Page | 1
NURS 3345 Exit HESI 2025
(265 Morsels of
NCLEX/HESI Goodness) |
Questions & Answers with
Rationales | A+ Guaranteed
, 265 Morsels of Exit HESI Goodness
1.ID: 9476788675
An emergency department nurse has a health care provider's
prescription to irrigate a client's ears. List in order of priority the
Page | 2
steps that the nurse should take in performing this procedure.
Correct
1. Use an otoscope to ensure that the tympanic membrane is
intact.
2. Warm tap water to body temperature.
3. Fill an irrigating syringe with warm water.
4. Insert the irrigating solution by directing the solution toward
the wall of the ear canal.
5. Document the completion of the procedure and how the client
tolerated it.
Rationale: Irrigation of the ear is not performed if the client has a perforated
tympanic membrane or otitis media. Therefore the nurse would first use an
otoscope to ensure that the tympanic membrane is intact. Once intactness of the
tympanic membrane has been verified, the nurse would warm the irrigation
solution to body temperature, fill an irrigating syringe with the solution, and instill
the solution by directing it toward the wall of the ear canal. Finally the nurse
would document that the procedure was performed and record how the client
tolerated it.
Test-Taking Strategy: Focus on the subject, the steps involved in ear irrigation.
Visualize this procedure to answer correctly. Remember that the tympanic
membrane must be intact before irrigation is performed. Also recall that the
nurse would document the procedure once it had been performed. Review the
procedure for ear irrigation if you had difficulty with this question.
Reference: Hammond, B., & Zimmermann, P. (2013) Sheehy’s Manual of
Emergency Care (7th ed., pp. 278, 280). St. Louis: Elsevier.
Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Adult Health/Ear
Giddens Concepts: Care Coordination, Sensory Perception
HESI Concepts: Collaboration/Managing Care – Care Coordination, Sensory
Perception
Awarded 1.0 points out of 1.0 possible points.
,Fin.
2.ID: 9476754035
A client is scheduled to undergo an upper gastrointestinal (GI) series,
and the nurse provides instructions to the client about the test. Which
statement by the client indicates a need for further instruction?
A. "The test will take about 30 minutes."
B. "I need to fast for 8 hours before the test." Incorrect
C. "I need to drink citrate of magnesia the night before the
test and give myself a Fleet enema on the morning of the
test." Correct
D. "I need to take a laxative after the test is completed, because
the liquid that I’ll have to drink for the test can be constipating."
Rationale: An upper GI series involves visualization of the esophagus, duodenum,
and upper jejunum by means of the use of a contrast medium. It involves
swallowing a contrast medium (usually barium), which is administered in a
flavored milkshake. Films are taken at intervals during the test, which takes
about 30 minutes. No special preparation is necessary before a GI series, except
that NPO status must be maintained for 8 hours before the test. After an upper GI
, series, the client is prescribed a laxative to hasten elimination of the barium.
Barium that remains in the colon may become hard and difficult to expel, leading
to fecal impaction.
Test-Taking Strategy: Use the process of elimination. Note the strategic words
"need for further instruction." These words indicate a negative event query and
the need to select the incorrect client statement. Focusing on the word "upper" in
the name of the test will direct you to the correct option. Review preprocedure
care for an upper GI series if you had difficulty with this question.
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-
surgical nursing: Assessment and management of clinical problems (9th ed., p.
879). St. Louis: Mosby.
Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Adult Health/Gastrointestinal
Giddens Concepts: Client Education, Clinical Judgment
HESI Concepts:Clinical Decision Making/Clinical Judgment, Teaching and
Learning/Patient Education
Awarded 0.0 points out of 1.0 possible points.
3.ID: 9476790957
Using Nagele’s rule, the nurse determines that the estimated date of
delivery (EDD) is:
A. June 2, 2018
B. July 2, 2018 Correct
C. October 2, 2018
D. September 18, 2018
Rationale: Accurate use of Nagele’s rule requires that the woman have a regular
28-day menstrual cycle. To calculate the EDD with the use of this rule, the nurse
would subtract 3 months from the date of the first day of her LMP, add 7 days,
and then adjust the year. First day of the LMP, September 25, 2017; subtract 3
months, June 25, 2017; add 7 days, July 2, 2017; add 1 year, July 2, 2018.
Test-Taking Strategy: Knowledge of how to use Nagele’s rule is required to
answer this question. Use caution when following the steps to determine the
estimated date of delivery. Read all of the options carefully, noting the dates in
the options and remembering that there are 30 days in the month of June.
Review Nagele’s rule if you had difficulty with this question.
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J.
(2013). Maternal-child nursing (4th ed., p.247). St. Louis: Elsevier.
