HESI HEALTH ASSESSMENT 246 EXAM
A client with chest pain, dizziness, and vomiting for the last 2 hours is admitted
for evaluation for Acute Coronary Syndrome (ACS). Which cardiac biomarker
should the registered nurse (RN) anticipate to be elevated if the client
experienced myocardial damage?
Creatine Kinase (CK-MB).
Serum troponin.
Myoglobin.
Ischemia modified albumin.
Serum troponin.
Troponin is the most sensitive and specific test for myocardial damage. Troponin
elevation is more specific than CK-MB.
The registered nurse (RN) is developing the plan of care for a client who is
admitted for alcohol detoxification. Which goal should be most important for the
RN to primarily focus the client's care?
The client maintains optimal nutritional status.
The client will remain alert and oriented.
The client will remain free from injury.
The client will remain alcohol free during hospitalization.
The client will remain free from injury.
Rationale
The client is at highest risk for injury due to altered cognitive and sensory disturbances
as well as delirium tremors during withdrawal. Remaining free from injury is the most
important goal for the acute phase of alcohol withdrawal.
The registered nurse (RN) is caring for a client with aplastic anemia who is
hospitalized for weight loss and generalized weakness. Laboratory values show a
white blood count (WBC) of 2,500/mm3 and a platelet countof 160,000/mm3.
Which intervention is the primary focus in the client's plan of care for the RN to
implement?
Assist with frequent ambulation.
Encourage visitors to visit.
Maintain strict protective precautions.
Avoid peripheral injections.
Maintain strict protective precautions.
Rationale
The client should be under strict protective transmission precautions because the WBC
values are low and normal WBC levels are 4,000-10,000/mm3, so the client is an
increased high risk for infection.
The registered nurse (RN) assesses a client's results for arterial blood gases who
has emphysema. Which finding is consistent with respiratory acidosis?
pH 7.32, pCO2 46 mmHg, HCO3 24 MEq/L.
pH 7.45 , pCO2 37 mmHg, HCO3 24 mEq/L.
pH 7.34, pCO2 36 mmHg, HCO3 21 mEq/L.
pH 7.46, pCO2 35 mmHg, HCO3 28 mEq/L.
,pH 7.32, pCO2 46 mmHg, HCO3 24 MEq/L.
Rationale
Normal ABG ranges are pH 7.35 to 7.45; pCO2 35 to 45 mmHg; HCO3 21 to 28 mEq/L,
and pO2 80 to 100 mmHg. An ABG of pH 7.32, pCO2 46 mmHg, HCO3 24 MEq/L
represents a client with respiratory acidosis which is characterized by: low pH,
pCO2higher than normal, and HCO3 within normal limits.
The registered nurse (RN) is caring for a client who has taken atenolol for 2 years.
The healthcare provider recently changed the medication to enalaprilto manage
the client's blood pressure. Which instruction should the RN provide the client
regarding the new medication?
Take the medication at bedtime.
Report presence of increased bruising.
Check pulse before taking medication.
Rise slowly when getting out of bed or chair.
Rise slowly when getting out of bed or chair.
Rationale
The client's new medication is an angiotensin-converting enzyme (ACE) inhibitor, which
has the side effect oforthostatic hypotension. Instructing the client to rise slowly from a
sitting or lying down position is important to teach the client to avoid dizziness and
potentially falling.
The registered nurse (RN) places an ice pack on a middle school student who
comes to the school clinic complaining of a sprained ankle. Which therapeutic
response should the RN anticipate?
Reduced pain and minimized brusing.
Lowering of body core temperature.
Increased circulation around injury.
Reabsorption of edema at injury.
Reduced pain and minimized brusing.
Rationale
Cold applications produce a topical anesthetic effect to reduce pain as well as constricts
blood vessels to minimize bruising.
Which action should the registered nurse (RN) implement to complete an
assessment for a client while using an interpreter?
Ask closed-ended questions with the assistance of the interpreter.
Maintain eye contact with the client while listening to the translation.
Instruct interpreter to answer questions from interpreter's point of view.
Protect the client's privacy by asking a limited number of questions.
Maintain eye contact with the client while listening to the translation.
Rationale
When completing an assessment, the RN should maintain eye contact with the client to
gather additional information from the client's nonverbal cues.
