HESI NCLEX Practice Questions
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1. A client has not had a bowel movement C. Assess the client's medical record to deter-
in 2 days and reports this information to mine his normal bowel pattern.
the nurse. Which intervention should the
nurse implement first? Bowel movements vary per person. Some
people go multiple times a day and others go
A. Instruct the caregiver to offer a glass of a few times a week. The answer is an assess-
warm prune juice at mealtimes. ment, not an intervention.
B. Notify the HCP and request a prescrip-
tion for a stool softener
C. Assess the client's medical record to
determine his normal bowel pattern.
D. Instruct the caregiver to increase the
client's fluids to five 8 ounce glasses per
day.
2. A client who has chronic obstructive pul- C. Raise the head of the bed higher
monary disease (COPD) is resting in a
semi-Fowler's position with oxygen at 2 For COPD you want an SpO2 >90%. Fowler's
L/min per nasal cannula. The client de- position can help to open up the chest wall
velops dyspnea. Which action should the and aid in breathing. B and D are normal-
nurse take first? ly done in the same assessment so you can
check those off.
A. Call the HCP
B. Obtain a bedside pulse oximeter
C. Raise the head of the bed higher
D. Assess the clients vital signs
3. A client who has hyperparathyroidism is D. Administer the dose of oral phosphate
scheduled to receive a prescribed dose of
oral phosphate. The nurse notes that the A normal calcium level is 5.5-10.5 mg/dL so
client's serum calcium is 12.5 mg/dL. What this value is high. Calcium and phosphate
action should the nurse take? have an inverse reaction so in order to lower
, HESI NCLEX Practice Questions
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the calcium, there needs to be more phos-
A. Hold the phosphate and notify the HCP phate. Giving the oral phosphate will be ben-
B. Review the client's serum parathyroid eficial to lowering the serum calcium level.
hormone level
C. Give a PRN dose of IV calcium per pro-
tocol
D. Administer the dose of oral phosphate
4. In completing a client's perioperative rou- C. Inform the HCP that the client has questions
tine, the nurse finds that the consent form about the surgery
has not been signed. The client begins
to ask more questions about the surgical The nurse has to witness the surgery in per-
procedure. Which action should the nurse son but because the client has questions, in-
take? formed consent is not given. The nurse cannot
answer questions about the surgery because
A. Witness the client's signature on the that is the HCP's responsibility. If the HCP does
consent form not know about questions, they may not an-
B. Answer the client's questions about the swer them before the surgery.
surgery
C. Inform the HCP that the client has ques-
tions about the surgery
D. Reassure the client that the surgeon
will answer any questions before the
anesthetic is administered
5. The unlicensed assistive personnel (UAP) A. The parameters of the state's or provinces
reports to the staff nurse that a client who nurse practice act
had surgery 4 hours ago has a decrease
in blood pressure (BP), from 150/80 to The nurse asked the UAP to perform a task
110/70, in the past hour. The nurse advises that is outside of their scope of practice. This
the UAP to check the client's dressings for is states in the Nurse Practice Act for the state
excess drainage and report the findings to or province.
, HESI NCLEX Practice Questions
Study online at https://quizlet.com/_a3ow91
the nurse. Which factor is most important
to consider when assessing the legal ram-
ifications of this situation?
A. The parameters of the state's or
province's nurse practice act
B. The need to complete an adverse occur-
rence report
C. Hospital protocol regarding the fre-
quency of vital sign assessment every
hour postoperatively
D. The healthcare provider's prescription
for changing the postoperative dressing
6. The newly licensed nurse overhears two B. Advise them to cease their communication
nurses talking in the elevator about a
client who will lose her leg because of This is a HIPPA violation and needs to be
negligence of the staff. Which action by addressed presently. The new nurse should
the newly licensed nurse should be imple- tell them to talk privately or not at all about
mented first? the case. If they continue the conversation
the nurse should inform the nurse manager
A. Monitor the nurses closely for further of the conversation. There is no event taken
occurrences place with a patient or to a patient so a report
B. Advise them to cease their communica- is not necessary.
tion
C. Inform the nurse manager of the con-
versation
D. Submit an occurrence or variance re-
port
7. An awake, alert client with impending pul- B. The client is awake and alter, which makes
monary edema is brought to the emer- the living will irrelevant and nonbinding
Study online at https://quizlet.com/_a3ow91
1. A client has not had a bowel movement C. Assess the client's medical record to deter-
in 2 days and reports this information to mine his normal bowel pattern.
the nurse. Which intervention should the
nurse implement first? Bowel movements vary per person. Some
people go multiple times a day and others go
A. Instruct the caregiver to offer a glass of a few times a week. The answer is an assess-
warm prune juice at mealtimes. ment, not an intervention.
