HESI 700 | QUESTIONS AND ANSWERS
Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will drink
plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best follow-
up action by the nurse? ** Answers ** Review with the client the need to avoid foods that are
rich in milk and cream
A male client with hypertension, who received new antihypertensive prescriptions at his last visit
returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and
he admits that he has not been taking the prescribed medication because the drugs make him
"feel bad". In explaining the need for hypertension control, the nurse should stress that an
elevated BP places the client at risk for which pathophysiological condition? ** Answers **
Stroke secondary to hemorrhage
The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client
who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the
side rails. What action should the nurse implement? ** Answers ** Instruct the UAP to obtain
soft blankets to secure to the side rails instead of pillows
An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past
12 days. Which assessment finding requires immediate follow-up ** Answers ** Describes
life without purpose
A 60-year-old female client with a positive family history of ovarian cancer has developed an
abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear
results are negative. What information should the nurse include in the client's teaching plan **
Answers ** Further evaluation involving surgery may be needed
A client who recently underwent a tracheostomy is being prepared for discharge to home. Which
instructions is most important for the nurse to include in the discharge plan? ** Answers **
Teach tracheal suctioning techniques
,In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen
reservoir bag does not deflate completely during inspiration and the client's respiratory rate is 14
breaths / minute. What action should the nurse implement ** Answers ** Document the
assessment data
Rational: reservoir bag should not deflate completely during inspiration and the client's
respiratory rate is within normal limits.
During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client
alarm should the nurse investigate first? ** Answers ** Respiratory apnea of 30 seconds
During a home visit, the nurse observed an elderly client with diabetes slip and fall. What action
should the nurse take first? ** Answers ** Check the client for lacerations or fractures
At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section), the client
tells the nurse that she drank a cup a coffee at 0400 because she wanted to avoid getting a
headache. Which action should the nurse take first? ** Answers ** Inform the anesthesia care
provider
After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds.
To determine if an S3 heart sound is present, what action should the nurse take first **
Answers ** Listen with the bell at the same location
A 66-year-old woman is retiring and will no longer have a health insurance through her place of
employment. Which agency should the client be referred to by the employee health nurse for
health insurance needs? ** Answers ** Medicare
A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset. What
snack should the nurse instruct the client to take with the tetracycline? ** Answers ** Toasted
wheat bread and jelly
Following a lumbar puncture, a client voices several complaints. What complaint indicated to the
nurse that the client is experiencing a complication? ** Answers ** "I have a headache that
gets worse when I sit up"
,An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with
incontinence. Which action should the nurse implement ** Answers ** Obtain a clean catch
mid-stream specimen
The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are
in keeping with the child's dietary restrictions. Which foods are contraindicated for this child?
** Answers ** Foods sweetened with aspartame
Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the
circulating nurse if a 3 minute surgical hand scrub is adequate preparation for this client. Which
response should the circulating nurse provide? ** Answers ** Direct the nurse to continue the
surgical hand scrub for a 5 minute duration
Which breakfast selection indicates that the client understands the nurse's instructions about the
dietary management of osteoporosis? ** Answers ** Bagel with jelly and skim milk
The charge nurse of a critical care unit is informed at the beginning of the shift that less than the
optimal number of registered nurses will be working that shift. In planning assignments, which
client should receive the most care hours by a registered nurse (RN) ** Answers ** An 82-
year-old client with Alzheimer's disease newly-fractures femur who has a Foley catheter and soft
wrist restrains applied
A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician's
office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the
bottom of the child's foot. Which action should the nurse implement first? ** Answers **
Cleanse the foot with soap and water and apply an antibiotic ointment
The mother of an adolescent tells the clinic nurse, "My son has athlete's foot, I have been
applying triple antibiotic ointment for two days, but there has been no improvement." What
instruction should the nurse provide? ** Answers ** Stop using the ointment and encourage
complete drying of the feet and wearing clean socks.
, A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and
levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the
prescribed dosage is too high for this client? The client experiences ** Answers **
Palpitations and shortness of breath
A client with a history of heart failure presents to the clinic with a nausea, vomiting, yellow
vision and palpitations. Which finding is most important for the nurse to assess to the client?
** Answers ** Obtain a list of medications taken for cardiac history
The healthcare provider prescribes an IV solution of isoproterenol (Isuprel) 1 mg in 250 ml of
D5W at 300 mcg/hour. The nurse should program the infusion pump to deliver how many
ml/hour? (Enter numeric value only.) ** Answers ** 75
Rationale: Convert mg to mcg and use the formula D/H x Q. 300 mcg/hour / 1,000 mcg x 250 ml
= 3/1 x 25 = 75 ml/hour
The pathophysiological mechanism are responsible for ascites related to liver failure? (Select all
that apply) ** Answers ** -Fluid shifts from intravascular to interstitial area due to decreased
serum protein
-Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen
-Increased circulating aldosterone levels that increase sodium and water retention
The nurse is auscultating a client's heart sounds. Which description should the nurse use to
document this sound? (Please listen to the audio first to select the option that applies) **
Answers ** Murmur
The healthcare provider prescribes celtazidime (Fortax) 35 mg every 8 hours IM for an infant.