The registered nurse (RN) is assessing common complications related to a
client's recent diagnosis, systemic lupus erythematosus (SLE). Which symptom
should the RN instruct the client to report immediately?
Fever related to infection.
Weight loss and anorexia.
, Depressed mood.
Break in tissue integrity.
Fever related to infection.
Rationale
Secondary infections are a major concern with SLE clients due to the use of
corticosteroids and chemotherapeutic agents, which suppresses the immune system, so
reporting fever and infections should be reported immediately.
An older client is admitted to the hospital with severe diarrhea. The registered
nurse (RN) is completing an assessment and notes the client has dry mucous
membranes and poor skin turgor. Which assessment data should the RN gather
to determine if the client has a fluid volume deficit?
Lower extremity edema.
Orthostatic hypotension.
Elevated blood pressure.
Cheyne-Stokes respirations.
Orthostatic hypotension.
Rationale
Orthostatic hypotension can be a sign of fluid volume deficit in an older client who has
experienced severe diarrhea.
The registered nurse (RN) is caring for an older client who recently experienced a
fractured pelvis from a fall. Which assessment finding is most important for the
RN to report the healthcare provider?
Lower back pain.
Headache of 7 on scale 1 to 10.
Blood pressure of 140/98.
Dyspnea.
Dyspnea.
Rationale
A client with a large bone fracture is at risk for intramedullary fat leaking into the blood
stream and becoming embolic. Dyspnea is an indication of fat embolism to the lungs
and should be reported to the healthcare provider immediately.
A client with cirrhosis of the liver asks the registered nurse (RN) to explain how
varicose veins can occur in the esophagus. Which statement should the RN
provide to teach the client about the physiological etiology?
The enlarged liver presses on the lower half of the esophagus which weakens
blood vessel walls.
Abnormal vessels form as a result of liver damage that causes chronic low serum
protein levels.
Esophageal swelling and tissue damage causes blood to circulate blood back
through the stomach.
Increased portal pressure causes blood flow through liver to be shunted to the
esophageal vessels.
Increased portal pressure causes blood flow through liver to be shunted to the
esophageal vessels.
Rationale
Cirrhotic and fibrosed liver damage causes obstructed blood flow through portal vessels
A client with chest pain, dizziness, and vomiting for the last 2 hours is admitted
for evaluation for Acute Coronary Syndrome (ACS). Which cardiac biomarker
should the registered nurse (RN) anticipate to be elevated if the client
experienced myocardial damage?
Creatine Kinase (CK-MB).
Serum troponin.
Myoglobin.
Ischemia modified albumin.
Serum troponin.
Troponin is the most sensitive and specific test for myocardial damage. Troponin
elevation is more specific than CK-MB.
The registered nurse (RN) is developing the plan of care for a client who is
admitted for alcohol detoxification. Which goal should be most important for the
RN to primarily focus the client's care?
The client maintains optimal nutritional status.
The client will remain alert and oriented.
The client will remain free from injury.
The client will remain alcohol free during hospitalization.
The client will remain free from injury.
Rationale
The client is at highest risk for injury due to altered cognitive and sensory disturbances
as well as delirium tremors during withdrawal. Remaining free from injury is the most
important goal for the acute phase of alcohol withdrawal.
The registered nurse (RN) is caring for a client with aplastic anemia who is
hospitalized for weight loss and generalized weakness. Laboratory values show a
white blood count (WBC) of 2,500/mm3 and a platelet countof 160,000/mm3.
Which intervention is the primary focus in the client's plan of care for the RN to
implement?
Assist with frequent ambulation.
Encourage visitors to visit.
Maintain strict protective precautions.
Avoid peripheral injections.
Maintain strict protective precautions.
Rationale
The client should be under strict protective transmission precautions because the WBC
values are low and normal WBC levels are 4,000-10,000/mm3, so the client is an
increased high risk for infection.
The registered nurse (RN) assesses a client's results for arterial blood gases who
has emphysema. Which finding is consistent with respiratory acidosis?
pH 7.32, pCO2 46 mmHg, HCO3 24 MEq/L.
pH 7.45 , pCO2 37 mmHg, HCO3 24 mEq/L.
pH 7.34, pCO2 36 mmHg, HCO3 21 mEq/L.
pH 7.46, pCO2 35 mmHg, HCO3 28 mEq/L.
