HESI Examination

Question 87

HESI Examination. The nurse is caring for a school-age child with asthma who is exhibiting decreased breath sounds, nasal flaring, and a respiratory rate of 40 breaths/minute. Which action(s) should the nurse take? Select all that apply.

• A Provide humidified oxygen.
• B Administer prescribed breathing treatment.
• C Monitor pulse oximetry.
• D Perform oral suctioning.
• E Start intravenous infusion access.

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Question 88

The nurse applies a blood pressure cuff around a client’s left thigh. To measure the client’s blood pressure, where should the diaphragm of the stethoscope be placed? (Mark the location on one of the images.)

• The popliteal artery (located in the popliteal fossa/crease behind the left knee).

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Question 89

When preparing to administer an intravenous medication through a client’s triple lumen central venous catheter, the nurse observes that there are no continuous intravenous fluids infusing. Which action should the nurse take?

• A Initiate an infusion of 0.9% normal saline solution.
• B Prepare a saline flush in a three mL syringe.
• C Position the client’s head facing away from the site.
• D Aspirate for the presence of a blood return.

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Question 90

A school-age child newly diagnosed with celiac disease is ordering a food tray. Which food item(s) should the nurse list as acceptable options for the child’s diet? Select all that apply.

• A Mashed potatoes.
• B Milk.
• C Chicken.
• D Wheat bread.
• E Gravy.
• F Corn.

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Question 91

A client on the mental health unit has been scowling and rapidly pacing up and down the hall for several minutes. Which behaviors are most important for the nurse to monitor?

• A Argumentativeness and use of profanity.
• B Repeated requests for attention from the nurse.
• C Periodic sighing and shaking the head.
• D Decreased activity level and change in affect.

Question 112

The nurse is caring for a client who tests positive for gonorrhea. The client reports having had prior sexually transmitted infections (STIs). Which response should the nurse provide?

• A Clarify that all STIs are transmitted through sexual intercourse.
• B Provide counseling that most contraceptives protect against infection.
• C Urge the client to have regular STI screening every two years.
• D Answer questions directly and correct any misinformation.

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Question 113

A mother brings her 3-year-old child to the clinic because pus is draining from the ear canal. The healthcare provider prescribes otic and systemic antibiotics. Which instruction(s) should the nurse provide the mother about the child’s home care? Select all that apply. HESI Examination

• A Remove exudate from the external ear canal before instilling otic drops.
• B Instill warmed sterile water into ear canal for cleansing.
• C Palpate around the ear and report unresolved pain.
• D Visualize the child’s ear with a flashlight for drainage daily.
• E Give acetaminophen liquid every 4 hours PRN for pain or fever.

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Question 114

A client is receiving a secondary infusion of azithromycin 500 mg in 500 mL of normal saline (NS) to be infused over 2 hours. The IV administration set delivers 20 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

• 83

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Question 115

The nurse provides sliding scale insulin administration instructions to an adult who was recently diagnosed with diabetes mellitus. The client demonstrates an understanding of the instructions provided by performing the procedure in which order? (Arrange with the first on top and the last on the bottom.)¹

1. Verify th²e insulin prescription.
2. Obtain blood glucose level.
3. Draw insulin into insulin syringe.
4. Cleanse the selected site.

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Question 116

To evaluate the effectiveness of a male client’s new prescription for ezetimibe, which action should the clinic nurse implement?

• A Teach the client to weigh himself weekly and keep a log of the measurements.
• B Remind the client to keep his appointments to have his cholesterol level checked.
• C Encourage the client to keep a diary of his food intake until his next visit to the clinic.
• D Assess the elasticity of the client’s skin at the next scheduled clinic appointment.

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Question 117

While caring for a client after a small bowel resection, the nurse is informed that the client has a history of methicillin-resistant Staphylococcus aureus (MRSA). To reduce the risk of recurrence of the MRSA in the postoperative wound, wh³ich intervention is most important for the nurse to implement?

