Western Governors University D 441
HESI LEVEL 1 PRACTICE EXAM with all solution
Terms in this set (129)
The nurse is caring for a client who is C
receiving 24-hour total parenteral nutrition
(TPN) via a central line at 54 ml/hr. When
initially assessing the client, the nurse notes
that the TPN solution has run out and
the next TPN solution is not available.
What
immediate action should the nurse take?
A. Infuse normal saline at a keep vein
open rate.
B.Discontinue the IV and flush the port
with heparin.
C. Infuse 10% dextrose and water at 54
ml/hour.
D.Obtain a stat blood glucose level
and notify the healthcare provider.
,A crying toddler has a blood pressure
B measurement of 120/70 mm Hg. What action
should the nurse implement?
A. Notify the healthcare provider of the
measurement.
B.Quiet the child and retake the blood
pressure.
C. Ask the parent if the child has a history
of hypertension.
D.Document the finding and recheck in 4
hours.
The mother of a neonate asks the nurse why
C
it is so important to keep the infant warm.
What information should the nurse provide?
A. The kidneys and renal function are
not fully developed.
B.Warmth promotes sleep so the infant
will grow quickly.
C. A large body surface area favors heat
loss to the environment.
D.The thick layer of subcutaneous fat
is inadequate for insulation.
What action by the nurse demonstrates A
culturally sensitive care?
A. Asks permission before touching a client.
B. Avoids questions about male-
female relationships.
C. Explains the differences
between Western medical care and
cultural folk remedies.
D.Applies knowledge of a cultural
group unless a client embraces Western
customs.
A client has a nursing diagnosis of, "Spiritual
B distress related to a loss of hope,
secondary
to impending death." What intervention is
best for the nurse to implement when
caring for this client?
A. Help the client to accept the final stage
of life.
B. Assist and support the
client in establishing short-
term goals.
C. Encourage the client to make
future plans, even if they are
unrealistic.
D.Instruct the client's family to focus on
positive aspects of the client's life.
,A client who is 5 foot 5 inches tall and
B weighs 200 pounds is scheduled for surgery
the next day. Which question is most
important for the nurse to include during the
preoperative assessment?
A. "What is your daily calorie consumption?"
B."What vitamin and mineral
supplements do you take?"
C. "Do you feel that you are overweight?"
D."Will a clear liquid diet be okay
after surgery?"
The nurse working in the emergency
D department is assessing four clients' ability
to tolerate pain. Which client is likely to
tolerate a higher level of pain?
A. A 10-year-old who was burned by a camp
fire earlier today.
B. A 70-year-old who has a
postoperative infection from a surgery
one week ago.
C. A 23-year-old woman who sprained her
knee while bicycling.
D.A 55-year-old woman who has had
moderate low back pain for three
months.
A hospitalized male client is receiving C
nasogastric tube feedings via a small-bore
tube and a continuous pump infusion. He
reports that he had a bad bout of
severe coughing a few minutes ago, but
feels fine now. What action is best for
the nurse to take?
A. Record the coughing incident. No further
action is required at this time.
B.Stop the feeding, explain to the
family why it is being stopped, and
notify the
healthcare provider.
C. After clearing the tube with 30 ml of
air, check the pH of fluid withdrawn
from the tube.
D.Inject 30 ml of air into the tube while
auscultating the epigastrium for gurgling.
In evaluating client care, which action A
should the nurse take first?
A. Determine if the expected outcomes of
care were achieved.
B.Review the rationales used as the basis
of nursing actions.
C. Document the care plan goals that were
successfully met.
D.Prioritize interventions to be added to the
client's plan of care.
, A female client asks the nurse to find
D someone who can translate her treatment
concerns into her native language. Which
action should the nurse take?
A. Explain that anyone who speaks
her language can answer her
questions.
B.Provide a translator only in an
emergency situation.
C. Ask a family member or friend of
the client to translate.
D.Request and document the name of
the certified translator.
An unlicensed assistive personnel (UAP) C
places a client in a left lateral position prior
to administering a soap suds enema.
Which instruction should the nurse
provide the UAP?
A. Position the client on the right side of
the bed in reverse Trendelenburg.
B.Fill the enema container with 1000 mL
of warm water and 5 mL of castile
soap.
C. Reposition in a Sims' position with the
client's weight on the anterior ilium.
D.Raise the side rails on both sides of
the bed and elevate the bed to waist
level.
A child with a penetrating eye injury comes
D to the school clinic. What action should the
nurse implement?
A. Remove the object impaled in the
eye and then apply a regular eye
patch.
B.Place an ice bag over the eye until
the healthcare provider is seen.
C. Irrigate the affected eye copiously with a
cool sterile saline solution.
D.Apply a Fox shield to the affected
eye and any type of patch to the
other eye.
When making the bed of a client who needs
D a bed cradle, which action should the nurse
include?
A. Teach the client to call for help
before getting out of bed.
B.Keep both the upper and lower side rails
in a raised position.
C. Keep the bed in the lowest position while
changing the sheets.
D. Drape the top sheet and covers
loosely over the bed cradle.
