Hesi level 2 (Nsg 170) Exam Questions With Complete
Solutions
A 12-month-old boy is admitted with a respiratory infection and
possible pneumonia. He is placed in a mist tent with oxygen.
Which nursing intervention has the greatest priority for this
infant?
A. Give small, frequent feedings of fluids.
B. Accurately chart observations regarding breath sounds.
C. Have a bulb syringe readily available to remove secretions.
D. Encourage older siblings to visit. Correct Answer C. have
a bulb syringe readily available to remove secretions
A patient airway has the highest priority. Humidification will
liquefy the nasal secretions thereby increasing the amount of
secretions and making (C) the highest priority. (A) maintains
hydration and prevents, but an open airway has the highest
priority. (B) is important for evaluations of therapy. When asked
"priority" questions, remember Maslow. Physical needs usually
have a higher priority than psychosocial needs. An open airway
is the highest physiological need
A 17-year-old unmarried, pregnant client with drug addiction is
a high school dropout, homeless, and has a history of past abuse
arrives at the clinic for her first prenatal visit. Which findings
should the nurse document as health risk factors for the client?
(Select all that apply.)
A.Age.
B.Drug addiction.
C.History of abuse.
D.Pregnancy.
,E.Homelessness.
F.Unmarried. Correct Answer A, B, C, D, E
Health risk factors for this client include age, drug addiction,
pregnancy, history of abuse and homelessness. Each factor
should be considered individually. The client, as an adolescent
mother, is at high risk for nutritional deficits, anemia, gestational
diabetes and hypertension, which also impact the fetus' risk for
small for gestational age, fetal anomalies, and fetal demise.
A 20-year-old female client calls the nurse to report a lump she
found in her breast. Which response is the best for the nurse to
provide?
A. "Check it again in one month, and if it is still there schedule
an appointment."
B. "Most lumps are benign, but it is always best to come in for
an examination."
C. "Try not to worry too much about it, because usually, most
lumps are benign."
D. "If you are in your menstrual period it is not a good time to
check for lumps." Correct Answer B) Most lumps are benign,
but it is always best to come in for an examination.
(B) provides the best response because it addresses the client's
anxiety most effectively and encourages prompt and immediate
action for a potential problem. (A) postpones treatment if the
lump is malignant, and does not relieve the client's anxiety. (C
and D) provide false reassurance and do not help relieve anxiety.
A 26-year-old, gravida 2, para 1 client is admitted to the hospital
at 28-weeks gestation in preterm labor. She is given 3 doses of
,terbutaline sulfate (Brethine) 0.25 mg subcutaneously to stop her
labor contractions. Which assessment finding would provide the
nurse the earliest indication that the client is experiencing
primary side effects of terbutaline sulfate?
A. Drowsiness and bradycardia.
B. Depressed reflexes and increased respirations.
C. Tachycardia and a feeling of nervousness.
D. A flushed, warm feeling and a dry mouth. Correct Answer
C. Tachycardia and a feeling of nervousness.
Terbutaline sulfate (Brethine), a beta-sympathomimetic drug
which stimulates beta-adrenergic receptors in the uterine muscle
to stop contractions. The beta-adrenergic agonist properties of
the drug may cause tachycardia, increased cardiac output,
restlessness, headache, and a feeling of "nervousness."
A 3-year-old is admitted to the pediatric unit after falling off a
bicycle. Which intervention should the nurse implement to assist
the child's adjustment to hospitalization?
A. Give detailed explanations of procedures.
B. Use terms of endearment to establish rapport.
C. Offer the child a choice when performing procedures.
D. Encourage the parents to go home and rest. Correct Answer
C. Offer the child a choice when performing procedures.
Altered daily schedules and loss of rituals are upsetting and
increase separation anxiety in toddlers and preschool-aged
children. The nurse's sensitivity to the needs and preferences of
a child can minimize the negative effects of hospitalization.
When possible, the nurse should offer the child a choice during
procedures to help the child gain self control and cooperation.
, A 32-year-old female client complains of severe abdominal pain
each month before her menstrual period, painful intercourse, and
painful defecation. Which additional history should the nurse
obtain that is consistent with the client's complaints?
A. Frequent urinary tract infections.
B. Inability to get pregnant.
C. Premenstrual syndrome.
D. Chronic use of laxatives. Correct Answer B) Inability to
get pregnant.
Dysmenorrhea, dyspareunia, and difficulty or painful defecation
are common symptoms of endometriosis, which is the abnormal
displacement of endometrial tissue in the dependent areas of the
pelvic peritoneum. A history of infertility (B) is another
common finding associated with endometriosis. Although (A, C,
and D) are common, nonspecific gynecological complaints, the
most common complaints of the client with endometriosis are
pain and infertility.
A 38-week primigravida who works as a secretary and sits at a
computer 8 hours each day tells the nurse that her feet have
begun to swell. Which instruction would be most effective in
preventing pooling of blood in the lower extremities?
A. Wear support stockings.
B. Reduce salt in her diet.
C. Move about every hour.
D. Avoid constrictive clothing. Correct Answer C. Move
about every hour.