• A Report any increase in the white blood cell count.
• B Wear a face mask while performing wound care.
• C Instruct the family to adhere to contact precautions.
• D Change the surgical dressing when soiled.

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Question 118

The nurse listens for heart sounds by firmly pressing the diaphragm of the stethoscope against the client’s chest. After hearing $S_1$ and $S_2$, which action should the nurse take to detect extra heart sounds?

• A Rotate the end piece of the stethoscope.
• B Adjust the earpieces of the stethoscope.
• C Continue to hold the stethoscope firmly in place with one hand.
• D Decrease the amount of pressure used to hold the stethoscope. HESI Examination

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Question 119

The nurse notes that a client who is unconscious, is experiencing wide fluctuations in body temperature. The nurse suspects disease or injury to which part of the body?

• A Adrenal gland.
• B Hypothalamus.
• C Pituitary.
• D Thermal skin receptors.

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Question 120

The nurse is assisting the healthcare provider with a thoracentesis for a client who has emphysema. Which equipment should the nurse have at the bedside in the event the procedure is ineffective?

• A Crash cart.
• B Ventilator.
• C Chest tube insertion tray.
• D Intubation tray.

Question 121

The nurse notes that a client with depression has been more withdrawn and non-communicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client? HESI Examination

• Engage the client in non-threatening conversations.
• Encourage the client to participate in group activities.
• Encourage the client’s family to visit more often.
• Schedule a daily conference with the social worker.

Question 122

The nurse is performing an admission assessment for a newborn who has asymmetrical buttocks. Which assessment test results should the nurse report to the healthcare provider?

• A. Babinski test that reveals fanning out of toes.
• B. Moro test precipitating a startle response.
• C. Plumb line test indicates fetal position curvature.
• D. Ortolani maneuver causing a click at the hip joint.

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Question 123

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.

Potential Condition:

• Bacterial conjunctivitis

Actions to Take:

• Initiate antibiotic drops
• Educate on infection control measures

Parameters to Monitor:

• Eye drainage
• Visual acuity

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Question 124

When the parents of a 6-year-old boy with a brain tumor are told that his condition is terminal, the mother shouts at the father, “This is your fault! It never would have happened if we had sought treatment sooner!” Which intervention is best for the nurse to implement?

• A. Refer the parents to the chaplain to provide grief counseling.
• B. Assure the parents that a terminal diagnosis was inevitable.
• C. Explain to the parents that anger is a common response to grief.
• D. Tell the parents that blaming each other will not change the situation. HESI Examination

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Question 125

The home health nurse is returning to visit a client with type 2 diabetes mellitus (DM) who lives alone and receives treatment for diabetic retinopathy. Which data is most important for the nurse to review in the assessment?

• A. Hemoglobin A1C.
• B. Fasting blood glucose.
• C. Weight.
• D. Blood lipid level.

Question 126

A client in labor begins bleeding profusely from the vagina. Which findings should the nurse report to the healthcare provider?

• A. Sharp fundal pain and uterine tenderness
• B. Increase in pulse and fetal rate reactivity
• C. Mild discomfort and elevated blood pressure
• D. Pain in lower quadrant and oliguria

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Question 127

A client who experiences recurrent episodes of depression tells the nurse of a desire to discontinue the prescribed antidepressant. The client describes feeling less depressed after taking the medication for the past couple of weeks and the client does not like the side effects of the medication. Which response is best for the nurse to provide?

• A. Remind the client that the medication’s therapeutic effect takes several weeks.
• B. Encourage the client to discuss the medication’s side effects with the healthcare provider.
• C. Reassure the client that the side effects will dissipate after taking the medication for a longer period.
• D. Inform the client that gradual tapering must be used to discontinue the medication.

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Question 128

The nurse is preparing an adult with Addison’s disease for self-management. Which information should the nurse include in the client’s instructions? HESI Examination

• A. Record daily weights.
• B. Maintain a high fiber, low fat diet.
• C. Check the client’s temperature daily.
• D. Events requiring steroid dose adjustments.