Nurs 310 HESI Review 2024 Questions
and Answers Graded A
A 75-year-old client who has a history of end stage renal failure and advanced lung
cancer, recently had a stroke. Two days ago the healthcare provider discontinued the
client's dialysis treatments, stating that death is inevitable, but the client is disoriented
and will not sign a DNR directive. What is the priority nursing intervention?
Review the client's most recent laboratory reports.
Refer the client and family members for hospice care.
Notify the hospital ethics committee of the client situation.
Determine who is legally empowered to make decisions. - Correct Ans-Determine who
is legally empowered to make decisions.
A male client with an infected wound tells the nurse that he follows a macrobiotic diet.
Which type of foods should the nurse recommend that the client select from the hospital
menu?
Low fat and low sodium foods.
Combination of plant proteins to provide essential amino acids.
Limited complex carbohydrates and fiber.
Increased amount of vitamin C and beta carotene rich foods. - Correct Ans-Combination
of plant proteins to provide essential amino acids.
A macrobiotic diet is high in whole-grain cereals, vegetables, sea vegetables, beans,
and vegetarian soups, and the client needs essential amino acids to provide complete
proteins to heal the infected wound. Although a macrobiotic diet contains no source of
animal protein, essential amino acids should be obtained by combining plant
(incomplete) proteins to provide complete (all essential amino acids) proteins (B) for
anabolic processes. (A, C, and D) do not provide the client with food choices consistent
with a macrobiotic diet and protein needs.
The nurse is administering an intermittent infusion of an antibiotic to a client whose
intravenous (IV) access is an antecubital saline lock. After the nurse opens the roller
clamp on the IV tubing, the alarm on the infusion pump indicates an obstruction. What
action should the nurse take first?
Check for a blood return.
,Reposition the client's arm.
Remove the IV site dressing.
Flush the lock with saline. - Correct Ans-Reposition the client's arm.
If the client's elbow is bent, the IV may be unable to infuse, resulting in an obstruction
alarm, so the nurse should first attempt to reposition the client's arm to alleviate any
obstruction
What action should the nurse implement to prevent the formation of a sacral ulcer for a
client who is immobile?
Maintain in a lateral position using protective wrist and vest devices.
Position prone with a small pillow below the diaphragm.
Raise the head and knee gatch when lying in a supine position.
Transfer into a wheelchair close to the nurse's station for observation. - Correct Ans-
Position prone with a small pillow below the diaphragm.
What intervention should the nurse include in the plan of care for a client who is being
treated with an Unna's paste boot for leg ulcers due to chronic venous insufficiency?
Check capillary refill of toes on lower extremity with Unna's paste boot.
Apply dressing to wound area before applying the Unna's paste boot.
Wrap the leg from the knee down towards the foot.
Remove the Unna's paste boot q8h to assess wound healing. - Correct Ans-Check
capillary refill of toes on lower extremity with Unna's paste boot.
Which nursing intervention is most beneficial in reducing the risk of urosepsis in a
hospitalized client with an indwelling urinary catheter?
Ensure that the client's perineal area is cleansed twice a day.
Maintain accurate documentation of the fluid intake and output.
Encourage frequent ambulation if allowed or regular turning if on bedrest.
Obtain a prescription for removal of the catheter as soon as possible. - Correct Ans-
Obtain a prescription for removal of the catheter as soon as possible.
, The best intervention to reduce the risk for urosepsis (spread of an infectious agent
from the urinary tract to systemic circulation) is removal of the urinary catheter as
quickly as possible (D). (A, B, and C) are helpful to reduce the risk of infection, but are
of less priority than (D) in reducing the risk of urosepsis.
A client provides the nurse with information about the reason for seeking care. The
nurse realizes that some information about past hospitalizations is missing. How should
the nurse obtain this information?
Solicit information on hospitalization from the insurance company.
Look up previous medical records from archived hospital documents.
Ask the client to discuss previous hospitalizations in the last 5 years.
Elicit specific facts about past hospitalizations with direct questions. - Correct Ans-Elicit
specific facts about past hospitalizations with direct questions.
Direct questions should be used after the client's opening narrative to fill in any details
that have been left out or during the review of systems to elicit specific facts about past
health problems.
A signed consent form indicated a client should have an electromyogram, but a
myelogram was performed instead. Though the myelogram revealed the cause of the
client's back pain, which was subsequently treated, the client filed a lawsuit against the
nurse and healthcare provider for performing the incorrect procedure. The court is likely
to rule in favor of the plaintiff because these events represent what infraction?
A quasi-intentional tort because a similar mistake can happen to anyone.
Failure to respect client autonomy to choose based on intentional tort law.
Assault and battery with deliberate intent to deviate from the consent form.
An unintentional tort because the client benefited from having the myelogram. - Correct
Ans-Assault and battery with deliberate intent to deviate from the consent form.
The client was not properly informed of the procedure, and failure to obtain informed
consent constitutes assault and battery (C). (A) is injury to economics and dignity, such
as invasion of privacy or defamation of character. This is not an incident of failure to
respect the client's autonomy (B). An unintentional tort (D) is an act in which the
outcome was not expected, such as negligence or malpractice.
A client in hospice care develops audible gurgling sounds on inspiration. Which nursing
action has the highest priority?
