HESI HEaltH aSSESSmEnt
nIgHtIngalE CollEgE
PRaCtICE EXam QUEStIonS WItH
CoRRECt DEtaIlED anSWERS |
alREaDY gRaDED a+<RECEnt
vERSIon>
1. SOAP modified format - ANSWER Subjective
Objective
Assessment
Plan
2. What colour ink should be used when documenting on paper - ANSWER Permanent black
ink
3. What is the correct order for vital signs - ANSWER T, P, RR, BP, extremity, pt position, SPO2
4. What should be at the top of every page of documentation - ANSWER Patient initials and
date and time of entry
5. What should be at the end of every documentation entry - ANSWER Interviewers
signature
6. How do you correct a mistake in documentation - ANSWER 1) Draw a single line through
the incorrect documentation
2) Write error above the entry
3) Initial and date the crossed out entry
7. Documentation tips - ANSWER 1) Avoid complete sentences
2) Do not use A, an, the
3) Do not put opinion in notes
, 4) Avoid use of normal or within normal limits
8. Normal oral temp range - ANSWER 96.4 - 99.1 F
9. Febrile - ANSWER With fever
10. Afebrile - ANSWER Without fever
11. Hyperthermia symptoms - ANSWER 1) Cessation of shivering
2) Bradycardia
3) Decrease in respiratory minute volume
12. Most common and easy method of assessing temperature - ANSWER Oral
13. The RN is caring for an older client who has been bedridden for 2 weeks. What assessment
finding indicates that the client is developing a complication related to mobility? -
ANSWER Stiffness in joints is an early sign of contractures and muscle atrophy related to
inactivity and immobility.
14. The RN is developing a plan of care for a client who is admitted for alcohol detoxification.
Which goal should be most important for the RN to primarily focus the client's care?
A. The client maintains optimal nutritional status.
B. The client will remain alert and oriented.
C. The client will remain free from injury.
D. The client will remain alcohol free during hospitalization. - ANSWER The client is
at highest risk for injury due to altered cognitive and sensory disturbances as well as
tremors during withdrawal. Remaining free from injury (C) is the most important
goal for the acute phase of alcohol withdrawal. (A, B, and D) are important goals to
obtain during the client's stay but not the priority during the acute phase of
withdrawal from alcohol.
15. What action should the RN implement to complete an assessment for a client while using an
interpreter? - ANSWER When completing an assessment, the RN should maintain eye
contact with the client to gather additional information from the client's non-verbal cues.
16. The RN is caring for a client with aplastic anaemia who is hospitalized for weight loss and
generalized weakness. Lab values show a white blood count (WBC) of 2,500/mm3 and a
, platelet count of 160,000/mm3. Which intervention is the primary focus in the client's plan
of care for the RN to implement?
A. Assist with frequent ambulation.
B. Encourage visitors to visit.
C. Maintain strict protective precautions.
D. Avoid peripheral injections. - ANSWER The client should be under strict
protective transmission precautions (C) b/c the WBC values are low, and the client is
at high risk for infection. Assisting the client w/ ambulation (A) should be limited to
the protective environment. Encouraging visitors to visit (B) expose the client to
possible infection and should include visitors to follow the plan of care that includes
protective transmission precautions. The client's platelet count is within normal limit
(D), avoiding peripheral injections are not needed at this time.
17. What info is most important for the RN to assess when reviewing the new prescription,
phenelzine, a monoamine oxidase inhibitor (MAOI), for a client on the psychiatric unit w/
depression? - ANSWER All alcohol and any foods that contain tyramine should be avoided
while taking an MAO inhibitor, which interact to cause a hypertensive crisis.
18. The RN is caring for a client with acute pancreatitis and assesses the admission lab results.
What lab value should the RN anticipate being elevated w/ this diagnosis? - ANSWER
Amylase. An elevated amylase level is associated w/ acute pancreatitis.
