreases to 4/minute, and the nurse caring for the client
notifies the healthcare provider and administers a dose of IV naloxone (Narcan). The charge nurse should counsel the
nurse regarding which intervention?
A. The initial administration of the analgesic.
B. The decision regarding when to call the healthcare provider.
C. The administration of naloxone (Narcan) via IV.
D. The documentation of the client's respiratory
rate. Answer
B. The decision regarding when to call the healthcare provider.
Rationale
The nurse should have called the healthcare provider when the respiratory rate decreased to 6/minute, rather than
waiting 30 minutes when the rate was 4/minute. This delay increased the risk for respiratory failure (B). The charge
nurse should initiate interventions such as completing an adverse occurrence report, and ensuring that the nurse
receives guidance to prevent further poor decision making. (A, C, and D) were all appropriate interventions by the nurse
and do not require further action by the charge nurse.
An adolescent is admitted to the hospital because of a suicide attempt with an overdose of acetaminophen (Tylenol).
Which blood values are most important for the nurse to monitor during the first 72 hours following ingestion of this
overdose?
A. LDH or LD, SGOT or ALT, SGPT or AST.
B. White blood count, hemoglobin, hematocrit.
C. BUN, creatinine, specific gravity.
D. pH, PCO2,
HCO3. Answer
A. LDH or LD, SGOT or ALT, SGPT or AST.
, NURS4300 hesi EXAM QUESTIONS WITH ANSWERS GRADED A+ and
rationale 2022
Rationale
All of these blood values should be monitored, but (A) it is most important for this particular client, because
acetaminophen (Tylenol) is extremely hepatotoxic. (B) might be an indication of infection or bleeding, (C) of renal
functioning, and (D) of gas exchange.