B. Notify the HCP and request a prescrip-
tion for a stool softener
C. Assess the client's medical record to
determine his normal bowel pattern.
D. Instruct the caregiver to increase the
client's fluids to five 8 ounce glasses per
day.
2. A client who has chronic obstructive pul- C. Raise the head of the bed higher
monary disease (COPD) is resting in a
semi-Fowler's position with oxygen at 2 For COPD you want an SpO2 >90%. Fowler's
L/min per nasal cannula. The client de- position can help to open up the chest wall
velops dyspnea. Which action should the and aid in breathing. B and D are normal-
nurse take first? ly done in the same assessment so you can
check those off.
A. Call the HCP
B. Obtain a bedside pulse oximeter
C. Raise the head of the bed higher
D. Assess the clients vital signs
3. A client who has hyperparathyroidism is D. Administer the dose of oral phosphate
scheduled to receive a prescribed dose of
oral phosphate. The nurse notes that the A normal calcium level is 5.5-10.5 mg/dL so
client's serum calcium is 12.5 mg/dL. What this value is high. Calcium and phosphate
action should the nurse take? have an inverse reaction so in order to lower
, HESI NCLEX Practice Questions
Study online at https://quizlet.com/_a3ow91
the calcium, there needs to be more phos-
A. Hold the phosphate and notify the HCP phate. Giving the oral phosphate will be ben-
B. Review the client's serum parathyroid eficial to lowering the serum calcium level.
hormone level
C. Give a PRN dose of IV calcium per pro-
tocol
D. Administer the dose of oral phosphate
4. In completing a client's perioperative rou- C. Inform the HCP that the client has questions
tine, the nurse finds that the consent form about the surgery
has not been signed. The client begins
to ask more questions about the surgical The nurse has to witness the surgery in per-
procedure. Which action should the nurse son but because the client has questions, in-
take? formed consent is not given. The nurse cannot
answer questions about the surgery because
A. Witness the client's signature on the that is the HCP's responsibility. If the HCP does
consent form not know about questions, they may not an-
B. Answer the client's questions about the swer them before the surgery.
surgery
C. Inform the HCP that the client has ques-
tions about the surgery
D. Reassure the client that the surgeon
will answer any questions before the
anesthetic is administered
5. The unlicensed assistive personnel (UAP) A. The parameters of the state's or provinces
reports to the staff nurse that a client who nurse practice act
had surgery 4 hours ago has a decrease
in blood pressure (BP), from 150/80 to The nurse asked the UAP to perform a task
110/70, in the past hour. The nurse advises that is outside of their scope of practice. This
the UAP to check the client's dressings for is states in the Nurse Practice Act for the state
excess drainage and report the findings to or province.
, HESI NCLEX Practice Questions
Study online at https://quizlet.com/_a3ow91
the nurse. Which factor is most important
to consider when assessing the legal ram-
ifications of this situation?
A. The parameters of the state's or
province's nurse practice act
B. The need to complete an adverse occur-
rence report
C. Hospital protocol regarding the fre-
quency of vital sign assessment every
hour postoperatively
D. The healthcare provider's prescription
for changing the postoperative dressing
6. The newly licensed nurse overhears two B. Advise them to cease their communication
nurses talking in the elevator about a
client who will lose her leg because of This is a HIPPA violation and needs to be
negligence of the staff. Which action by addressed presently. The new nurse should
the newly licensed nurse should be imple- tell them to talk privately or not at all about
mented first? the case. If they continue the conversation
the nurse should inform the nurse manager
A. Monitor the nurses closely for further of the conversation. There is no event taken
occurrences place with a patient or to a patient so a report
B. Advise them to cease their communica- is not necessary.
tion
C. Inform the nurse manager of the con-
versation
D. Submit an occurrence or variance re-
port
7. An awake, alert client with impending pul- B. The client is awake and alter, which makes
monary edema is brought to the emer- the living will irrelevant and nonbinding