Ensure cultural customs are observed.
and Answers Graded A
A 75-year-old client who has a history of end stage renal failure and advanced lung
cancer, recently had a stroke. Two days ago the healthcare provider discontinued the
client's dialysis treatments, stating that death is inevitable, but the client is disoriented
and will not sign a DNR directive. What is the priority nursing intervention?
Review the client's most recent laboratory reports.
Refer the client and family members for hospice care.
Notify the hospital ethics committee of the client situation.
Determine who is legally empowered to make decisions. - Correct Ans-Determine who
is legally empowered to make decisions.
A male client with an infected wound tells the nurse that he follows a macrobiotic diet.
Which type of foods should the nurse recommend that the client select from the hospital
menu?
Low fat and low sodium foods.
Combination of plant proteins to provide essential amino acids.
Limited complex carbohydrates and fiber.
Increased amount of vitamin C and beta carotene rich foods. - Correct Ans-Combination
of plant proteins to provide essential amino acids.
A macrobiotic diet is high in whole-grain cereals, vegetables, sea vegetables, beans,
and vegetarian soups, and the client needs essential amino acids to provide complete
proteins to heal the infected wound. Although a macrobiotic diet contains no source of
animal protein, essential amino acids should be obtained by combining plant
(incomplete) proteins to provide complete (all essential amino acids) proteins (B) for
anabolic processes. (A, C, and D) do not provide the client with food choices consistent
with a macrobiotic diet and protein needs.
The nurse is administering an intermittent infusion of an antibiotic to a client whose
intravenous (IV) access is an antecubital saline lock. After the nurse opens the roller
clamp on the IV tubing, the alarm on the infusion pump indicates an obstruction. What
action should the nurse take first?
Check for a blood return.
,Reposition the client's arm.
Remove the IV site dressing.
Flush the lock with saline. - Correct Ans-Reposition the client's arm.
If the client's elbow is bent, the IV may be unable to infuse, resulting in an obstruction
alarm, so the nurse should first attempt to reposition the client's arm to alleviate any
obstruction
What action should the nurse implement to prevent the formation of a sacral ulcer for a
client who is immobile?
Maintain in a lateral position using protective wrist and vest devices.
Position prone with a small pillow below the diaphragm.
Raise the head and knee gatch when lying in a supine position.
Transfer into a wheelchair close to the nurse's station for observation. - Correct Ans-
Position prone with a small pillow below the diaphragm.
What intervention should the nurse include in the plan of care for a client who is being
treated with an Unna's paste boot for leg ulcers due to chronic venous insufficiency?
Check capillary refill of toes on lower extremity with Unna's paste boot.
Apply dressing to wound area before applying the Unna's paste boot.
Wrap the leg from the knee down towards the foot.
Remove the Unna's paste boot q8h to assess wound healing. - Correct Ans-Check
capillary refill of toes on lower extremity with Unna's paste boot.
Which nursing intervention is most beneficial in reducing the risk of urosepsis in a
hospitalized client with an indwelling urinary catheter?
Ensure that the client's perineal area is cleansed twice a day.
Maintain accurate documentation of the fluid intake and output.
Encourage frequent ambulation if allowed or regular turning if on bedrest.
Obtain a prescription for removal of the catheter as soon as possible. - Correct Ans-
Obtain a prescription for removal of the catheter as soon as possible.
, The best intervention to reduce the risk for urosepsis (spread of an infectious agent
from the urinary tract to systemic circulation) is removal of the urinary catheter as
quickly as possible (D). (A, B, and C) are helpful to reduce the risk of infection, but are
of less priority than (D) in reducing the risk of urosepsis.
A client provides the nurse with information about the reason for seeking care. The
nurse realizes that some information about past hospitalizations is missing. How should
the nurse obtain this information?
Solicit information on hospitalization from the insurance company.
Look up previous medical records from archived hospital documents.
Ask the client to discuss previous hospitalizations in the last 5 years.
Elicit specific facts about past hospitalizations with direct questions. - Correct Ans-Elicit
specific facts about past hospitalizations with direct questions.
Direct questions should be used after the client's opening narrative to fill in any details
that have been left out or during the review of systems to elicit specific facts about past
health problems.
A signed consent form indicated a client should have an electromyogram, but a
myelogram was performed instead. Though the myelogram revealed the cause of the
client's back pain, which was subsequently treated, the client filed a lawsuit against the
nurse and healthcare provider for performing the incorrect procedure. The court is likely
to rule in favor of the plaintiff because these events represent what infraction?
A quasi-intentional tort because a similar mistake can happen to anyone.
Failure to respect client autonomy to choose based on intentional tort law.
Assault and battery with deliberate intent to deviate from the consent form.
An unintentional tort because the client benefited from having the myelogram. - Correct
Ans-Assault and battery with deliberate intent to deviate from the consent form.
The client was not properly informed of the procedure, and failure to obtain informed
consent constitutes assault and battery (C). (A) is injury to economics and dignity, such
as invasion of privacy or defamation of character. This is not an incident of failure to
respect the client's autonomy (B). An unintentional tort (D) is an act in which the
outcome was not expected, such as negligence or malpractice.
A client in hospice care develops audible gurgling sounds on inspiration. Which nursing
action has the highest priority?
Ensure cultural customs are observed.