HESI LEVEL 1 PRACTICE EXAM with all solution
Terms in this set (129)
The nurse is caring for a client who is C
receiving 24-hour total parenteral nutrition
(TPN) via a central line at 54 ml/hr. When
initially assessing the client, the nurse notes
that the TPN solution has run out and
the next TPN solution is not available.
What
immediate action should the nurse take?
A. Infuse normal saline at a keep vein
open rate.
B.Discontinue the IV and flush the port
with heparin.
C. Infuse 10% dextrose and water at 54
ml/hour.
D.Obtain a stat blood glucose level
and notify the healthcare provider.
,A crying toddler has a blood pressure
B measurement of 120/70 mm Hg. What action
should the nurse implement?
A. Notify the healthcare provider of the
measurement.
B.Quiet the child and retake the blood
pressure.
C. Ask the parent if the child has a history
of hypertension.
D.Document the finding and recheck in 4
hours.
The mother of a neonate asks the nurse why
C
it is so important to keep the infant warm.
What information should the nurse provide?
A. The kidneys and renal function are
not fully developed.
B.Warmth promotes sleep so the infant
will grow quickly.
C. A large body surface area favors heat
loss to the environment.
D.The thick layer of subcutaneous fat
is inadequate for insulation.
What action by the nurse demonstrates A
culturally sensitive care?
A. Asks permission before touching a client.
B. Avoids questions about male-
female relationships.
C. Explains the differences
between Western medical care and
cultural folk remedies.
D.Applies knowledge of a cultural
group unless a client embraces Western
customs.
A client has a nursing diagnosis of, "Spiritual
B distress related to a loss of hope,
secondary
to impending death." What intervention is
best for the nurse to implement when
caring for this client?
A. Help the client to accept the final stage
of life.
B. Assist and support the
client in establishing short-
term goals.
C. Encourage the client to make
future plans, even if they are
unrealistic.
D.Instruct the client's family to focus on
positive aspects of the client's life.
,A client who is 5 foot 5 inches tall and
B weighs 200 pounds is scheduled for surgery
the next day. Which question is most
important for the nurse to include during the
preoperative assessment?
A. "What is your daily calorie consumption?"
B."What vitamin and mineral
supplements do you take?"
C. "Do you feel that you are overweight?"
D."Will a clear liquid diet be okay
after surgery?"
The nurse working in the emergency
D department is assessing four clients' ability
to tolerate pain. Which client is likely to
tolerate a higher level of pain?
A. A 10-year-old who was burned by a camp
fire earlier today.
B. A 70-year-old who has a
postoperative infection from a surgery
one week ago.
C. A 23-year-old woman who sprained her
knee while bicycling.
D.A 55-year-old woman who has had
moderate low back pain for three
months.
A hospitalized male client is receiving C
nasogastric tube feedings via a small-bore
tube and a continuous pump infusion. He
reports that he had a bad bout of
severe coughing a few minutes ago, but
feels fine now. What action is best for
the nurse to take?
A. Record the coughing incident. No further
action is required at this time.
B.Stop the feeding, explain to the
family why it is being stopped, and
notify the
healthcare provider.
C. After clearing the tube with 30 ml of
air, check the pH of fluid withdrawn
from the tube.
D.Inject 30 ml of air into the tube while
auscultating the epigastrium for gurgling.
In evaluating client care, which action A
should the nurse take first?
A. Determine if the expected outcomes of
care were achieved.
B.Review the rationales used as the basis
of nursing actions.
C. Document the care plan goals that were
successfully met.
D.Prioritize interventions to be added to the
client's plan of care.
, A female client asks the nurse to find
D someone who can translate her treatment
concerns into her native language. Which
action should the nurse take?
A. Explain that anyone who speaks
her language can answer her
questions.
B.Provide a translator only in an
emergency situation.
C. Ask a family member or friend of
the client to translate.
D.Request and document the name of
the certified translator.
An unlicensed assistive personnel (UAP) C
places a client in a left lateral position prior
to administering a soap suds enema.
Which instruction should the nurse
provide the UAP?
A. Position the client on the right side of
the bed in reverse Trendelenburg.
B.Fill the enema container with 1000 mL
of warm water and 5 mL of castile
soap.
C. Reposition in a Sims' position with the
client's weight on the anterior ilium.
D.Raise the side rails on both sides of
the bed and elevate the bed to waist
level.
A child with a penetrating eye injury comes
D to the school clinic. What action should the
nurse implement?
A. Remove the object impaled in the
eye and then apply a regular eye
patch.
B.Place an ice bag over the eye until
the healthcare provider is seen.
C. Irrigate the affected eye copiously with a
cool sterile saline solution.
D.Apply a Fox shield to the affected
eye and any type of patch to the
other eye.
When making the bed of a client who needs
D a bed cradle, which action should the nurse
include?
A. Teach the client to call for help
before getting out of bed.
B.Keep both the upper and lower side rails
in a raised position.
C. Keep the bed in the lowest position while
changing the sheets.
D. Drape the top sheet and covers
loosely over the bed cradle.