,pH 7.32, pCO2 46 mmHg, HCO3 24 MEq/L.
Rationale
Normal ABG ranges are pH 7.35 to 7.45; pCO2 35 to 45 mmHg; HCO3 21 to 28 mEq/L,
and pO2 80 to 100 mmHg. An ABG of pH 7.32, pCO2 46 mmHg, HCO3 24 MEq/L
represents a client with respiratory acidosis which is characterized by: low pH,
pCO2higher than normal, and HCO3 within normal limits.
The registered nurse (RN) is caring for a client who has taken atenolol for 2 years.
The healthcare provider recently changed the medication to enalaprilto manage
the client's blood pressure. Which instruction should the RN provide the client
regarding the new medication?
Take the medication at bedtime.
Report presence of increased bruising.
Check pulse before taking medication.
Rise slowly when getting out of bed or chair.
Rise slowly when getting out of bed or chair.
Rationale
The client's new medication is an angiotensin-converting enzyme (ACE) inhibitor, which
has the side effect oforthostatic hypotension. Instructing the client to rise slowly from a
sitting or lying down position is important to teach the client to avoid dizziness and
potentially falling.
The registered nurse (RN) places an ice pack on a middle school student who
comes to the school clinic complaining of a sprained ankle. Which therapeutic
response should the RN anticipate?
Reduced pain and minimized brusing.
Lowering of body core temperature.
Increased circulation around injury.
Reabsorption of edema at injury.
Reduced pain and minimized brusing.
Rationale
Cold applications produce a topical anesthetic effect to reduce pain as well as constricts
blood vessels to minimize bruising.
Which action should the registered nurse (RN) implement to complete an
assessment for a client while using an interpreter?
Ask closed-ended questions with the assistance of the interpreter.
Maintain eye contact with the client while listening to the translation.
Instruct interpreter to answer questions from interpreter's point of view.
Protect the client's privacy by asking a limited number of questions.
Maintain eye contact with the client while listening to the translation.
Rationale
When completing an assessment, the RN should maintain eye contact with the client to
gather additional information from the client's nonverbal cues.
The registered nurse (RN) is assessing common complications related to a
client's recent diagnosis, systemic lupus erythematosus (SLE). Which symptom
should the RN instruct the client to report immediately?
Fever related to infection.
Weight loss and anorexia.
, Depressed mood.
Break in tissue integrity.
Fever related to infection.
Rationale
Secondary infections are a major concern with SLE clients due to the use of
corticosteroids and chemotherapeutic agents, which suppresses the immune system, so
reporting fever and infections should be reported immediately.
An older client is admitted to the hospital with severe diarrhea. The registered
nurse (RN) is completing an assessment and notes the client has dry mucous
membranes and poor skin turgor. Which assessment data should the RN gather
to determine if the client has a fluid volume deficit?
Lower extremity edema.
Orthostatic hypotension.
Elevated blood pressure.
Cheyne-Stokes respirations.
Orthostatic hypotension.
Rationale
Orthostatic hypotension can be a sign of fluid volume deficit in an older client who has
experienced severe diarrhea.
The registered nurse (RN) is caring for an older client who recently experienced a
fractured pelvis from a fall. Which assessment finding is most important for the
RN to report the healthcare provider?
Lower back pain.
Headache of 7 on scale 1 to 10.
Blood pressure of 140/98.
Dyspnea.
Dyspnea.
Rationale
A client with a large bone fracture is at risk for intramedullary fat leaking into the blood
stream and becoming embolic. Dyspnea is an indication of fat embolism to the lungs
and should be reported to the healthcare provider immediately.
A client with cirrhosis of the liver asks the registered nurse (RN) to explain how
varicose veins can occur in the esophagus. Which statement should the RN
provide to teach the client about the physiological etiology?
The enlarged liver presses on the lower half of the esophagus which weakens
blood vessel walls.
Abnormal vessels form as a result of liver damage that causes chronic low serum
protein levels.
Esophageal swelling and tissue damage causes blood to circulate blood back
through the stomach.
Increased portal pressure causes blood flow through liver to be shunted to the
esophageal vessels.
Increased portal pressure causes blood flow through liver to be shunted to the
esophageal vessels.
Rationale
Cirrhotic and fibrosed liver damage causes obstructed blood flow through portal vessels
