HESI V1EXAM QUESTIONS AND
ANSWERS
While assessing a client with diabetes mellitus, the nurse observes an absence of
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hair growth on the client's legs. What additional assessment provides further data t
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o support this finding?
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a. Palpate for the presence of femoral pulses bilaterally.
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b. Assess for the presence of a positive Homan's sign.
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c. Observe the appearance of the skin on the client's legs.
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d. Watch the client's posture and balance during ambulation. - ANS: C
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Signs of chronic arterial insufficiency include decreased hair growth in the legs and
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feet, absent or decreased pedal pulses, infection in the foot, poor wound healing,
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thickened nails, and a shiny appearance of the skin (C). Femoral pulses (A) should
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still be palpable in the diabetic with chronic arterial insufficiency. A positive Homa
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n's sign is an indicator of deep vein thrombosis (B). (D) would probably not be affe
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cted significantly by chronic arterial insufficiency.
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The healthcare provider prescribes 15 mg/
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kg of Streptomycin for an infant weighing 4 pounds. The drug is diluted in 25 ml of
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D5W to run over 8 hours. How much Streptomycin will the infant receive?
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a. 9 mg.
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b. 18 mg.
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c. 27 mg.
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d. 36 mg. - ANS: C
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4 lbs /
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2.2 = 1.8 kg. 1.8 x 15 = 27 mg (C). NOTE, the fact that the drug is diluted in 25
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ml of D5W, is not relevant to the calculation requested.
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In assessing a client with preeclampsia who is receiving magnesium sulfate, the nu
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rse determines that her deep tendon reflexes are 1+; respiratory rate is 12 breaths/
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minute; urinary output is 90 ml in 4 hours; magnesium sulfate level is 9 mg/
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dl. Based on these findings, what intervention should the nurse implement?
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a. Continue the magnesium sulfate infusion as prescribed.
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b. Decrease the magnesium sulfate infusion by one-half.
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c. Stop the magnesium sulfate infusion immediately.
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d. Administer calcium gluconate immediately. - ANS: C
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The client is exhibiting symptoms of magnesium sulfate toxicity--
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decreased reflexes (normal is +2), a low normal respiratory rate (normal is 12 to 2
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0 breaths/min), a less than average urinary output (30 ml/
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hour is average), and a low magnesium sulfate level (normal is 4 to 8mg/
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dl). Based on these findings, the nurse should stop the infusion (C). (A) is contrain
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dicated. (B) would not fully alleviate the magnesium sulfate toxicity symptoms. (D)
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(the antagonist for magnesium sulfate) would be indicated if the respiratory rate we
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re less than 12 breaths/minute.
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A client is on a mechanical ventilator. Which client response indicates that the neu
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romuscular blocker tubocurarine chloride (Tubarine) is effective?
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,a. The client's extremities are paralyzed.
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b. The peripheral nerve stimulator causes twitching.
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c. The client clinches fist upon command.
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d. The client's Glasgow Coma Scale score is 14. - ANS: A
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This medication causes paralysis (A) following intravenous injection. Peak effects p
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ersist for 35 to 60 minutes. (B and C) would not be possible if the medication is eff
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ective. The Glasgow coma scale is used to evaluate the neurological status of the
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client and does not evaluate the effectiveness (D) of this medication.
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An elderly female client comes to the clinic for a regular check-
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up. The client tells the nurse that she has increased her daily doses of acetaminop
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hen (Tylenol) for the past month to control joint pain. Based on this client's comme
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nt, what previous lab values should the nurse compare with today's lab report?
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a. Look at last quarter's hemoglobin and hematocrit, expecting an increase today d
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ue to dehydration.
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b. Look for an increase in today's LDH compared to the previous one to assess for
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possible liver damage.
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c. Expect to find an increase in today's APTT as compared to last quarter's due to
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bleeding.
d. Determine if there is a decrease in serum potassium due to renal compromise. -
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ANS: B
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Frequent and/ vb
or large doses of acetaminophen can cause an increase in liver enzymes, indicatin
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g possible liver damage (B). If the client reported unusual bleeding, or an increase
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in aspirin usage, it would be important for the nurse to assess for increased bleedi
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ng and monitor (A and/
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or C). (D) is not affected by increases in acetaminophen doses.
