HESI Comprehensive Review for the
NCLEX-RN Examination
In assisting an older adult client prepare to take a tub bath, which nursing action is most
important?
A.
Check the bath water temperature.
B.
Shut the bathroom door.
C.
Ensure that the client has voided.
D.
Provide extra towels. correct answers A.
Check the bath water temperature.
The nurse determines that a postoperative client's respiratory rate has increased from
18 to 24 breaths/min. Based on this assessment finding, what is the priority nursing
action?
A.
Encourage the client to increase ambulation in the room.
B.
Offer the client a high-carbohydrate snack for energy.
C.
Force fluids to thin the client's pulmonary secretions.
D.
Determine if pain is causing the client's tachypnea. correct answers D.
Determine if pain is causing the client's tachypnea.
The nurse is aware that malnutrition is a common problem among clients served by a
community health clinic for the homeless. Which laboratory value is the most reliable
indicator of chronic protein malnutrition?
A.
Low serum albumin level
B.
Low serum transferrin level
C.
High hemoglobin level
D.
High cholesterol level correct answers A.
Low serum albumin level
,During a routine assessment, an obese 50-year-old client states, "I feel so unlovable
because of my weight." Which is the best response by the nurse?
A.
Reassure the client that many obese people have concerns about sex.
B.
Remind the client that sexual relationships need not be affected by obesity.
C.
Determine the frequency of sexual intercourse.
D.
Ask the client to talk about specific concerns. correct answers D.
Ask the client to talk about specific concerns.
The nurse is evaluating measures implemented for the non-responsive client. Which
findings indicate the effectiveness of the care delivered? (Select all that apply.)
A.
Footboard at the end of the bed
B.
Heals without redness bilaterally
C.
Skin intact on the back
D.
Sheepskin booties in place
E.
Elbow joint fully flexes and extends.
F.
Ankle joint rotates 360 degrees freely. correct answers B.
Heals without redness bilaterally
C.
Skin intact on the back
E.
Elbow joint fully flexes and extends.
F.
Ankle joint rotates 360 degrees freely.
The mental health nurse plans to discuss a client's depression with the health care
provider in the emergency department. There are two clients sitting across from the
emergency department desk. Which nursing action is best?
A.
Only refer to the client by gender.
B.
Identify the client only by age.
C.
Avoid using the client's name.
D.
Discuss the client another time. correct answers D.
Discuss the client another time.
,The nurse is teaching a client how to perform progressive muscle relaxation techniques
to relieve insomnia. A week later the client reports, "I am still unable to sleep, despite
following the same routine every night." Which action should the nurse take next?
A.
Instruct the client to add regular exercise as a daily routine.
B.
Determine if the client has been keeping a sleep diary.
C.
Encourage the client to continue the routine until sleep is achieved.
D.
Ask the client to describe the routine he is currently following. correct answers D.
Ask the client to describe the routine he is currently following.
The nurse administered 10 mg of diazepam to the preoperative client. What steps will
the nurse take next? (Select all that apply.)
A.
Place the client in the bed next to the nurse's station.
B.
Instruct the client not to get out of bed.
C.
Place the call bell within the client's reach.
D.
Place the side rails up, according to institutional policy.
E.
Assist the client to the bathroom. correct answers B.
Instruct the client not to get out of bed.
C.
Place the call bell within the client's reach.
D.
Place the side rails up, according to institutional policy.
When emptying 350 mL of pale yellow urine from a client's urinal, the nurse notes that
this is the first time the client has voided in 4 hours. Which action should the nurse take
next?
A.
Record the amount on the client's fluid output record.
B.
Encourage the client to increase oral fluid intake.
C.
Notify the health care provider of the findings.
D.
Palpate the client's bladder for distention. correct answers A.
Record the amount on the client's fluid output record.
, The nurse is providing care to clients at a day treatment center. One of the clients who
is usually talkative and eats well is now confused and did not eat lunch. The nurse
learns these are new findings as of today. What are the next nursing actions? (Select all
that apply.)
A.
Obtain a clean catch urine sample.
B.
Take the client's vital signs.
C.
Assess for the initiation of any new medications.
D.
Obtain an oxygen saturation.
E.
Call the client's children to report the confusion.
F.
Call the facility's bus service to return the client home. correct answers A.
Obtain a clean catch urine sample.
B.
Take the client's vital signs.
C.
Assess for the initiation of any new medications.
D.
Obtain an oxygen saturation.
A 65-year-old client who attends an adult daycare program and is wheelchair mobile
has redness in the sacral area. Which instruction is most important for the nurse to
provide?
A.
"Take a vitamin supplement tablet once a day."
B.
"Change positions in the chair frequently"
C.
"Increase daily intake of water or other oral fluids."
D.
"Purchase a newer model wheelchair." correct answers B.
"Change positions in the chair frequently"
By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain
of infection?
A.
Mode of transmission
B.
Portal of entry
C.
