HESI NCLEX TEST BANK 1ST EDITION
BY PROF EDWARD;OVER 500
QUESTIONS AND ANSWERS FULLY
SOLVED 100%;CREATED AUGUST18,
2024
A client with a diagnosis of preeclampsia suddenly begins to exhibit seizure activity. The first action on
the part of the nurse is:
Calling the physician
Inserting an oral airway
Turning the client on her side
Noting the time of the seizure - ------CORRECT ANSWER -----C
If seizure activity occurs, the nurse remains with the client and presses the emergency bell for
assistance. The client is turned on her side because a side-lying position permits greater circulation
through the placenta and helps prevent aspiration. The nurse then notes the time and sequence of the
seizure. The physician is notified that a seizure has occurred, because this is an obstetric emergency
associated with cerebral hemorrhage, abruptio placentae, severe fetal hypoxia, and death. No object
should be placed in the client's mouth during a seizure. An airway may be inserted after the seizure, and
the client's mouth and nose are suctioned to prevent aspiration. Oxygen may be administered by way of
face mask during the seizure to increase oxygenation of the placenta and all maternal organs.
,A nurse reviewing the medical history of an infant experiencing gastroesophageal reflux (GER) would
expect to note documentation of:
Refusal to suck
Frequent diarrhea
Recurrent otitis media
Inability to pass stools - ------CORRECT ANSWER -----C
GER is regurgitation of gastric contents back into the esophagus. The three types of GER are physiologic,
functional, and pathologic. Vomiting or spitting up after a meal, hiccupping, and recurrent otitis media
resulting from pooling of secretions in the nasopharynx during sleep are characteristics of all types of
GER. Refusal to suck, diarrhea, and inability to pass stools are not associated with GER.
A nurse is caring for a client who has just undergone cardioversion. Which of the following interventions
is the nurse's priority after this procedure?
Administering oxygen
Monitoring the blood pressure
Administering antidysrhythmic medications
Monitoring the client's level of consciousness - ------CORRECT ANSWER -----A
Nursing responsibilities after cardioversion include maintenance of a patent airway, oxygen
administration, assessment of vital signs and level of consciousness, and detection of dysrhythmias. The
priority nursing intervention here is administering oxygen.
A nurse is assigned to conduct an admission assessment of a client who was treated in the emergency
department after attempting suicide by cutting her wrists with a razor blade. When the client arrives at
the nursing unit, the nurse should first:
Ask the client to sign a no-harm contract
Ask the client to report any suicidal thoughts immediately
Place the client under suicide precautions with 15-minute checks
Check the dressings that were placed over the client's wrists in the emergency department - ------
CORRECT ANSWER -----D
,The nurse would first assess the physical status of the client. Therefore, the first nursing intervention is
to check the dressings that have been placed over the client's wrists. The nurse would also immediately
implement one-to-one suicide precautions (not 15-minute checks) for the client who has attempted
suicide. The client would be asked to sign a no-harm contract, but this would not be the first action.
Asking the client to report any suicidal thoughts immediately is a component of a no-harm contract.
A nurse is evaluating outcomes for a client with Guillain-Barré syndrome. Which of the following
outcomes does the nurse recognize as optimal respiratory outcomes for the client? Select all that apply.
Normal deep tendon reflexes
Improved skeletal muscle tone
Absence of paresthesias in the lower extremities
Clear sounds in the lower lung fields bilaterally
pO2 of 85 mm Hg and Pco2 of 40 mm Hg - ------CORRECT ANSWER -----D E
Satisfactory respiratory outcomes include clear breath sounds on auscultation, clear mentation,
spontaneous breathing, normal vital capacity, and normal arterial blood gases. The ABG results listed
here — a Po2 of 85% and a Pco2 of 40 mm Hg — are normal. The presence of normal deep tendon
reflexes, improved skeletal muscle tone, and absence of paresthesias in the lower extremities reflect
improvement in the symptoms associated with Guillain-Barré but are not specific to a respiratory
outcome.
A nurse provides instruction to a client with chronic obstructive pulmonary disease (COPD) about home
oxygen therapy. Which statement by the client indicates a need for further instruction? Select all that
apply.
"I should limit activity as much as I possibly can."
"If I have trouble breathing, I need to call the doctor."
"I need to drink lots of fluids to keep my mucus thin."
"I can apply Vaseline to my nose if the oxygen dries it out."