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Aspirin is prescribed for a 9-year-vb vb vb vb vb
old child with rheumatic fever to control the inflammatory process, promote comfort
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, and reduce fever. What intervention is most important for the nurse to implement
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?
a. Instruct the parents to hold the aspirin until the child has first had a tepid spong
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e bath.
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b. Administer the aspirin with at least two ounces of water or juice.
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c. Notify the healthcare provider if the child complains of ringing in the ears.
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d. Advise the parents to question the child about seeing yellow halos around objec
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ts. - ANS: C
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Ringing in the ears (tinnitus) (C) is an important sign of aspirin overdosage and sh
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ould be reported immediately. Though a tepid sponge bath may lower the child's te
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mperature, the prescription for aspirin should not be held (A). Aspirin should be tak
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en with at least eight ounces of water to completely wash the tablet into the stoma
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ch and to help prevent GI discomfort (B). Yellow halos are associated with Digoxin
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btoxicity, not aspirin (D). vb vb vb
Which signs or symptoms are characteristic of an adult client diagnosed with Cushi
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ng's syndrome? vb
a. Husky voice and complaints of hoarseness.
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b. Warm, soft, moist, salmon-colored skin.
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c. Visible swelling of the neck, with no pain.
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,d. Central-type obesity, with thin extremities. - ANS: D
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The classic picture of Cushing's syndrome in the adult is central-
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type obesity with thin extremities (D), along with a "buffalo hump" in the supraclavi
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cular area, heavy trunk, and thin fragile skin. The symptoms described in (A) are cl
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inical manifestations of hypothyroidism, and in (B) of hyperthyroidism. (C) may indi
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cate a goiter or a tumor of the thyroid gland.
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A charge nurse agrees to cover another nurse's assignment during a lunch break.
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Based on the status report provided by the nurse who is leaving for lunch, which cl
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ient should be checked first by the charge nurse? The client:
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a. admitted yesterday with diabetic ketoacidosis whose blood glucose level is now
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195 mg/dl. vb
b. with an ileal conduit created two days ago with a scant amount of blood in the d
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rainage pouch. vb
c. post-
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triple coronary bypass four days ago who has serosanguinous drainage in the che
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st tube.
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d. with a pneumothorax secondary to a gunshot wound with a current pulse oximet
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er reading of 90%. - ANS: D
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A pulse oximeter reading of 90% indicates an arterial blood gas of less than 80 to
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100 and should be assessed immediately (D). (A) is an expected finding. (B) is not
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an unusual finding. (C) is an expected finding for this client.
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An outcome for treatment of peripheral vascular disease is, "the client will have de
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creased venous congestion." What client behavior would indicate to the nurse that
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this outcome has been met?
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a. Avoids prolonged sitting or standing.
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b. Avoids trauma and irritation to skin.
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c. Wears protective shoes.
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d. Quits smoking. - ANS: A
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Client behaviors indicating that the expected outcome of, "decreased venous cong
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estion" has been met would include elevating the legs, increasing walking time, an
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d an observable decrease in edema of the lower extremities (A). (B and C) would
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be appropriate for outcomes for, "Attains or maintains tissue integrity." (D) would b
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e an appropriate outcome for, "Demonstrates an increase in arterial blood supply t
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o extremities."
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The healthcare provider performs a paracentesis on a client with ascites and 3 liter
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s of fluid are removed. Which assessment parameter is most critical for the nurse t
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o monitor following the procedure?
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a. Pedal pulses.
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b. Breath sounds.
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c. Gag reflex.
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d. Vital signs. - ANS: D
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Life-
threatening complications such as hypovolemia and sepsis can occur following a p
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aracentesis, and measurement of vital signs (D) will provide assessment data that
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will help detect the occurrence of such complications. (A) might be assessed to ch
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eck for circulation in the lower extremities, but are not indicated for postparacentes
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is assessment. Reduction of (B) may occur as the result of decreased fluid in the
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, peritoneal cavity, but is a desired outcome, not a complication, of this procedure. (
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C) is not affected by a paracentesis procedure.
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The nurse is administering sevelamer (RenaGel) during lunch to a client with end s
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tage renal disease (ESRD). The client asks the nurse to bring the medication later.
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The nurse should describe which action of RenaGel as an explanation for taking it
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with meals?
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a. Prevents indigestion associated with ingestion of spicy foods.
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b. Binds with phosphorus in foods and prevents absorption.
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c. Promotes stomach emptying and prevents gastric reflux.