Reservoir
D.
NCLEX-RN Examination
In assisting an older adult client prepare to take a tub bath, which nursing action is most
important?
A.
Check the bath water temperature.
B.
Shut the bathroom door.
C.
Ensure that the client has voided.
D.
Provide extra towels. correct answers A.
Check the bath water temperature.
The nurse determines that a postoperative client's respiratory rate has increased from
18 to 24 breaths/min. Based on this assessment finding, what is the priority nursing
action?
A.
Encourage the client to increase ambulation in the room.
B.
Offer the client a high-carbohydrate snack for energy.
C.
Force fluids to thin the client's pulmonary secretions.
D.
Determine if pain is causing the client's tachypnea. correct answers D.
Determine if pain is causing the client's tachypnea.
The nurse is aware that malnutrition is a common problem among clients served by a
community health clinic for the homeless. Which laboratory value is the most reliable
indicator of chronic protein malnutrition?
A.
Low serum albumin level
B.
Low serum transferrin level
C.
High hemoglobin level
D.
High cholesterol level correct answers A.
Low serum albumin level
,During a routine assessment, an obese 50-year-old client states, "I feel so unlovable
because of my weight." Which is the best response by the nurse?
A.
Reassure the client that many obese people have concerns about sex.
B.
Remind the client that sexual relationships need not be affected by obesity.
C.
Determine the frequency of sexual intercourse.
D.
Ask the client to talk about specific concerns. correct answers D.
Ask the client to talk about specific concerns.
The nurse is evaluating measures implemented for the non-responsive client. Which
findings indicate the effectiveness of the care delivered? (Select all that apply.)
A.
Footboard at the end of the bed
B.
Heals without redness bilaterally
C.
Skin intact on the back
D.
Sheepskin booties in place
E.
Elbow joint fully flexes and extends.
F.
Ankle joint rotates 360 degrees freely. correct answers B.
Heals without redness bilaterally
C.
Skin intact on the back
E.
Elbow joint fully flexes and extends.
F.
Ankle joint rotates 360 degrees freely.
The mental health nurse plans to discuss a client's depression with the health care
provider in the emergency department. There are two clients sitting across from the
emergency department desk. Which nursing action is best?
A.
Only refer to the client by gender.
B.
Identify the client only by age.
C.
Avoid using the client's name.
D.
Discuss the client another time. correct answers D.
Discuss the client another time.
,The nurse is teaching a client how to perform progressive muscle relaxation techniques
to relieve insomnia. A week later the client reports, "I am still unable to sleep, despite
following the same routine every night." Which action should the nurse take next?
A.
Instruct the client to add regular exercise as a daily routine.
B.
Determine if the client has been keeping a sleep diary.
C.
Encourage the client to continue the routine until sleep is achieved.
D.
Ask the client to describe the routine he is currently following. correct answers D.
Ask the client to describe the routine he is currently following.
The nurse administered 10 mg of diazepam to the preoperative client. What steps will
the nurse take next? (Select all that apply.)
A.
Place the client in the bed next to the nurse's station.
B.
Instruct the client not to get out of bed.
C.
Place the call bell within the client's reach.
D.
Place the side rails up, according to institutional policy.
E.
Assist the client to the bathroom. correct answers B.
Instruct the client not to get out of bed.
C.
Place the call bell within the client's reach.
D.
Place the side rails up, according to institutional policy.
When emptying 350 mL of pale yellow urine from a client's urinal, the nurse notes that
this is the first time the client has voided in 4 hours. Which action should the nurse take
next?
A.
Record the amount on the client's fluid output record.
B.
Encourage the client to increase oral fluid intake.
C.
Notify the health care provider of the findings.
D.
Palpate the client's bladder for distention. correct answers A.
Record the amount on the client's fluid output record.
, The nurse is providing care to clients at a day treatment center. One of the clients who
is usually talkative and eats well is now confused and did not eat lunch. The nurse
learns these are new findings as of today. What are the next nursing actions? (Select all
that apply.)
A.
Obtain a clean catch urine sample.
B.
Take the client's vital signs.
C.
Assess for the initiation of any new medications.
D.
Obtain an oxygen saturation.
E.
Call the client's children to report the confusion.
F.
Call the facility's bus service to return the client home. correct answers A.
Obtain a clean catch urine sample.
B.
Take the client's vital signs.
C.
Assess for the initiation of any new medications.
D.
Obtain an oxygen saturation.
A 65-year-old client who attends an adult daycare program and is wheelchair mobile
has redness in the sacral area. Which instruction is most important for the nurse to
provide?
A.
"Take a vitamin supplement tablet once a day."
B.
"Change positions in the chair frequently"
C.
"Increase daily intake of water or other oral fluids."
D.
"Purchase a newer model wheelchair." correct answers B.
"Change positions in the chair frequently"
By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain
of infection?
A.
Mode of transmission
B.
Portal of entry
C.
Reservoir
D.