Solutions
A 12-month-old boy is admitted with a respiratory infection and
possible pneumonia. He is placed in a mist tent with oxygen.
Which nursing intervention has the greatest priority for this
infant?
A. Give small, frequent feedings of fluids.
B. Accurately chart observations regarding breath sounds.
C. Have a bulb syringe readily available to remove secretions.
D. Encourage older siblings to visit. Correct Answer C. have
a bulb syringe readily available to remove secretions
A patient airway has the highest priority. Humidification will
liquefy the nasal secretions thereby increasing the amount of
secretions and making (C) the highest priority. (A) maintains
hydration and prevents, but an open airway has the highest
priority. (B) is important for evaluations of therapy. When asked
"priority" questions, remember Maslow. Physical needs usually
have a higher priority than psychosocial needs. An open airway
is the highest physiological need
A 17-year-old unmarried, pregnant client with drug addiction is
a high school dropout, homeless, and has a history of past abuse
arrives at the clinic for her first prenatal visit. Which findings
should the nurse document as health risk factors for the client?
(Select all that apply.)
A.Age.
B.Drug addiction.
C.History of abuse.
D.Pregnancy.
,E.Homelessness.
F.Unmarried. Correct Answer A, B, C, D, E
Health risk factors for this client include age, drug addiction,
pregnancy, history of abuse and homelessness. Each factor
should be considered individually. The client, as an adolescent
mother, is at high risk for nutritional deficits, anemia, gestational
diabetes and hypertension, which also impact the fetus' risk for
small for gestational age, fetal anomalies, and fetal demise.
A 20-year-old female client calls the nurse to report a lump she
found in her breast. Which response is the best for the nurse to
provide?
A. "Check it again in one month, and if it is still there schedule
an appointment."
B. "Most lumps are benign, but it is always best to come in for
an examination."
C. "Try not to worry too much about it, because usually, most
lumps are benign."
D. "If you are in your menstrual period it is not a good time to
check for lumps." Correct Answer B) Most lumps are benign,
but it is always best to come in for an examination.
(B) provides the best response because it addresses the client's
anxiety most effectively and encourages prompt and immediate
action for a potential problem. (A) postpones treatment if the
lump is malignant, and does not relieve the client's anxiety. (C
and D) provide false reassurance and do not help relieve anxiety.
A 26-year-old, gravida 2, para 1 client is admitted to the hospital
at 28-weeks gestation in preterm labor. She is given 3 doses of
,terbutaline sulfate (Brethine) 0.25 mg subcutaneously to stop her
labor contractions. Which assessment finding would provide the
nurse the earliest indication that the client is experiencing
primary side effects of terbutaline sulfate?
A. Drowsiness and bradycardia.
B. Depressed reflexes and increased respirations.
C. Tachycardia and a feeling of nervousness.
D. A flushed, warm feeling and a dry mouth. Correct Answer
C. Tachycardia and a feeling of nervousness.
Terbutaline sulfate (Brethine), a beta-sympathomimetic drug
which stimulates beta-adrenergic receptors in the uterine muscle
to stop contractions. The beta-adrenergic agonist properties of
the drug may cause tachycardia, increased cardiac output,
restlessness, headache, and a feeling of "nervousness."
A 3-year-old is admitted to the pediatric unit after falling off a
bicycle. Which intervention should the nurse implement to assist
the child's adjustment to hospitalization?
A. Give detailed explanations of procedures.
B. Use terms of endearment to establish rapport.
C. Offer the child a choice when performing procedures.
D. Encourage the parents to go home and rest. Correct Answer
C. Offer the child a choice when performing procedures.
Altered daily schedules and loss of rituals are upsetting and
increase separation anxiety in toddlers and preschool-aged
children. The nurse's sensitivity to the needs and preferences of
a child can minimize the negative effects of hospitalization.
When possible, the nurse should offer the child a choice during
procedures to help the child gain self control and cooperation.
, A 32-year-old female client complains of severe abdominal pain
each month before her menstrual period, painful intercourse, and
painful defecation. Which additional history should the nurse
obtain that is consistent with the client's complaints?
A. Frequent urinary tract infections.
B. Inability to get pregnant.
C. Premenstrual syndrome.
D. Chronic use of laxatives. Correct Answer B) Inability to
get pregnant.
Dysmenorrhea, dyspareunia, and difficulty or painful defecation
are common symptoms of endometriosis, which is the abnormal
displacement of endometrial tissue in the dependent areas of the
pelvic peritoneum. A history of infertility (B) is another
common finding associated with endometriosis. Although (A, C,
and D) are common, nonspecific gynecological complaints, the
most common complaints of the client with endometriosis are
pain and infertility.
A 38-week primigravida who works as a secretary and sits at a
computer 8 hours each day tells the nurse that her feet have
begun to swell. Which instruction would be most effective in
preventing pooling of blood in the lower extremities?
A. Wear support stockings.
B. Reduce salt in her diet.
C. Move about every hour.
D. Avoid constrictive clothing. Correct Answer C. Move
about every hour.