19. The RN is assessing a male client who arrives at the client w/ severe abdominal cramping,
pain, tenesmus, and dehydration. The RN discovers that the client has had 14 to 20 loose
stools w/ rectal bleeding. What condition should the RN ask the client about his medical hx?
- ANSWER The RN should ask the client if he has a hx of Ulcerative colitis, which is
characterized by these presenting symptoms.
20. Ulcerative colitis - ANSWER Sx: severe abdominal cramping, pain, tenesmus, and
dehydration. Lots of loose stools w/ rectal bleeding
21. Irritable bowel syndrome - ANSWER often includes irregular bowel movements w/
constipation, bowel irregularity, and cramping.
22. Crohn's disease - ANSWER can cause constipation or diarrhea, abscess formation, and
abdominal cramping, but tenesmus is rare
23. The RN is caring for an Asian client who refuses to make eye contact during conversations.
How should the RN assess this client's response? - ANSWER In some Asian cultures, it is
, not appropriate to look a person of authority in the eyes, so the client is being respectful by
looking down while speaking to the nurse.
24. What methods of assessing temperature reflects core temperature - ANSWER 1) Oral
2) Rectal
3) Tympanic
4) Temporal Artery
25. What is the least accurate method of assessing temperature - ANSWER axillary
26. Which patients are contraindicated for rectal temperature readings - ANSWER Patients
with increased HR
27. Anasarca - ANSWER heart failure, organ failure
28. Nevi acronym - ANSWER ABCDE
29. ABCDE - ANSWER A - Asymmetry
B - Border irregularity
C - Color non uniform
D - Diameter greater than 6 mm
E - Evolving size and shape
30. Basal Cell Carcinoma - ANSWER - most common form of skin cancer
- Basal layer of epidermis
- Deeply pigmented, central red ulcer, pearly edges-may look like an open
pore (face, ears and neck, scalp shoulders are common sites)
- Warning signs
1) Open sore
2) Bleeding
3) Wont heal
4) Older age
5) Toxin exposure
6) Repeated trauma
31. Squamous cell - ANSWER - Less common
- Grows rapidly
- Central ulcer with surrounding erythema
nIgHtIngalE CollEgE
PRaCtICE EXam QUEStIonS WItH
CoRRECt DEtaIlED anSWERS |
alREaDY gRaDED a+<RECEnt
vERSIon>
1. SOAP modified format - ANSWER Subjective
Objective
Assessment
Plan
2. What colour ink should be used when documenting on paper - ANSWER Permanent black
ink
3. What is the correct order for vital signs - ANSWER T, P, RR, BP, extremity, pt position, SPO2
4. What should be at the top of every page of documentation - ANSWER Patient initials and
date and time of entry
5. What should be at the end of every documentation entry - ANSWER Interviewers
signature
6. How do you correct a mistake in documentation - ANSWER 1) Draw a single line through
the incorrect documentation
2) Write error above the entry
3) Initial and date the crossed out entry
7. Documentation tips - ANSWER 1) Avoid complete sentences
2) Do not use A, an, the
3) Do not put opinion in notes
, 4) Avoid use of normal or within normal limits
8. Normal oral temp range - ANSWER 96.4 - 99.1 F
9. Febrile - ANSWER With fever
10. Afebrile - ANSWER Without fever
11. Hyperthermia symptoms - ANSWER 1) Cessation of shivering
2) Bradycardia
3) Decrease in respiratory minute volume
12. Most common and easy method of assessing temperature - ANSWER Oral
13. The RN is caring for an older client who has been bedridden for 2 weeks. What assessment
finding indicates that the client is developing a complication related to mobility? -
ANSWER Stiffness in joints is an early sign of contractures and muscle atrophy related to
inactivity and immobility.
14. The RN is developing a plan of care for a client who is admitted for alcohol detoxification.
Which goal should be most important for the RN to primarily focus the client's care?