"I should wear a scarf over my nose and mouth in cold weather."
"If I get a flu shot, I don't have to worry about being around people with colds." - ------CORRECT
ANSWER -----A D F
Clients with COPD should be encouraged to keep up their daily activities as much as possible to help
prevent muscle wasting and maintain activity tolerance. An occupational therapy consult may be useful
, in helping the client learn how to perform activities in ways that conserve energy. Oxygen is drying to
the membranes of the nose, but the client should apply a water-soluble lubricant (K-Y Jelly) to the inside
of the nose to reduce dryness and cracking rather than petroleum jelly (Vaseline), which could be
inhaled. Every client with COPD should be encouraged to get a yearly flu vaccination, but because of the
increased risk of infection, the client must still avoid crowds and people with infections. The remaining
options are appropriate home care measures.
A man calls the emergency department and tells the nurse that he sustained a bee sting on his leg while
working in his yard. The client states that he is not allergic to bees and wants to know how to treat the
sting. The nurse tells the client to first:
Place a cool compress on the sting site
Apply an antipruritic lotion to the sting site
Apply a topical corticosteroid to the sting site
Take an oral antihistamine such as diphenhydramine (Benadryl) - ------CORRECT ANSWER -----A
Treatment for a bee sting depends on the severity of the reaction. Mild reactions are treated with
elevation, cool compresses, antipruritic lotions, and oral antihistamines. Rings, watches, and restrictive
clothing are removed. In this situation, there is no information to indicate that the client is experiencing
a severe reaction, so the nurse would first tell the client to apply a cool compress to the sting site. More
severe reactions are treated with intravenous antihistamines such as diphenhydramine, subcutaneous
epinephrine, and corticosteroids.
A nurse provides dietary instructions to the mother of a child with iron-deficiency anemia. The nurse
should tell the mother that the food highest in iron is:
Milk
Cheese
Orange juice
Cream of Wheat - ------CORRECT ANSWER -----D
Foods high in iron include liver, dried beans, Cream of Wheat, iron-fortified cereal, apricots and prunes
(and other dried fruits), egg yolks, and dark-green leafy vegetables. Milk and cheese are high in calcium.
Orange juice is high in vitamin C.
BY PROF EDWARD;OVER 500
QUESTIONS AND ANSWERS FULLY
SOLVED 100%;CREATED AUGUST18,
2024
A client with a diagnosis of preeclampsia suddenly begins to exhibit seizure activity. The first action on
the part of the nurse is:
Calling the physician
Inserting an oral airway
Turning the client on her side
Noting the time of the seizure - ------CORRECT ANSWER -----C
If seizure activity occurs, the nurse remains with the client and presses the emergency bell for
assistance. The client is turned on her side because a side-lying position permits greater circulation
through the placenta and helps prevent aspiration. The nurse then notes the time and sequence of the
seizure. The physician is notified that a seizure has occurred, because this is an obstetric emergency
associated with cerebral hemorrhage, abruptio placentae, severe fetal hypoxia, and death. No object
should be placed in the client's mouth during a seizure. An airway may be inserted after the seizure, and
the client's mouth and nose are suctioned to prevent aspiration. Oxygen may be administered by way of
face mask during the seizure to increase oxygenation of the placenta and all maternal organs.
,A nurse reviewing the medical history of an infant experiencing gastroesophageal reflux (GER) would
expect to note documentation of:
Refusal to suck
Frequent diarrhea
Recurrent otitis media
Inability to pass stools - ------CORRECT ANSWER -----C
GER is regurgitation of gastric contents back into the esophagus. The three types of GER are physiologic,
functional, and pathologic. Vomiting or spitting up after a meal, hiccupping, and recurrent otitis media
resulting from pooling of secretions in the nasopharynx during sleep are characteristics of all types of
GER. Refusal to suck, diarrhea, and inability to pass stools are not associated with GER.
A nurse is caring for a client who has just undergone cardioversion. Which of the following interventions
is the nurse's priority after this procedure?
Administering oxygen
Monitoring the blood pressure
Administering antidysrhythmic medications
Monitoring the client's level of consciousness - ------CORRECT ANSWER -----A
Nursing responsibilities after cardioversion include maintenance of a patent airway, oxygen
administration, assessment of vital signs and level of consciousness, and detection of dysrhythmias. The
priority nursing intervention here is administering oxygen.
