4
hesi inet version 5 EXAM TEST BANK WITH ALL
VERSIONS OF THE EXAM WITH ALLMODULES
COVERED | ACCURATE AND VERIFIED
QUESTIONS AND ANSWERS FOR GUARANTEED
PASS| LATEST UPDATE
A 4-year-old girl returns to the pediatrician's office for a postoperative visit following
hospitalization for minor surgery.. When observing the child in the waiting area, which
behavior should the nurse consider normal for this age child?
a.. Draws picture of self with facial features.
b.. "Talks" to an imaginary friend.
c.. Sits quietly in her mother's lap.
d.. Ignores other children in the play area.
b.. "talks" to an imaginary friend
Engaging with imaginary friends is a common and normal part of play for many children around
the age of 4.. It reflects their developing imagination and creativity.. It's a way for children to
explore their understanding of the world and express their thoughts and feelings.
A client who is an avid hiker expresses concern about losing too much potassium while
hiking.. In teaching the client to prepare potassium-rich snack mix the nurse should
encourage the client to include which items? (Select all that apply.)
a.. Dried apricots.
b.. Seedless raisins.
c.. Lightly salted peanuts.
d.. Dried bananas.
e.. Dried apples.
a.. Dried apricots.
b.. Seedless raisins.
d.. Dried bananas.
These items are good sources of potassium and can help replenish potassium lost through
sweating during hiking.. Lightly salted peanuts and dried apples are not particularly high in
potassium and may not be as effective for this purpose.
4
,4
The nurse notes that the influenza immunization rates are much lower for certain
demographic groups than for others.. Which intervention is likely to be most useful in
increasing the rates of immunization in these under-served immunization groups?
a.. Reports describing influenza rates during times of greatest prevalence.
b.. Designation of clinics conveniently located in target neighborhoods.
c.. Legislative proposals that mandate influenza vaccinations for all.
d.. Radio announcements about the availability of the influenza vaccine.
b.. Designation of clinics conveniently located in target neighborhoods.
By providing easy access to vaccination clinics in the communities where these demographic
groups reside, you can help overcome barriers such as transportation issues and make it more
convenient for individuals to receive the influenza vaccine.. This approach can lead to higher
immunization rates among under-served populations.
While inserting an indwelling urinary catheter into a client, the nurse observes urine flow in
the tubing.. Which action should be taken next?
a.. Inflate the balloon with 5 ml of sterile water.
b.. Document the color and clarity of the urine.
c.. Ask the client to breathe deeply and slowly exhale.
d.. Insert the catheter an additional inch.
d.. Insert the catheter an additional inch.
When urine is first noted in the catheter tubing, it indicates that the catheter tip has entered
the bladder.. However, the catheter should be advanced a bit further to ensure proper
placement before the balloon is inflated.. This helps to prevent injury to the bladder and
ensures the balloon is fully within the bladder when inflated.
A client who takes nonsteroidal antiinflammatory drugs (NSAIDs) every day for rheumatoid
arthrits Is being treated for anemia.. Which intervention is most important for the nurse to
include in the plan of care?
a.. Offer dietary selections rich in iron.
b.. Monitor liver function test results.
c.. Protect skin from bruising.
d.. Observe for gastrointestinal bleeding.
d.. Observe for gastrointestinal bleeding.
Clients taking NSAIDs are at an increased risk of gastrointestinal (GI) bleeding and ulcers, which
can lead to anemia.. Monitoring for signs of GI bleeding, such as melena (black, tarry stools) or
hematemesis (vomiting blood), is crucial.. This allows for early detection and intervention,
which can help prevent further complications and worsening of anemia.. While offering dietary
4
,4
selections rich in iron (Option a) is generally important for managing anemia, in this case,
addressing the potential GI bleeding takes precedence.. Monitoring liver function (Option b)
and protecting the skin from bruising (Option c) are not the primary concerns related to NSAID
use and anemia.
Which long-term outcome is most important for the nurse include in the plan of care for an
older adult client with chronic pyelonephritis?
a.. Maintains blood pressure within normal limits.
b.. Manages activities of daily living independently.
c.. Restricts fluid intake to 1 L/day.
d.. Measures oral temperature daily.
b.. Manages activities of daily living independently.
The most important long-term outcome for an older adult client with chronic pyelonephritis is
to maintain their ability to manage activities of daily living independently.. Chronic
pyelonephritis is a progressive condition that can lead to kidney damage, which may affect a
person's overall health and functional abilities.
A primigravida client being treated for preeclampsla with magneslum sulfate delivered a 7-
pound infant four hours ago by cesarean delivery.. Which nursing problem has the highest
priority?
a.. Impaired parenting related to inexperience.
b.. Acute pain related to abdominal incision.
c.. Risk for injury related to uterine atony.
d.. Ineffective breastfeeding related to fatigue.
c.. Risk for injury related to uterine atony.
The highest-priority nursing problem in this scenario is the risk for injury related to uterine
atony.. Uterine atony is a common complication after childbirth, especially in clients with a
history of preeclampsia.. Uterine atony can lead to excessive bleeding (postpartum
hemorrhage), which is a life-threatening condition.. Therefore, assessing and managing uterine
atony is of utmost importance to prevent severe complications.
