NURS 170 HESI PREP QUESTIONS WITH ACCURATE
ANSWERS
A 20-year-old female client with a noticeable body odor has refused to shower for
the last 3 days. She states, "I have been told that it is harmful to bathe during my
period." Which action should the nurse take first?
a. Accept and document the client's wish to refrain from bathing.
b. Offer to give the client a bed bath, avoiding the perineal area.
c. Obtain written brochures about menstruation to give to the client.
d. Teach the importance of personal hygiene during menstruation with the client.
correct answer Correct Answer: D
Rationale: Because a shower is most beneficial for the client in terms of hygiene,
the client should receive teaching first (D), respecting any personal beliefs such as
cultural or spiritual values. After client teaching, the client may still choose (A or
B). Brochures reinforce the teaching (C).
A 65-year-old client who attends an adult daycare program and is wheelchair-
mobile has redness in the sacral area. Which instruction is most important for the
nurse to provide?
a. Take a vitamin supplement tablet once a day.
b. Change positions in the chair at least every hour.
c. Increase daily intake of water or other oral fluids.
d. Purchase a newer model wheelchair. correct answer Correct Answer: B
,Rationale: The most important teaching is to change positions frequently (B)
because pressure is the most significant factor related to the development of
pressure ulcers. Increased vitamin and fluid intake (A and C) may also be
beneficial promote healing and reduce further risk. (D) is an intervention of last
resort because this will be very expensive for the client.
A client becomes angry while waiting for a supervised break to smoke a cigarette
outside and states, "I want to go outside now and smoke. It takes forever to get
anything done here!" Which intervention is best for the nurse to implement?
a. Encourage the client to use a nicotine patch.
b. Reassure the client that it is almost time for another break.
c. Have the client leave the unit with another staff.
d. Review the schedule of outdoor breaks with the client. correct answer Correct
Answer: D
Rationale: The best nursing action is to review the schedule of outdoor breaks (D)
and provide concrete information about the schedule. (A) is contraindicated if the
client wants to continue smoking. (B) is insufficient to encourage a trusting
relationship with the client. (C) is preferential for this client only and is
inconsistent with unit rules.
A client has a nasogastric tube connected to low intermittent suction. When
administering medications through the nasogastric tube, which action should the
nurse do first?
a. Clamp the nasogastric tube.
b. Confirm placement of the tube.
,c. Use a syringe to instill the medications.
d. Turn off the intermittent suction device. correct answer Correct Answer: D
Rationale: The nurse should first turn off the suction (D) and then confirm
placement of the tube in the stomach (B) before instilling the medications (C). To
prevent immediate removal of the instilled medications and allow absorption, the
tube should be clamped for a period of time (A) before reconnecting the suction.
A client has a nursing diagnosis of Altered sleep patterns related to nocturia.
Which client instruction is important for the nurse to provide?
a. Decrease intake of fluids after the evening meal.
b. Drink a glass of cranberry juice every day.
c. Drink a glass of warm decaffeinated beverage at bedtime.
d. Consult the health care provider about a sleeping pill. correct answer Correct
Answer: A
Rationale: Nocturia is urination during the night. (A) is helpful to decrease the
production of urine, thus decreasing the need to void at night. (B) helps prevent
bladder infections. (C) may promote sleep, but the fluid will contribute to
nocturia. (D) may result in urinary incontinence if the client is sedated and does
not awaken to void.
A client in a long-term care facility reports to the nurse that he has not had a
bowel movement in 2 days. Which intervention should the nurse implement first?
a. Instruct the caregiver to offer a glass of warm prune juice at mealtimes.
, b. Notify the health care provider and request a prescription for a large-volume
enema.
c. Assess the client's medical record to determine the client's normal bowel
pattern.
d. Instruct the caregiver to increase the client's fluids to five 8-ounce glasses per
day. correct answer Correct Answer: C
Rationale: This client may not routinely have a daily bowel movement, so the
nurse should first assess this client's normal bowel habits before attempting any
intervention (C). (A, B, or D) may then be implemented, if warranted.
A client is in the radiology department at 0900 when prescription levofloxacin
(Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to
the unit at 1300. What is the best intervention for the nurse to implement?
a. Contact the healthcare provider and complete a medication variance form.
b. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning.
c. Notify the charge nurse and complete an incident report to explain the missed
dose.
d. Give the missed dose at 1300 and change the schedule to administer daily at
1300. correct answer d. Give the missed dose at 1300 and change the schedule to
administer daily at 1300.