A nurse is assigned to conduct an admission assessment of a client who was treated in the emergency
department after attempting suicide by cutting her wrists with a razor blade. When the client arrives at
the nursing unit, the nurse should first:
Ask the client to sign a no-harm contract
Ask the client to report any suicidal thoughts immediately
Place the client under suicide precautions with 15-minute checks
Check the dressings that were placed over the client's wrists in the emergency department - ------
CORRECT ANSWER -----D
,The nurse would first assess the physical status of the client. Therefore, the first nursing intervention is
to check the dressings that have been placed over the client's wrists. The nurse would also immediately
implement one-to-one suicide precautions (not 15-minute checks) for the client who has attempted
suicide. The client would be asked to sign a no-harm contract, but this would not be the first action.
Asking the client to report any suicidal thoughts immediately is a component of a no-harm contract.
A nurse is evaluating outcomes for a client with Guillain-Barré syndrome. Which of the following
outcomes does the nurse recognize as optimal respiratory outcomes for the client? Select all that apply.
Normal deep tendon reflexes
Improved skeletal muscle tone
Absence of paresthesias in the lower extremities
Clear sounds in the lower lung fields bilaterally
pO2 of 85 mm Hg and Pco2 of 40 mm Hg - ------CORRECT ANSWER -----D E
Satisfactory respiratory outcomes include clear breath sounds on auscultation, clear mentation,
spontaneous breathing, normal vital capacity, and normal arterial blood gases. The ABG results listed
here — a Po2 of 85% and a Pco2 of 40 mm Hg — are normal. The presence of normal deep tendon
reflexes, improved skeletal muscle tone, and absence of paresthesias in the lower extremities reflect
improvement in the symptoms associated with Guillain-Barré but are not specific to a respiratory
outcome.
A nurse provides instruction to a client with chronic obstructive pulmonary disease (COPD) about home
oxygen therapy. Which statement by the client indicates a need for further instruction? Select all that
apply.
"I should limit activity as much as I possibly can."
"If I have trouble breathing, I need to call the doctor."
"I need to drink lots of fluids to keep my mucus thin."
"I can apply Vaseline to my nose if the oxygen dries it out."
"I should wear a scarf over my nose and mouth in cold weather."
"If I get a flu shot, I don't have to worry about being around people with colds." - ------CORRECT
ANSWER -----A D F
Clients with COPD should be encouraged to keep up their daily activities as much as possible to help
prevent muscle wasting and maintain activity tolerance. An occupational therapy consult may be useful
, in helping the client learn how to perform activities in ways that conserve energy. Oxygen is drying to
the membranes of the nose, but the client should apply a water-soluble lubricant (K-Y Jelly) to the inside
of the nose to reduce dryness and cracking rather than petroleum jelly (Vaseline), which could be
inhaled. Every client with COPD should be encouraged to get a yearly flu vaccination, but because of the
increased risk of infection, the client must still avoid crowds and people with infections. The remaining
options are appropriate home care measures.
A man calls the emergency department and tells the nurse that he sustained a bee sting on his leg while
working in his yard. The client states that he is not allergic to bees and wants to know how to treat the
sting. The nurse tells the client to first:
Place a cool compress on the sting site
Apply an antipruritic lotion to the sting site
Apply a topical corticosteroid to the sting site
Take an oral antihistamine such as diphenhydramine (Benadryl) - ------CORRECT ANSWER -----A
Treatment for a bee sting depends on the severity of the reaction. Mild reactions are treated with
elevation, cool compresses, antipruritic lotions, and oral antihistamines. Rings, watches, and restrictive
clothing are removed. In this situation, there is no information to indicate that the client is experiencing
a severe reaction, so the nurse would first tell the client to apply a cool compress to the sting site. More
severe reactions are treated with intravenous antihistamines such as diphenhydramine, subcutaneous
epinephrine, and corticosteroids.
A nurse provides dietary instructions to the mother of a child with iron-deficiency anemia. The nurse
should tell the mother that the food highest in iron is:
Milk
Cheese
Orange juice
Cream of Wheat - ------CORRECT ANSWER -----D
Foods high in iron include liver, dried beans, Cream of Wheat, iron-fortified cereal, apricots and prunes
(and other dried fruits), egg yolks, and dark-green leafy vegetables. Milk and cheese are high in calcium.
Orange juice is high in vitamin C.
