HESI V1
1. While assessing a client with diabetes mellitus, the nurse observes an ab- sence of
hair growth on the client's legs.What additional assessment provides further data to
support this finding?
a. Palpate for the presence of femoral pulses bilaterally.
b. Assess for the presence of a positive Homan's sign.
c. Observe the appearance of the skin on the client's legs.
d. Watch the client's posture and balance during ambulation.: Ans: C
Signs of chronic arterial insufficiency include decreased hair growth in the legs and feet,
absent or decreased pedal pulses, infection in the foot, poor wound healing, thickened nails
and a shiny appearance of the skin (C). Femoral pulses (A) should still be palpable in the
diabetic with chronic arterial insufficiency. A positive Homan's sign is an indicator of deep
vein thrombosis (B). (D) would probably not be affected significantly by chronic arterial
insufficiency.
2. The healthcare provider prescribes 15 mg/kg of Streptomycin for an infant
weighing 4 pounds. The drug is diluted in 25 ml of D5W to run over 8 hours. How
much Streptomycin will the infant receive?
a. 9 mg.
b. 18 mg.
c. 27 mg.
d. 36 mg.: Ans: C
4 lbs / 2.2 = 1.8 kg. 1.8 x 15 = 27 mg (C). NOTE, the fact that the drug is diluted in 25 ml
of D5W, is not relevant to the calculation requested.
3. In assessing a client with preeclampsia who is receiving magnesium sulfate, the nurse
determines that her deep tendon reflexes are 1+; respiratory rate is 12
,breaths/minute; urinary output is 90 ml in 4 hours; magnesium sulfate level is 9
mg/dl. Based on these findings, what intervention should the nurse implement?
a. Continue the magnesium sulfate infusion as prescribed.
b. Decrease the magnesium sulfate infusion by one-half.
c. Stop the magnesium sulfate infusion immediately.
d. Administer calcium gluconate immediately.: Ans: C
The client is exhibiting symptoms of magnesium sulfate toxicity--decreased reflexes
(normal is +2), a low normal respiratory rate (normal is 12 to 20 breaths/min), a less than
average urinary output (30 ml/hour is average), and a low magnesium sulfate level (normal
is 4 to 8mg/dl). Based on these findings, the nurse should stop the infusion (C). (A) is
contraindicated. (B) would not fully alleviate the magnesium sulfate toxicity symptoms. (D
(the antagonist for magnesium sulfate) would be indicated if the respiratory rate were less
than 12 breaths/minute.
,4. A client is on a mechanical ventilator. Which client response indicates that the
neuromuscular blocker tubocurarine chloride (Tubarine) is effective?
a. The client's extremities are paralyzed.
b. The peripheral nerve stimulator causes twitching.
c. The client clinches fist upon command.
d. The client's Glasgow Coma Scale score is 14.: Ans: A
This medication causes paralysis (A) following intravenous injection. Peak effects persist
for 35 to 60 minutes. (B and C) would not be possible if the medication is effective. The
Glasgow coma scale is used to evaluate the neurological status of the client and does not
evaluate the effectiveness (D) of this medication.
5. An elderly female client comes to the clinic for a regular check-up. The client tells
the nurse that she has increased her daily doses of acetaminophen (Tylenol) for the
past month to control joint pain. Based on this client's comment, what previous lab
values should the nurse compare with today's lab report?
a. Look at last quarter's hemoglobin and hematocrit, expecting an increase today
due to dehydration.
b. Look for an increase in today's LDH compared to the previous one to assess for
possible liver damage.
c. Expect to find an increase in today's APTT as compared to last quarter's due to
bleeding.
d. Determine if there is a decrease in serum potassium due to renal compro- mise.:
Ans: B
Frequent and/or large doses of acetaminophen can cause an increase in liver en- zymes,
indicating possible liver damage (B). If the client reported unusual bleeding, or an increase
in aspirin usage, it would be important for the nurse to assess for increased bleeding and
, monitor (A and/or C). (D) is not affected by increases in acetaminophen doses.
