NSG 233 – HESI FINAL 2024 QUESTIONS AND CORRECT
VERIFIED ANSWERS
Which assessment finding indicates to the nurse that a client with cirrhosis has
progressed to the end stage of hepatic encephalopathy?
C) A foul, "musty" odor of the breath.
A nurse arrives at the scene of a motor vehicle collision and finds that the driver is
sitting in the car screaming about severe knee pain. The client is alert and
oriented, but the knee is crushed into the dashboard. A bystander reports that a
911 call has been made and help is on the way. Which intervention should the
nurse implement?
B) Instruct the driver to stay in the car and try not to m unnecessarily.
A client with a recent automatic implantable cardioverter- defibrillator (AICD)
comes to the emergency department complaining of shortness of breath and
episodes of palpitations. the client is normotensive with 95% oxygen saturation
on room air. Which intervention should the nurse implement first?
C) Record Continuous Cardiac Monitoring
A client with AIDS is diagnosed with cutaneous Kaposi's sarcoma following a
punch biopsy. Which pathophysiological changes should the nurse identify in the
lesions that increase the client's risk for infection
D) Large lesions may ulcerate, open, and drain
,After a computed tomography (CT) scan with IV contrast, a client returns to the
room and reports shortness of breath and itching. Which interventions should the
nurse implements?
B) Prepare a PRN dose of Epinephrine.
After two minutes of cardiopulmonary resuscitation, the client's
electrocardiogram shows third degree heart block with no palpable pulse. which
intervention should the nurse implement?
D) Prepare Epinephrine 1 mg IV
The nurse assesses the telemetry monitor of a client who is 24 hours
postoperative for a pacemaker insertion. The nurse observes that a pacemaker
spike is present before each QRS complex in electrocardiogram (ECG) lead II.
Which intervention should the nurse implement?
B) Document that the client is experiencing a paced rythm
A homeless man who remains unconscious after having a generalized seizure
while standing on the street median in the hot August weather is transprted to
the emergency department with possible heat stroke. the nurse obtains IV access
and vital signs that reveal 2 core body temperature of 104.8 F ( 40.4 C). Which
action should the nurse implements first?
C) Spray a mist of water on the face and direct airflow on the client
, A client returns to the unit following a suprapubic prostatectomy. He has a three
way catheter in place with a continous bladder irrigation infusing. Which
assessment finding warrants immediate intervention by the nurse?
B) Bloody urine output with clots
A client with end stage liver diease is scheduled to receive a liver transplant
tomorrow. While completing preoprative teaching with the client and the client's
spouse, the nurse detemines that the client is becoming increaseingly confused.
Which action should the nurse implement first?
C) Review the client's most recent serum laboratory values.
A client is admitted to the emergency department (ED) with slurred speech and
severe lethargy after being found semi-conscious by a roommate. The roommate
voices concern about the client's involvement in using drugs. Which approach is
best for the nurse to take when the client is alert to answer questions about
substance use?
D) Begin with questions that are less sensitive in nature.
Following a motor vehicle accident, an unconscious client is admitted to the
emergency department via ambulance. Vital signs on arrival are a heart rate of
100 beats/minute, respirations of 16 breaths/minute, and a blood pressure of
130/76 mm Hg. The nurse plans to monitor the client for complications associated
with a basilar skull fracture. Which finding confirms this complication?
VERIFIED ANSWERS
Which assessment finding indicates to the nurse that a client with cirrhosis has
progressed to the end stage of hepatic encephalopathy?
C) A foul, "musty" odor of the breath.
A nurse arrives at the scene of a motor vehicle collision and finds that the driver is
sitting in the car screaming about severe knee pain. The client is alert and
oriented, but the knee is crushed into the dashboard. A bystander reports that a
911 call has been made and help is on the way. Which intervention should the
nurse implement?
B) Instruct the driver to stay in the car and try not to m unnecessarily.
A client with a recent automatic implantable cardioverter- defibrillator (AICD)
comes to the emergency department complaining of shortness of breath and
episodes of palpitations. the client is normotensive with 95% oxygen saturation
on room air. Which intervention should the nurse implement first?
C) Record Continuous Cardiac Monitoring
A client with AIDS is diagnosed with cutaneous Kaposi's sarcoma following a
punch biopsy. Which pathophysiological changes should the nurse identify in the
lesions that increase the client's risk for infection
D) Large lesions may ulcerate, open, and drain
,After a computed tomography (CT) scan with IV contrast, a client returns to the
room and reports shortness of breath and itching. Which interventions should the
nurse implements?
B) Prepare a PRN dose of Epinephrine.
After two minutes of cardiopulmonary resuscitation, the client's
electrocardiogram shows third degree heart block with no palpable pulse. which
intervention should the nurse implement?
D) Prepare Epinephrine 1 mg IV
The nurse assesses the telemetry monitor of a client who is 24 hours
postoperative for a pacemaker insertion. The nurse observes that a pacemaker
spike is present before each QRS complex in electrocardiogram (ECG) lead II.
Which intervention should the nurse implement?
B) Document that the client is experiencing a paced rythm
A homeless man who remains unconscious after having a generalized seizure
while standing on the street median in the hot August weather is transprted to
the emergency department with possible heat stroke. the nurse obtains IV access
and vital signs that reveal 2 core body temperature of 104.8 F ( 40.4 C). Which
action should the nurse implements first?
C) Spray a mist of water on the face and direct airflow on the client
, A client returns to the unit following a suprapubic prostatectomy. He has a three
way catheter in place with a continous bladder irrigation infusing. Which
assessment finding warrants immediate intervention by the nurse?
B) Bloody urine output with clots
A client with end stage liver diease is scheduled to receive a liver transplant
tomorrow. While completing preoprative teaching with the client and the client's
spouse, the nurse detemines that the client is becoming increaseingly confused.
Which action should the nurse implement first?
C) Review the client's most recent serum laboratory values.
A client is admitted to the emergency department (ED) with slurred speech and
severe lethargy after being found semi-conscious by a roommate. The roommate
voices concern about the client's involvement in using drugs. Which approach is
best for the nurse to take when the client is alert to answer questions about
substance use?
D) Begin with questions that are less sensitive in nature.
Following a motor vehicle accident, an unconscious client is admitted to the
emergency department via ambulance. Vital signs on arrival are a heart rate of
100 beats/minute, respirations of 16 breaths/minute, and a blood pressure of
130/76 mm Hg. The nurse plans to monitor the client for complications associated
with a basilar skull fracture. Which finding confirms this complication?
