BSN 246 Practice HESI (1 & 2) question with
verified answers /rationales
1. The registered nurse (RN) is caring for a young adult who is having an oral glucose
tolerance tests (OGTT). Which laboratory result should the RN assess as a normal value for
the two hour postprandial result?
140 mg/dl.
160 mg/dl.
180 mg/dl.
200 mg/dl.: 140 mg/dl.
Rationale
The two hour postprandial level should be less 140 mg/dl for a young adult client.
2. The registered nurse (RN) is caring for a client who has a closed head injury from a
motor vehicle collision. Which finding should the RN assess the client for the risk of
diabetes insipidus (DI)?
High fever.
Low blood pressure.
Muscle rigidity.
Polydipsia.: Polydipsia.
Rationale
A characteristic finding of DI is excretion of large quantities of urine (5 to 20L/day), and most clients
compensate for fluid loss by drinking large amounts of water (polydipsia). DI can occur when there
has been damage or injury to the pituitary gland or hypothalamus as a result of head trauma, tumor
or an illness such as meningitis. This damage interrupts the ADH production, storage and release
causing the excessive urination and thirst.
3. The registered nurse (RN) is caring for a client who developed oliguria and was
diagnosed with sepsis and dehydration 48 hours ago. Which assessment finding indicates
to the RN that the client is stabilizing?
Urine output of 40 mL/hour.
Apical pulse 100 and blood pressure 76/42. Urine
specific gravity 1.001.
Tented skin on dorsal surface of hands.: Urine output of 40 mL/hour.
Rationale
A decrease in urinary output is a sign of dehydration. When the urine output returns
,to a normal range, 40 mL/hour, the client's kidneys are perfusing adequately and indicates the
client's status is stablizing.
4. A client who is uses ipratropium reports having nausea, blurred vision, headaches,
and insomnia after using the inhaler. Which action should the registered nurse (RN)
implement first?
Withhold medication and report symptoms and vital signs to healthcare provider.
Give PRN medication for nausea and vomiting and evaluate client in 30 min- utes.
Reassure client that the ipratropium given will alleviate the symptoms.
Delay administration of ipratropium until next maintenance medication is scheduled.:
Withhold medication and report symptoms and vital signs to healthcare provider.
Rationale
Headache, nausea, blurred vision and insomnia are symptoms of excessive use of ipratropium, so
withholding the medication until the healthcare provider is notified should be initiated to maintain
client safety.
5. The registered nurse (RN) is assessing a client who was discharged home after
management of chronic hypertension. Which equipment should the RN instruct the client
to use at home?
Exercise bicycle.
Sphygmomanometer.
Blood glucose monitor.
Weekly medication box.: Sphygmomanometer.
Rationale
Self-awareness is the best way for a client to manage chronic hypertension, so the client should
obtain a sphygmomanometer and learn how to monitor blood pressure daily and maintain a record.
6. The registered nurse (RN) is teaching a client who is newly diagnosed with emphysema
how to perform pursed lip breathing. What is the primary reason for teaching the client this
method of breathing?
Decreases respiratory rate.
Increases O2 saturation throughout the body.
, Conserves energy while ambulating.
Promotes CO2 elimination.: Promotes CO2 elimination.
Rationale
Pursed lip breathing helps eliminate CO2 by increasing positive pressure within the alveoli
increasing the surface area of the alveoli making it easier for the O2 and CO2 gas exchange to
occur .
7. The registered nurse (RN) reviews the new prescription, phenelzine (Nardil), a
monoamine oxidase inhibitor (MAOI), for a client on the psychiatric unit with depression.
Which information is most important for the RN to assess? Consumption of any alcohol or
tyramine-rich foods.
Complaints of nausea or vomiting.
Therapeutic serum drug levels.
Blood pressure and pulse prior to taking each dose.: Consumption of any alcohol or
tyramine-rich foods
Rationale
The consumption of any type of tyramine containing foods such as aged cheeses, fermented fruits
and vegetables, smoked or cured meats, dark wines and other alcoholic products should be
avoided when a client is prescribed a MAOIs due
to the a food-drug interaction causing a hypertensive crisis which can lead to a hemorrhagic stroke.
8. A registered nurse (RN) is performing a mini-mental state examination (MMSE) for a
client who is being admitted to an assisted living community. Which communication
techniques should the RN implement to decrease anx- iety in the client? (Select all that
apply.)Select all that apply
Use simple sentences during the examination.
Move to another question if the client seems confused. Reduce
environmental detractors during the examination. Allow family to
answer for the client to decrease frustration.
Ask questions one at a time to decrease confusion.: Use simple sentences during the
examination.
Reduce environmental detractors during the examination. Ask
questions one at a time to decrease confusion.