6. Aspirin is prescribed for a 9-year-old child with rheumatic fever to control the
inflammatory process, promote comfort, and reduce fever. What interven- tion is
most important for the nurse to implement?
a. Instruct the parents to hold the aspirin until the child has first had a tepid sponge
bath.
b. Administer the aspirin with at least two ounces of water or juice.
c. Notify the healthcare provider if the child complains of ringing in the ears.
d. Advise the parents to question the child about seeing yellow halos around objects.:
Ans: C
Ringing in the ears (tinnitus) (C) is an important sign of aspirin overdosage and should be
reported immediately. Though a tepid sponge bath may lower the child's
1. While assessing a client with diabetes mellitus, the nurse observes an ab- sence of
hair growth on the client's legs.What additional assessment provides further data to
support this finding?
a. Palpate for the presence of femoral pulses bilaterally.
b. Assess for the presence of a positive Homan's sign.
c. Observe the appearance of the skin on the client's legs.
d. Watch the client's posture and balance during ambulation.: Ans: C
Signs of chronic arterial insufficiency include decreased hair growth in the legs and feet,
absent or decreased pedal pulses, infection in the foot, poor wound healing, thickened nails
and a shiny appearance of the skin (C). Femoral pulses (A) should still be palpable in the
diabetic with chronic arterial insufficiency. A positive Homan's sign is an indicator of deep
vein thrombosis (B). (D) would probably not be affected significantly by chronic arterial
insufficiency.
2. The healthcare provider prescribes 15 mg/kg of Streptomycin for an infant
weighing 4 pounds. The drug is diluted in 25 ml of D5W to run over 8 hours. How
much Streptomycin will the infant receive?
a. 9 mg.
b. 18 mg.
c. 27 mg.
d. 36 mg.: Ans: C
4 lbs / 2.2 = 1.8 kg. 1.8 x 15 = 27 mg (C). NOTE, the fact that the drug is diluted in 25 ml
of D5W, is not relevant to the calculation requested.
3. In assessing a client with preeclampsia who is receiving magnesium sulfate, the nurse
determines that her deep tendon reflexes are 1+; respiratory rate is 12
,breaths/minute; urinary output is 90 ml in 4 hours; magnesium sulfate level is 9
mg/dl. Based on these findings, what intervention should the nurse implement?
a. Continue the magnesium sulfate infusion as prescribed.
b. Decrease the magnesium sulfate infusion by one-half.
c. Stop the magnesium sulfate infusion immediately.
d. Administer calcium gluconate immediately.: Ans: C
The client is exhibiting symptoms of magnesium sulfate toxicity--decreased reflexes
(normal is +2), a low normal respiratory rate (normal is 12 to 20 breaths/min), a less than
average urinary output (30 ml/hour is average), and a low magnesium sulfate level (normal
is 4 to 8mg/dl). Based on these findings, the nurse should stop the infusion (C). (A) is
contraindicated. (B) would not fully alleviate the magnesium sulfate toxicity symptoms. (D
(the antagonist for magnesium sulfate) would be indicated if the respiratory rate were less
than 12 breaths/minute.
,4. A client is on a mechanical ventilator. Which client response indicates that the
neuromuscular blocker tubocurarine chloride (Tubarine) is effective?
a. The client's extremities are paralyzed.
b. The peripheral nerve stimulator causes twitching.
c. The client clinches fist upon command.
d. The client's Glasgow Coma Scale score is 14.: Ans: A
This medication causes paralysis (A) following intravenous injection. Peak effects persist
for 35 to 60 minutes. (B and C) would not be possible if the medication is effective. The
Glasgow coma scale is used to evaluate the neurological status of the client and does not
evaluate the effectiveness (D) of this medication.
5. An elderly female client comes to the clinic for a regular check-up. The client tells
the nurse that she has increased her daily doses of acetaminophen (Tylenol) for the
past month to control joint pain. Based on this client's comment, what previous lab
values should the nurse compare with today's lab report?
a. Look at last quarter's hemoglobin and hematocrit, expecting an increase today
due to dehydration.
b. Look for an increase in today's LDH compared to the previous one to assess for
possible liver damage.
c. Expect to find an increase in today's APTT as compared to last quarter's due to
bleeding.
d. Determine if there is a decrease in serum potassium due to renal compro- mise.:
Ans: B
Frequent and/or large doses of acetaminophen can cause an increase in liver en- zymes,
indicating possible liver damage (B). If the client reported unusual bleeding, or an increase
in aspirin usage, it would be important for the nurse to assess for increased bleeding and
, monitor (A and/or C). (D) is not affected by increases in acetaminophen doses.
6. Aspirin is prescribed for a 9-year-old child with rheumatic fever to control the
inflammatory process, promote comfort, and reduce fever. What interven- tion is
most important for the nurse to implement?
a. Instruct the parents to hold the aspirin until the child has first had a tepid sponge
bath.
b. Administer the aspirin with at least two ounces of water or juice.
c. Notify the healthcare provider if the child complains of ringing in the ears.
d. Advise the parents to question the child about seeing yellow halos around objects.:
Ans: C
Ringing in the ears (tinnitus) (C) is an important sign of aspirin overdosage and should be
reported immediately. Though a tepid sponge bath may lower the child's