A client is receiving a secondary infusion of a 300 mg dose medication q6h. The
preparation arrives from the pharmacy diluted in 50 mL of 0.9% Sodium Chloride
(NaCl). The nurse plans to administer the dose over 20 minutes. For how many
mL/hour should the nurse program the infusion pump to deliver the secondary
infusion? correct answer 150 mL/hour
ANSWERS
A 20-year-old female client with a noticeable body odor has refused to shower for
the last 3 days. She states, "I have been told that it is harmful to bathe during my
period." Which action should the nurse take first?
a. Accept and document the client's wish to refrain from bathing.
b. Offer to give the client a bed bath, avoiding the perineal area.
c. Obtain written brochures about menstruation to give to the client.
d. Teach the importance of personal hygiene during menstruation with the client.
correct answer Correct Answer: D
Rationale: Because a shower is most beneficial for the client in terms of hygiene,
the client should receive teaching first (D), respecting any personal beliefs such as
cultural or spiritual values. After client teaching, the client may still choose (A or
B). Brochures reinforce the teaching (C).
A 65-year-old client who attends an adult daycare program and is wheelchair-
mobile has redness in the sacral area. Which instruction is most important for the
nurse to provide?
a. Take a vitamin supplement tablet once a day.
b. Change positions in the chair at least every hour.
c. Increase daily intake of water or other oral fluids.
d. Purchase a newer model wheelchair. correct answer Correct Answer: B
,Rationale: The most important teaching is to change positions frequently (B)
because pressure is the most significant factor related to the development of
pressure ulcers. Increased vitamin and fluid intake (A and C) may also be
beneficial promote healing and reduce further risk. (D) is an intervention of last
resort because this will be very expensive for the client.
A client becomes angry while waiting for a supervised break to smoke a cigarette
outside and states, "I want to go outside now and smoke. It takes forever to get
anything done here!" Which intervention is best for the nurse to implement?
a. Encourage the client to use a nicotine patch.
b. Reassure the client that it is almost time for another break.
c. Have the client leave the unit with another staff.
d. Review the schedule of outdoor breaks with the client. correct answer Correct
Answer: D
Rationale: The best nursing action is to review the schedule of outdoor breaks (D)
and provide concrete information about the schedule. (A) is contraindicated if the
client wants to continue smoking. (B) is insufficient to encourage a trusting
relationship with the client. (C) is preferential for this client only and is
inconsistent with unit rules.
A client has a nasogastric tube connected to low intermittent suction. When
administering medications through the nasogastric tube, which action should the
nurse do first?
a. Clamp the nasogastric tube.
b. Confirm placement of the tube.
,c. Use a syringe to instill the medications.
d. Turn off the intermittent suction device. correct answer Correct Answer: D
Rationale: The nurse should first turn off the suction (D) and then confirm
placement of the tube in the stomach (B) before instilling the medications (C). To
prevent immediate removal of the instilled medications and allow absorption, the
tube should be clamped for a period of time (A) before reconnecting the suction.
A client has a nursing diagnosis of Altered sleep patterns related to nocturia.
Which client instruction is important for the nurse to provide?
a. Decrease intake of fluids after the evening meal.
b. Drink a glass of cranberry juice every day.
c. Drink a glass of warm decaffeinated beverage at bedtime.
d. Consult the health care provider about a sleeping pill. correct answer Correct
Answer: A
Rationale: Nocturia is urination during the night. (A) is helpful to decrease the
production of urine, thus decreasing the need to void at night. (B) helps prevent
bladder infections. (C) may promote sleep, but the fluid will contribute to
nocturia. (D) may result in urinary incontinence if the client is sedated and does
not awaken to void.
A client in a long-term care facility reports to the nurse that he has not had a
bowel movement in 2 days. Which intervention should the nurse implement first?
a. Instruct the caregiver to offer a glass of warm prune juice at mealtimes.
, b. Notify the health care provider and request a prescription for a large-volume
enema.
c. Assess the client's medical record to determine the client's normal bowel
pattern.
d. Instruct the caregiver to increase the client's fluids to five 8-ounce glasses per
day. correct answer Correct Answer: C
Rationale: This client may not routinely have a daily bowel movement, so the
nurse should first assess this client's normal bowel habits before attempting any
intervention (C). (A, B, or D) may then be implemented, if warranted.
A client is in the radiology department at 0900 when prescription levofloxacin
(Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to
the unit at 1300. What is the best intervention for the nurse to implement?
a. Contact the healthcare provider and complete a medication variance form.
b. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning.
c. Notify the charge nurse and complete an incident report to explain the missed
dose.
d. Give the missed dose at 1300 and change the schedule to administer daily at
1300. correct answer d. Give the missed dose at 1300 and change the schedule to
administer daily at 1300.
A client is receiving a secondary infusion of a 300 mg dose medication q6h. The
preparation arrives from the pharmacy diluted in 50 mL of 0.9% Sodium Chloride
(NaCl). The nurse plans to administer the dose over 20 minutes. For how many
mL/hour should the nurse program the infusion pump to deliver the secondary
infusion? correct answer 150 mL/hour