A. The client maintains optimal nutritional status.
B. The client will remain alert and oriented.
C. The client will remain free from injury.
D. The client will remain alcohol free during hospitalization. - ANSWER The client is
at highest risk for injury due to altered cognitive and sensory disturbances as well as
tremors during withdrawal. Remaining free from injury (C) is the most important
goal for the acute phase of alcohol withdrawal. (A, B, and D) are important goals to
obtain during the client's stay but not the priority during the acute phase of
withdrawal from alcohol.
15. What action should the RN implement to complete an assessment for a client while using an
interpreter? - ANSWER When completing an assessment, the RN should maintain eye
contact with the client to gather additional information from the client's non-verbal cues.
16. The RN is caring for a client with aplastic anaemia who is hospitalized for weight loss and
generalized weakness. Lab values show a white blood count (WBC) of 2,500/mm3 and a
, platelet count of 160,000/mm3. Which intervention is the primary focus in the client's plan
of care for the RN to implement?
A. Assist with frequent ambulation.
B. Encourage visitors to visit.
C. Maintain strict protective precautions.
D. Avoid peripheral injections. - ANSWER The client should be under strict
protective transmission precautions (C) b/c the WBC values are low, and the client is
at high risk for infection. Assisting the client w/ ambulation (A) should be limited to
the protective environment. Encouraging visitors to visit (B) expose the client to
possible infection and should include visitors to follow the plan of care that includes
protective transmission precautions. The client's platelet count is within normal limit
(D), avoiding peripheral injections are not needed at this time.
17. What info is most important for the RN to assess when reviewing the new prescription,
phenelzine, a monoamine oxidase inhibitor (MAOI), for a client on the psychiatric unit w/
depression? - ANSWER All alcohol and any foods that contain tyramine should be avoided
while taking an MAO inhibitor, which interact to cause a hypertensive crisis.
18. The RN is caring for a client with acute pancreatitis and assesses the admission lab results.
What lab value should the RN anticipate being elevated w/ this diagnosis? - ANSWER
Amylase. An elevated amylase level is associated w/ acute pancreatitis.
19. The RN is assessing a male client who arrives at the client w/ severe abdominal cramping,
pain, tenesmus, and dehydration. The RN discovers that the client has had 14 to 20 loose
stools w/ rectal bleeding. What condition should the RN ask the client about his medical hx?
- ANSWER The RN should ask the client if he has a hx of Ulcerative colitis, which is
characterized by these presenting symptoms.
20. Ulcerative colitis - ANSWER Sx: severe abdominal cramping, pain, tenesmus, and
dehydration. Lots of loose stools w/ rectal bleeding
21. Irritable bowel syndrome - ANSWER often includes irregular bowel movements w/
constipation, bowel irregularity, and cramping.
22. Crohn's disease - ANSWER can cause constipation or diarrhea, abscess formation, and
abdominal cramping, but tenesmus is rare
23. The RN is caring for an Asian client who refuses to make eye contact during conversations.
How should the RN assess this client's response? - ANSWER In some Asian cultures, it is
, not appropriate to look a person of authority in the eyes, so the client is being respectful by
looking down while speaking to the nurse.
24. What methods of assessing temperature reflects core temperature - ANSWER 1) Oral
2) Rectal
3) Tympanic
4) Temporal Artery
25. What is the least accurate method of assessing temperature - ANSWER axillary
26. Which patients are contraindicated for rectal temperature readings - ANSWER Patients
with increased HR
27. Anasarca - ANSWER heart failure, organ failure
28. Nevi acronym - ANSWER ABCDE
29. ABCDE - ANSWER A - Asymmetry
B - Border irregularity
C - Color non uniform
D - Diameter greater than 6 mm
E - Evolving size and shape
30. Basal Cell Carcinoma - ANSWER - most common form of skin cancer
- Basal layer of epidermis
- Deeply pigmented, central red ulcer, pearly edges-may look like an open
pore (face, ears and neck, scalp shoulders are common sites)
- Warning signs
1) Open sore
2) Bleeding
3) Wont heal
4) Older age
5) Toxin exposure
6) Repeated trauma
31. Squamous cell - ANSWER - Less common
- Grows rapidly
- Central ulcer with surrounding erythema