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d. Buffers hydrochloric acid and prevents gastric erosion. - ANS: B
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RenaGel is an intestinal phosphate binder and should be taken with meals to prev
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ent contributing to the hyperphosphatemia (B), associated with ESRD. (A, C, and
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D) are not the therapeutic actions of RenaGel.
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The nurse formulates a nursing diagnosis of, "High risk for ineffective airway cleara
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nce" for a client with myasthenia gravis. What is the most likely etiology for this nu
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rsing diagnosis? vb
a. Pain when coughing.
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b. Diminished cough effort.
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c. Thick dry secretions.
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d. Excessive inflammation. - ANS: B
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The client with myasthenia gravis experiences fatigue and muscle weakness, whic
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h is likely to result in a diminished cough effort (B). (A, C, and D) are not common
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in clients with myasthenia gravis.
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Following a CVA, the nurse assess that a client developed dysphagia, hypoactive
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bowel sounds and firm, distended abdomen. Which prescription for the client shoul
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d the nurse question?
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a. Continous tube feeding at 65 ml/hr via gastrostomy.
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b. Total parenteral nutrition to be infused at 125 ml/hour.
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c. Nasogastric tube connected to low intermittent suction.
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d. Metoclopramide (Reglan) intermittent piggyback. - ANS: A
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The nurse should question the administration of a tube feeding into the GI tract (A)
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, which may result in vomiting and aspiration, because the client is exhibiting signs
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bof decreased peristalsis and possible bowel obstruction. (B) provides a means of s
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afely providing nutrition while GI tract function is inhibited. (C) benefits the client by
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reducing any excess gastric contents. (D) helps stimulate peristalsis.
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A client's telemetry monitor indicates the sudden onset of ventricular fibrillation. Wh
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ich assessment finding should the nurse anticipate?
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a. Bounding erratic pulse.
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b. Regularly irregular pulse.
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c. Thready irregular pulse.
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d. No palpable pulse. - ANS: D
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The client would have no palpable pulse (D), because ventricular fibrillation is chao
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tic electrical activity which does not produce cardiac output. This is a medical emer
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gency which requires immediate treatment to prevent death. (A, B, and C) are not
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typical of pulses in ventricular fibrillation.
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ANSWERS
While assessing a client with diabetes mellitus, the nurse observes an absence of
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hair growth on the client's legs. What additional assessment provides further data t
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o support this finding?
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a. Palpate for the presence of femoral pulses bilaterally.
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b. Assess for the presence of a positive Homan's sign.
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c. Observe the appearance of the skin on the client's legs.
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d. Watch the client's posture and balance during ambulation. - ANS: C
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Signs of chronic arterial insufficiency include decreased hair growth in the legs and
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feet, absent or decreased pedal pulses, infection in the foot, poor wound healing,
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thickened nails, and a shiny appearance of the skin (C). Femoral pulses (A) should
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still be palpable in the diabetic with chronic arterial insufficiency. A positive Homa
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n's sign is an indicator of deep vein thrombosis (B). (D) would probably not be affe
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cted significantly by chronic arterial insufficiency.
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The healthcare provider prescribes 15 mg/
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kg of Streptomycin for an infant weighing 4 pounds. The drug is diluted in 25 ml of
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D5W to run over 8 hours. How much Streptomycin will the infant receive?
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a. 9 mg.
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b. 18 mg.
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c. 27 mg.
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d. 36 mg. - ANS: C
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4 lbs /
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2.2 = 1.8 kg. 1.8 x 15 = 27 mg (C). NOTE, the fact that the drug is diluted in 25
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ml of D5W, is not relevant to the calculation requested.
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In assessing a client with preeclampsia who is receiving magnesium sulfate, the nu
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rse determines that her deep tendon reflexes are 1+; respiratory rate is 12 breaths/
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minute; urinary output is 90 ml in 4 hours; magnesium sulfate level is 9 mg/
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dl. Based on these findings, what intervention should the nurse implement?
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a. Continue the magnesium sulfate infusion as prescribed.
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b. Decrease the magnesium sulfate infusion by one-half.
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c. Stop the magnesium sulfate infusion immediately.