A client is hospitalized with an inflammatory bowel disease (IBD) exacerbation and is being
treated with a corticosteroid.. The client develops a rigid abdomen with rebound
tenderness.. Which action should the nurse take?
a.. Obtain vital sign measurements.
b.. Measure capillary glucose level.
c.. Encourage ambulation in the room.
d.. Monitor for bloody diarrheal stools.
4
, 4
a.. obtain vital sign measurements
A rigid abdomen with rebound tenderness can be a sign of a serious complication, such as
perforation of the bowel.. This is a medical emergency that requires immediate attention.
Obtaining vital signs is a critical first step in assessing the client's overall status and identifying
any immediate life-threatening changes.. Changes in vital signs (such as increased heart rate,
decreased blood pressure) can indicate shock or severe internal distress.
When is it most important for the nurse to assess a pregnant client's deep tendon reflexes
(DTRS)?
a.. Within the first trimester of pregnancy.
b.. During admission to labor and delivery.
c.. When the client has ankle edema.
d.. If the client has an elevated blood pressure.
d.. If the client has an elevated blood pressure.
Deep tendon reflexes (DTRs) should be assessed if the client has an elevated blood pressure, as
this could be indicative of preeclampsia, a serious pregnancy complication.. Assessing DTRs can
help determine if there are neurological changes associated with elevated blood pressure, and it
is an important part of the evaluation for preeclampsia.. It is not typically assessed in routine
pregnancy care unless there is a specific indication like hypertension or other concerning
symptoms.
When preparing a client who is to undergo a resection of a leiomyosarcoma of the uterus, the
nurse notices that apixaban is listed on the medication reconciliation list.. Which assessment
finding requires immediate nursing intervention?
a.. Abdominal redness and itching.
b.. Nausea and dry mouth.
c.. Bleeding gums.
d.. Finger joint pain.
c.. Bleeding gums.
Apixaban is an anticoagulant medication, and bleeding gums can be a sign of abnormal bleeding
or an adverse effect of the medication.. It is important to assess for signs of bleeding and
monitor the client for any potential complications related to anticoagulant therapy.. If the client
is scheduled for surgery, the healthcare provider may need to adjust the medication regimen or
provide specific instructions regarding its use before the procedure.. The nurse should notify
the healthcare provider immediately regarding the bleeding gums to ensure appropriate
management.
In conducting a pain assessment of a client with osteoarthritis, which action should the nurse
include?
4
hesi inet version 5 EXAM TEST BANK WITH ALL
VERSIONS OF THE EXAM WITH ALLMODULES
COVERED | ACCURATE AND VERIFIED
QUESTIONS AND ANSWERS FOR GUARANTEED
PASS| LATEST UPDATE
A 4-year-old girl returns to the pediatrician's office for a postoperative visit following
hospitalization for minor surgery.. When observing the child in the waiting area, which
behavior should the nurse consider normal for this age child?
a.. Draws picture of self with facial features.
b.. "Talks" to an imaginary friend.
c.. Sits quietly in her mother's lap.
d.. Ignores other children in the play area.
b.. "talks" to an imaginary friend
Engaging with imaginary friends is a common and normal part of play for many children around
the age of 4.. It reflects their developing imagination and creativity.. It's a way for children to
explore their understanding of the world and express their thoughts and feelings.
A client who is an avid hiker expresses concern about losing too much potassium while
hiking.. In teaching the client to prepare potassium-rich snack mix the nurse should
encourage the client to include which items? (Select all that apply.)
a.. Dried apricots.
b.. Seedless raisins.
c.. Lightly salted peanuts.
d.. Dried bananas.
e.. Dried apples.
a.. Dried apricots.
b.. Seedless raisins.
d.. Dried bananas.
These items are good sources of potassium and can help replenish potassium lost through
sweating during hiking.. Lightly salted peanuts and dried apples are not particularly high in
potassium and may not be as effective for this purpose.
4
,4
The nurse notes that the influenza immunization rates are much lower for certain
demographic groups than for others.. Which intervention is likely to be most useful in
increasing the rates of immunization in these under-served immunization groups?
a.. Reports describing influenza rates during times of greatest prevalence.
b.. Designation of clinics conveniently located in target neighborhoods.
c.. Legislative proposals that mandate influenza vaccinations for all.
d.. Radio announcements about the availability of the influenza vaccine.
b.. Designation of clinics conveniently located in target neighborhoods.
By providing easy access to vaccination clinics in the communities where these demographic
groups reside, you can help overcome barriers such as transportation issues and make it more
convenient for individuals to receive the influenza vaccine.. This approach can lead to higher
immunization rates among under-served populations.
While inserting an indwelling urinary catheter into a client, the nurse observes urine flow in
the tubing.. Which action should be taken next?
a.. Inflate the balloon with 5 ml of sterile water.
b.. Document the color and clarity of the urine.
c.. Ask the client to breathe deeply and slowly exhale.
d.. Insert the catheter an additional inch.
d.. Insert the catheter an additional inch.