The 500 mg vial is labeled with the instruction to add 5.3 ml diluent to provide a concentration
of 100 mg/ml. How many ml should the nurse administered for each dose? (Enter numeric value
only. If rounding is required, round to the nearest tenth ** Answers ** 0.4
rationale: 35mg/100mg x 1 = 0.35 = 0.4 ml
Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will drink
plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best follow-
up action by the nurse? ** Answers ** Review with the client the need to avoid foods that are
rich in milk and cream
A male client with hypertension, who received new antihypertensive prescriptions at his last visit
returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and
he admits that he has not been taking the prescribed medication because the drugs make him
"feel bad". In explaining the need for hypertension control, the nurse should stress that an
elevated BP places the client at risk for which pathophysiological condition? ** Answers **
Stroke secondary to hemorrhage
The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client
who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the
side rails. What action should the nurse implement? ** Answers ** Instruct the UAP to obtain
soft blankets to secure to the side rails instead of pillows
An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past
12 days. Which assessment finding requires immediate follow-up ** Answers ** Describes
life without purpose
A 60-year-old female client with a positive family history of ovarian cancer has developed an
abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear
results are negative. What information should the nurse include in the client's teaching plan **
Answers ** Further evaluation involving surgery may be needed
A client who recently underwent a tracheostomy is being prepared for discharge to home. Which
instructions is most important for the nurse to include in the discharge plan? ** Answers **
Teach tracheal suctioning techniques
,In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen
reservoir bag does not deflate completely during inspiration and the client's respiratory rate is 14
breaths / minute. What action should the nurse implement ** Answers ** Document the
assessment data
Rational: reservoir bag should not deflate completely during inspiration and the client's
respiratory rate is within normal limits.
During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client
alarm should the nurse investigate first? ** Answers ** Respiratory apnea of 30 seconds
During a home visit, the nurse observed an elderly client with diabetes slip and fall. What action
should the nurse take first? ** Answers ** Check the client for lacerations or fractures
At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section), the client
tells the nurse that she drank a cup a coffee at 0400 because she wanted to avoid getting a
headache. Which action should the nurse take first? ** Answers ** Inform the anesthesia care
provider
After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds.
To determine if an S3 heart sound is present, what action should the nurse take first **
Answers ** Listen with the bell at the same location
A 66-year-old woman is retiring and will no longer have a health insurance through her place of
employment. Which agency should the client be referred to by the employee health nurse for
health insurance needs? ** Answers ** Medicare
A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset. What
snack should the nurse instruct the client to take with the tetracycline? ** Answers ** Toasted
wheat bread and jelly
Following a lumbar puncture, a client voices several complaints. What complaint indicated to the
nurse that the client is experiencing a complication? ** Answers ** "I have a headache that
gets worse when I sit up"
,An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with
incontinence. Which action should the nurse implement ** Answers ** Obtain a clean catch
mid-stream specimen
The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are
in keeping with the child's dietary restrictions. Which foods are contraindicated for this child?
** Answers ** Foods sweetened with aspartame
Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the
circulating nurse if a 3 minute surgical hand scrub is adequate preparation for this client. Which
response should the circulating nurse provide? ** Answers ** Direct the nurse to continue the
surgical hand scrub for a 5 minute duration
Which breakfast selection indicates that the client understands the nurse's instructions about the
dietary management of osteoporosis? ** Answers ** Bagel with jelly and skim milk
The charge nurse of a critical care unit is informed at the beginning of the shift that less than the
optimal number of registered nurses will be working that shift. In planning assignments, which
client should receive the most care hours by a registered nurse (RN) ** Answers ** An 82-
year-old client with Alzheimer's disease newly-fractures femur who has a Foley catheter and soft
wrist restrains applied
A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician's
office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the
bottom of the child's foot. Which action should the nurse implement first? ** Answers **
Cleanse the foot with soap and water and apply an antibiotic ointment
The mother of an adolescent tells the clinic nurse, "My son has athlete's foot, I have been
applying triple antibiotic ointment for two days, but there has been no improvement." What
instruction should the nurse provide? ** Answers ** Stop using the ointment and encourage
complete drying of the feet and wearing clean socks.
, A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and
levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the
prescribed dosage is too high for this client? The client experiences ** Answers **
Palpitations and shortness of breath
A client with a history of heart failure presents to the clinic with a nausea, vomiting, yellow
vision and palpitations. Which finding is most important for the nurse to assess to the client?
** Answers ** Obtain a list of medications taken for cardiac history
The healthcare provider prescribes an IV solution of isoproterenol (Isuprel) 1 mg in 250 ml of
D5W at 300 mcg/hour. The nurse should program the infusion pump to deliver how many
ml/hour? (Enter numeric value only.) ** Answers ** 75
Rationale: Convert mg to mcg and use the formula D/H x Q. 300 mcg/hour / 1,000 mcg x 250 ml
= 3/1 x 25 = 75 ml/hour
The pathophysiological mechanism are responsible for ascites related to liver failure? (Select all
that apply) ** Answers ** -Fluid shifts from intravascular to interstitial area due to decreased
serum protein
-Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen
-Increased circulating aldosterone levels that increase sodium and water retention
The nurse is auscultating a client's heart sounds. Which description should the nurse use to
document this sound? (Please listen to the audio first to select the option that applies) **
Answers ** Murmur
The healthcare provider prescribes celtazidime (Fortax) 35 mg every 8 hours IM for an infant.
The 500 mg vial is labeled with the instruction to add 5.3 ml diluent to provide a concentration
of 100 mg/ml. How many ml should the nurse administered for each dose? (Enter numeric value
only. If rounding is required, round to the nearest tenth ** Answers ** 0.4
rationale: 35mg/100mg x 1 = 0.35 = 0.4 ml