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d. Administer calcium gluconate immediately. - ANS: C
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The client is exhibiting symptoms of magnesium sulfate toxicity--
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decreased reflexes (normal is +2), a low normal respiratory rate (normal is 12 to 2
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0 breaths/min), a less than average urinary output (30 ml/
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hour is average), and a low magnesium sulfate level (normal is 4 to 8mg/
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dl). Based on these findings, the nurse should stop the infusion (C). (A) is contrain
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dicated. (B) would not fully alleviate the magnesium sulfate toxicity symptoms. (D)
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(the antagonist for magnesium sulfate) would be indicated if the respiratory rate we
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re less than 12 breaths/minute.
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A client is on a mechanical ventilator. Which client response indicates that the neu
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romuscular blocker tubocurarine chloride (Tubarine) is effective?
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,a. The client's extremities are paralyzed.
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b. The peripheral nerve stimulator causes twitching.
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c. The client clinches fist upon command.
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d. The client's Glasgow Coma Scale score is 14. - ANS: A
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This medication causes paralysis (A) following intravenous injection. Peak effects p
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ersist for 35 to 60 minutes. (B and C) would not be possible if the medication is eff
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ective. The Glasgow coma scale is used to evaluate the neurological status of the
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client and does not evaluate the effectiveness (D) of this medication.
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An elderly female client comes to the clinic for a regular check-
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up. The client tells the nurse that she has increased her daily doses of acetaminop
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hen (Tylenol) for the past month to control joint pain. Based on this client's comme
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nt, what previous lab values should the nurse compare with today's lab report?
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a. Look at last quarter's hemoglobin and hematocrit, expecting an increase today d
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ue to dehydration.
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b. Look for an increase in today's LDH compared to the previous one to assess for
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possible liver damage.
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c. Expect to find an increase in today's APTT as compared to last quarter's due to
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bleeding.
d. Determine if there is a decrease in serum potassium due to renal compromise. -
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ANS: B
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Frequent and/ vb
or large doses of acetaminophen can cause an increase in liver enzymes, indicatin
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g possible liver damage (B). If the client reported unusual bleeding, or an increase
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in aspirin usage, it would be important for the nurse to assess for increased bleedi
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ng and monitor (A and/
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or C). (D) is not affected by increases in acetaminophen doses.
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Aspirin is prescribed for a 9-year-vb vb vb vb vb
old child with rheumatic fever to control the inflammatory process, promote comfort
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, and reduce fever. What intervention is most important for the nurse to implement
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?
a. Instruct the parents to hold the aspirin until the child has first had a tepid spong
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e bath.
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b. Administer the aspirin with at least two ounces of water or juice.
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c. Notify the healthcare provider if the child complains of ringing in the ears.
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d. Advise the parents to question the child about seeing yellow halos around objec
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ts. - ANS: C
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Ringing in the ears (tinnitus) (C) is an important sign of aspirin overdosage and sh
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ould be reported immediately. Though a tepid sponge bath may lower the child's te
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mperature, the prescription for aspirin should not be held (A). Aspirin should be tak
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en with at least eight ounces of water to completely wash the tablet into the stoma
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ch and to help prevent GI discomfort (B). Yellow halos are associated with Digoxin
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btoxicity, not aspirin (D). vb vb vb
Which signs or symptoms are characteristic of an adult client diagnosed with Cushi
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ng's syndrome? vb
a. Husky voice and complaints of hoarseness.
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b. Warm, soft, moist, salmon-colored skin.
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c. Visible swelling of the neck, with no pain.
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,d. Central-type obesity, with thin extremities. - ANS: D
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The classic picture of Cushing's syndrome in the adult is central-
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type obesity with thin extremities (D), along with a "buffalo hump" in the supraclavi
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cular area, heavy trunk, and thin fragile skin. The symptoms described in (A) are cl
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inical manifestations of hypothyroidism, and in (B) of hyperthyroidism. (C) may indi
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cate a goiter or a tumor of the thyroid gland.
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A charge nurse agrees to cover another nurse's assignment during a lunch break.
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Based on the status report provided by the nurse who is leaving for lunch, which cl
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ient should be checked first by the charge nurse? The client:
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a. admitted yesterday with diabetic ketoacidosis whose blood glucose level is now
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195 mg/dl. vb
b. with an ileal conduit created two days ago with a scant amount of blood in the d
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rainage pouch. vb
c. post-
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triple coronary bypass four days ago who has serosanguinous drainage in the che
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st tube.