Cognitive Ability: Understanding
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Maternity/Antepartum
Giddens Concepts: Clinical Judgment, Reproduction
HESI Concepts: Assessment, Sexuality/Reproduction
NURS 3345 Exit HESI 2025
(265 Morsels of
NCLEX/HESI Goodness) |
Questions & Answers with
Rationales | A+ Guaranteed
, 265 Morsels of Exit HESI Goodness
1.ID: 9476788675
An emergency department nurse has a health care provider's
prescription to irrigate a client's ears. List in order of priority the
Page | 2
steps that the nurse should take in performing this procedure.
Correct
1. Use an otoscope to ensure that the tympanic membrane is
intact.
2. Warm tap water to body temperature.
3. Fill an irrigating syringe with warm water.
4. Insert the irrigating solution by directing the solution toward
the wall of the ear canal.
5. Document the completion of the procedure and how the client
tolerated it.
Rationale: Irrigation of the ear is not performed if the client has a perforated
tympanic membrane or otitis media. Therefore the nurse would first use an
otoscope to ensure that the tympanic membrane is intact. Once intactness of the
tympanic membrane has been verified, the nurse would warm the irrigation
solution to body temperature, fill an irrigating syringe with the solution, and instill
the solution by directing it toward the wall of the ear canal. Finally the nurse
would document that the procedure was performed and record how the client
tolerated it.
Test-Taking Strategy: Focus on the subject, the steps involved in ear irrigation.
Visualize this procedure to answer correctly. Remember that the tympanic
membrane must be intact before irrigation is performed. Also recall that the
nurse would document the procedure once it had been performed. Review the
procedure for ear irrigation if you had difficulty with this question.
Reference: Hammond, B., & Zimmermann, P. (2013) Sheehy’s Manual of
Emergency Care (7th ed., pp. 278, 280). St. Louis: Elsevier.
Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Adult Health/Ear
Giddens Concepts: Care Coordination, Sensory Perception
HESI Concepts: Collaboration/Managing Care – Care Coordination, Sensory
Perception
Awarded 1.0 points out of 1.0 possible points.
,Fin.
2.ID: 9476754035
A client is scheduled to undergo an upper gastrointestinal (GI) series,
and the nurse provides instructions to the client about the test. Which
statement by the client indicates a need for further instruction?
A. "The test will take about 30 minutes."
B. "I need to fast for 8 hours before the test." Incorrect
C. "I need to drink citrate of magnesia the night before the
test and give myself a Fleet enema on the morning of the
test." Correct
D. "I need to take a laxative after the test is completed, because
the liquid that I’ll have to drink for the test can be constipating."
Rationale: An upper GI series involves visualization of the esophagus, duodenum,
and upper jejunum by means of the use of a contrast medium. It involves
swallowing a contrast medium (usually barium), which is administered in a
flavored milkshake. Films are taken at intervals during the test, which takes
about 30 minutes. No special preparation is necessary before a GI series, except
that NPO status must be maintained for 8 hours before the test. After an upper GI
, series, the client is prescribed a laxative to hasten elimination of the barium.
Barium that remains in the colon may become hard and difficult to expel, leading
to fecal impaction.
Test-Taking Strategy: Use the process of elimination. Note the strategic words
"need for further instruction." These words indicate a negative event query and
the need to select the incorrect client statement. Focusing on the word "upper" in
the name of the test will direct you to the correct option. Review preprocedure
care for an upper GI series if you had difficulty with this question.
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-
surgical nursing: Assessment and management of clinical problems (9th ed., p.
879). St. Louis: Mosby.
Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Adult Health/Gastrointestinal
Giddens Concepts: Client Education, Clinical Judgment
HESI Concepts:Clinical Decision Making/Clinical Judgment, Teaching and
Learning/Patient Education
Awarded 0.0 points out of 1.0 possible points.
3.ID: 9476790957
Using Nagele’s rule, the nurse determines that the estimated date of
delivery (EDD) is:
A. June 2, 2018
B. July 2, 2018 Correct
C. October 2, 2018
D. September 18, 2018
Rationale: Accurate use of Nagele’s rule requires that the woman have a regular
28-day menstrual cycle. To calculate the EDD with the use of this rule, the nurse
would subtract 3 months from the date of the first day of her LMP, add 7 days,
and then adjust the year. First day of the LMP, September 25, 2017; subtract 3
months, June 25, 2017; add 7 days, July 2, 2017; add 1 year, July 2, 2018.
Test-Taking Strategy: Knowledge of how to use Nagele’s rule is required to
answer this question. Use caution when following the steps to determine the
estimated date of delivery. Read all of the options carefully, noting the dates in
the options and remembering that there are 30 days in the month of June.
Review Nagele’s rule if you had difficulty with this question.
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J.
(2013). Maternal-child nursing (4th ed., p.247). St. Louis: Elsevier.
Cognitive Ability: Understanding
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Maternity/Antepartum
Giddens Concepts: Clinical Judgment, Reproduction
HESI Concepts: Assessment, Sexuality/Reproduction