Rationale
verified answers /rationales
1. The registered nurse (RN) is caring for a young adult who is having an oral glucose
tolerance tests (OGTT). Which laboratory result should the RN assess as a normal value for
the two hour postprandial result?
140 mg/dl.
160 mg/dl.
180 mg/dl.
200 mg/dl.: 140 mg/dl.
Rationale
The two hour postprandial level should be less 140 mg/dl for a young adult client.
2. The registered nurse (RN) is caring for a client who has a closed head injury from a
motor vehicle collision. Which finding should the RN assess the client for the risk of
diabetes insipidus (DI)?
High fever.
Low blood pressure.
Muscle rigidity.
Polydipsia.: Polydipsia.
Rationale
A characteristic finding of DI is excretion of large quantities of urine (5 to 20L/day), and most clients
compensate for fluid loss by drinking large amounts of water (polydipsia). DI can occur when there
has been damage or injury to the pituitary gland or hypothalamus as a result of head trauma, tumor
or an illness such as meningitis. This damage interrupts the ADH production, storage and release
causing the excessive urination and thirst.
3. The registered nurse (RN) is caring for a client who developed oliguria and was
diagnosed with sepsis and dehydration 48 hours ago. Which assessment finding indicates
to the RN that the client is stabilizing?
Urine output of 40 mL/hour.
Apical pulse 100 and blood pressure 76/42. Urine
specific gravity 1.001.
Tented skin on dorsal surface of hands.: Urine output of 40 mL/hour.
Rationale
A decrease in urinary output is a sign of dehydration. When the urine output returns
,to a normal range, 40 mL/hour, the client's kidneys are perfusing adequately and indicates the
client's status is stablizing.
4. A client who is uses ipratropium reports having nausea, blurred vision, headaches,
and insomnia after using the inhaler. Which action should the registered nurse (RN)
implement first?
Withhold medication and report symptoms and vital signs to healthcare provider.
Give PRN medication for nausea and vomiting and evaluate client in 30 min- utes.
Reassure client that the ipratropium given will alleviate the symptoms.
Delay administration of ipratropium until next maintenance medication is scheduled.:
Withhold medication and report symptoms and vital signs to healthcare provider.
Rationale
Headache, nausea, blurred vision and insomnia are symptoms of excessive use of ipratropium, so
withholding the medication until the healthcare provider is notified should be initiated to maintain
client safety.
5. The registered nurse (RN) is assessing a client who was discharged home after
management of chronic hypertension. Which equipment should the RN instruct the client
to use at home?
Exercise bicycle.
Sphygmomanometer.
Blood glucose monitor.
Weekly medication box.: Sphygmomanometer.
Rationale
Self-awareness is the best way for a client to manage chronic hypertension, so the client should
obtain a sphygmomanometer and learn how to monitor blood pressure daily and maintain a record.
6. The registered nurse (RN) is teaching a client who is newly diagnosed with emphysema
how to perform pursed lip breathing. What is the primary reason for teaching the client this
method of breathing?
Decreases respiratory rate.
Increases O2 saturation throughout the body.
, Conserves energy while ambulating.
Promotes CO2 elimination.: Promotes CO2 elimination.
Rationale
Pursed lip breathing helps eliminate CO2 by increasing positive pressure within the alveoli
increasing the surface area of the alveoli making it easier for the O2 and CO2 gas exchange to
occur .
7. The registered nurse (RN) reviews the new prescription, phenelzine (Nardil), a
monoamine oxidase inhibitor (MAOI), for a client on the psychiatric unit with depression.
Which information is most important for the RN to assess? Consumption of any alcohol or
tyramine-rich foods.
Complaints of nausea or vomiting.
Therapeutic serum drug levels.
Blood pressure and pulse prior to taking each dose.: Consumption of any alcohol or
tyramine-rich foods
Rationale
The consumption of any type of tyramine containing foods such as aged cheeses, fermented fruits
and vegetables, smoked or cured meats, dark wines and other alcoholic products should be
avoided when a client is prescribed a MAOIs due
to the a food-drug interaction causing a hypertensive crisis which can lead to a hemorrhagic stroke.
8. A registered nurse (RN) is performing a mini-mental state examination (MMSE) for a
client who is being admitted to an assisted living community. Which communication
techniques should the RN implement to decrease anx- iety in the client? (Select all that
apply.)Select all that apply
Use simple sentences during the examination.
Move to another question if the client seems confused. Reduce
environmental detractors during the examination. Allow family to
answer for the client to decrease frustration.
Ask questions one at a time to decrease confusion.: Use simple sentences during the
examination.
Reduce environmental detractors during the examination. Ask
questions one at a time to decrease confusion.
Rationale