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d. with a pneumothorax secondary to a gunshot wound with a current pulse oximet
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er reading of 90%. - ANS: D
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A pulse oximeter reading of 90% indicates an arterial blood gas of less than 80 to
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100 and should be assessed immediately (D). (A) is an expected finding. (B) is not
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an unusual finding. (C) is an expected finding for this client.
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An outcome for treatment of peripheral vascular disease is, "the client will have de
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creased venous congestion." What client behavior would indicate to the nurse that
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this outcome has been met?
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a. Avoids prolonged sitting or standing.
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b. Avoids trauma and irritation to skin.
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c. Wears protective shoes.
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d. Quits smoking. - ANS: A
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Client behaviors indicating that the expected outcome of, "decreased venous cong
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estion" has been met would include elevating the legs, increasing walking time, an
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d an observable decrease in edema of the lower extremities (A). (B and C) would
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be appropriate for outcomes for, "Attains or maintains tissue integrity." (D) would b
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e an appropriate outcome for, "Demonstrates an increase in arterial blood supply t
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o extremities."
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The healthcare provider performs a paracentesis on a client with ascites and 3 liter
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s of fluid are removed. Which assessment parameter is most critical for the nurse t
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o monitor following the procedure?
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a. Pedal pulses.
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b. Breath sounds.
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c. Gag reflex.
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d. Vital signs. - ANS: D
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Life-
threatening complications such as hypovolemia and sepsis can occur following a p
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aracentesis, and measurement of vital signs (D) will provide assessment data that
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will help detect the occurrence of such complications. (A) might be assessed to ch
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eck for circulation in the lower extremities, but are not indicated for postparacentes
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is assessment. Reduction of (B) may occur as the result of decreased fluid in the
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, peritoneal cavity, but is a desired outcome, not a complication, of this procedure. (
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C) is not affected by a paracentesis procedure.
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The nurse is administering sevelamer (RenaGel) during lunch to a client with end s
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tage renal disease (ESRD). The client asks the nurse to bring the medication later.
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The nurse should describe which action of RenaGel as an explanation for taking it
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with meals?
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a. Prevents indigestion associated with ingestion of spicy foods.
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b. Binds with phosphorus in foods and prevents absorption.
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c. Promotes stomach emptying and prevents gastric reflux.
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d. Buffers hydrochloric acid and prevents gastric erosion. - ANS: B
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RenaGel is an intestinal phosphate binder and should be taken with meals to prev
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ent contributing to the hyperphosphatemia (B), associated with ESRD. (A, C, and
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D) are not the therapeutic actions of RenaGel.
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The nurse formulates a nursing diagnosis of, "High risk for ineffective airway cleara
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nce" for a client with myasthenia gravis. What is the most likely etiology for this nu
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rsing diagnosis? vb
a. Pain when coughing.
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b. Diminished cough effort.
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c. Thick dry secretions.
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d. Excessive inflammation. - ANS: B
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The client with myasthenia gravis experiences fatigue and muscle weakness, whic
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h is likely to result in a diminished cough effort (B). (A, C, and D) are not common
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in clients with myasthenia gravis.
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Following a CVA, the nurse assess that a client developed dysphagia, hypoactive
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bowel sounds and firm, distended abdomen. Which prescription for the client shoul
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d the nurse question?
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a. Continous tube feeding at 65 ml/hr via gastrostomy.
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b. Total parenteral nutrition to be infused at 125 ml/hour.
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c. Nasogastric tube connected to low intermittent suction.
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d. Metoclopramide (Reglan) intermittent piggyback. - ANS: A
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The nurse should question the administration of a tube feeding into the GI tract (A)
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, which may result in vomiting and aspiration, because the client is exhibiting signs
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bof decreased peristalsis and possible bowel obstruction. (B) provides a means of s
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afely providing nutrition while GI tract function is inhibited. (C) benefits the client by
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reducing any excess gastric contents. (D) helps stimulate peristalsis.
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A client's telemetry monitor indicates the sudden onset of ventricular fibrillation. Wh
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ich assessment finding should the nurse anticipate?
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a. Bounding erratic pulse.
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b. Regularly irregular pulse.
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c. Thready irregular pulse.
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d. No palpable pulse. - ANS: D
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The client would have no palpable pulse (D), because ventricular fibrillation is chao
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tic electrical activity which does not produce cardiac output. This is a medical emer
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gency which requires immediate treatment to prevent death. (A, B, and C) are not
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typical of pulses in ventricular fibrillation.
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