When urine is first noted in the catheter tubing, it indicates that the catheter tip has entered
the bladder.. However, the catheter should be advanced a bit further to ensure proper
placement before the balloon is inflated.. This helps to prevent injury to the bladder and
ensures the balloon is fully within the bladder when inflated.
A client who takes nonsteroidal antiinflammatory drugs (NSAIDs) every day for rheumatoid
arthrits Is being treated for anemia.. Which intervention is most important for the nurse to
include in the plan of care?
a.. Offer dietary selections rich in iron.
b.. Monitor liver function test results.
c.. Protect skin from bruising.
d.. Observe for gastrointestinal bleeding.
d.. Observe for gastrointestinal bleeding.
Clients taking NSAIDs are at an increased risk of gastrointestinal (GI) bleeding and ulcers, which
can lead to anemia.. Monitoring for signs of GI bleeding, such as melena (black, tarry stools) or
hematemesis (vomiting blood), is crucial.. This allows for early detection and intervention,
which can help prevent further complications and worsening of anemia.. While offering dietary
4
,4
selections rich in iron (Option a) is generally important for managing anemia, in this case,
addressing the potential GI bleeding takes precedence.. Monitoring liver function (Option b)
and protecting the skin from bruising (Option c) are not the primary concerns related to NSAID
use and anemia.
Which long-term outcome is most important for the nurse include in the plan of care for an
older adult client with chronic pyelonephritis?
a.. Maintains blood pressure within normal limits.
b.. Manages activities of daily living independently.
c.. Restricts fluid intake to 1 L/day.
d.. Measures oral temperature daily.
b.. Manages activities of daily living independently.
The most important long-term outcome for an older adult client with chronic pyelonephritis is
to maintain their ability to manage activities of daily living independently.. Chronic
pyelonephritis is a progressive condition that can lead to kidney damage, which may affect a
person's overall health and functional abilities.
A primigravida client being treated for preeclampsla with magneslum sulfate delivered a 7-
pound infant four hours ago by cesarean delivery.. Which nursing problem has the highest
priority?
a.. Impaired parenting related to inexperience.
b.. Acute pain related to abdominal incision.
c.. Risk for injury related to uterine atony.
d.. Ineffective breastfeeding related to fatigue.
c.. Risk for injury related to uterine atony.
The highest-priority nursing problem in this scenario is the risk for injury related to uterine
atony.. Uterine atony is a common complication after childbirth, especially in clients with a
history of preeclampsia.. Uterine atony can lead to excessive bleeding (postpartum
hemorrhage), which is a life-threatening condition.. Therefore, assessing and managing uterine
atony is of utmost importance to prevent severe complications.
A client is hospitalized with an inflammatory bowel disease (IBD) exacerbation and is being
treated with a corticosteroid.. The client develops a rigid abdomen with rebound
tenderness.. Which action should the nurse take?
a.. Obtain vital sign measurements.
b.. Measure capillary glucose level.
c.. Encourage ambulation in the room.
d.. Monitor for bloody diarrheal stools.
4
, 4
a.. obtain vital sign measurements
A rigid abdomen with rebound tenderness can be a sign of a serious complication, such as
perforation of the bowel.. This is a medical emergency that requires immediate attention.
Obtaining vital signs is a critical first step in assessing the client's overall status and identifying
any immediate life-threatening changes.. Changes in vital signs (such as increased heart rate,
decreased blood pressure) can indicate shock or severe internal distress.
When is it most important for the nurse to assess a pregnant client's deep tendon reflexes
(DTRS)?
a.. Within the first trimester of pregnancy.
b.. During admission to labor and delivery.
c.. When the client has ankle edema.
d.. If the client has an elevated blood pressure.
d.. If the client has an elevated blood pressure.
Deep tendon reflexes (DTRs) should be assessed if the client has an elevated blood pressure, as
this could be indicative of preeclampsia, a serious pregnancy complication.. Assessing DTRs can
help determine if there are neurological changes associated with elevated blood pressure, and it
is an important part of the evaluation for preeclampsia.. It is not typically assessed in routine
pregnancy care unless there is a specific indication like hypertension or other concerning
symptoms.
When preparing a client who is to undergo a resection of a leiomyosarcoma of the uterus, the
nurse notices that apixaban is listed on the medication reconciliation list.. Which assessment
finding requires immediate nursing intervention?
a.. Abdominal redness and itching.
b.. Nausea and dry mouth.
c.. Bleeding gums.
d.. Finger joint pain.
c.. Bleeding gums.
Apixaban is an anticoagulant medication, and bleeding gums can be a sign of abnormal bleeding
or an adverse effect of the medication.. It is important to assess for signs of bleeding and
monitor the client for any potential complications related to anticoagulant therapy.. If the client
is scheduled for surgery, the healthcare provider may need to adjust the medication regimen or
provide specific instructions regarding its use before the procedure.. The nurse should notify
the healthcare provider immediately regarding the bleeding gums to ensure appropriate
management.
In conducting a pain assessment of a client with osteoarthritis, which action should the nurse
include?
4
