HESI Comprehensive Review for the
NCLEX-RN Examination
In assisting an older adult client prepare to take a tub bath, which nursing
action is most
importan
t?
A.
Check the bath water
temperature.
B.
Shut the bathroom
door.
C.
Ensure that the client has
voided.
D
.
Provide extra towels. correct
answers
Check A.bath water
the
temperature.
The nurse determines that a postoperative client's respiratory rate has
increased
18 from
to 24 breaths/min. Based on this assessment finding, what is the
priority nursing
action
?
A.
Encourage the client to increase ambulation in
the
B. room.
Offer the client a high-carbohydrate snack for
energy.
C.
Force fluids to thin the client's pulmonary
secretions.
D
Determine
. if pain is causing the client's tachypnea. correct
answers D. if pain is causing the client's
Determine
tachypnea.
The nurse is aware that malnutrition is a common problem among clients
served by a health clinic for the homeless. Which laboratory value is the
community
most reliable
indicator of chronic protein
A.
malnutrition?
Low serum albumin
level
B
.
Low serum transferrin
level
C.
High hemoglobin
level
D
.
High cholesterol level correct
answers
Low serumA. albumin
level
,During a routine assessment, an obese 50-year-old client states, "I feel so
unlovable
because of my weight." Which is the best response by
the nurse?
A.
Reassure the client that many obese people have concerns
about
B. sex.
Remind the client that sexual relationships need not be affected
by
C. obesity.
Determine the frequency of sexual
intercourse.
D
.
Ask the client to talk about specific concerns. correct
answers
Ask D.
the client to talk about specific
concerns.
The nurse is evaluating measures implemented for the non-responsive
client. Which
findings indicate the effectiveness of the care delivered? (Select all
that apply.)
A.
Footboard at the end of the
bed
B
.
Heals without redness
bilaterally
C.
Skin intact on the
back
D
.
Sheepskin booties in
place
E.
Elbow joint fully flexes and
extends.
F.
Ankle joint rotates 360 degrees freely. correct
answers
Heals B.
without redness
bilaterally
C.
Skin intact on the
back
E.
Elbow joint fully flexes and
extends.
F.
Ankle joint rotates 360 degrees
freely.
The mental health nurse plans to discuss a client's depression with the
health care
provider in the emergency department. There are two clients sitting
across from department
emergency the desk. Which nursing action
is best?
A.
Only refer to the client by
gender.
B
.
Identify the client only by
age.
C.
Avoid using the client's
name.
D.
Discuss the client another time. correct
answersthe
Discuss D. client another
time.
,The nurse is teaching a client how to perform progressive muscle relaxation
techniques
to relieve insomnia. A week later the client reports, "I am still unable to
sleep, despite
following the same routine every night." Which action should the nurse
take next?
A.
Instruct the client to add regular exercise as a daily
routine.
B.
Determine if the client has been keeping a
sleep
C. diary.
Encourage the client to continue the routine until sleep is
achieved.
D
.
Ask the client to describe the routine he is currently following. correct
answers
Ask D.
the client to describe the routine he is currently
following.
The nurse administered 10 mg of diazepam to the preoperative client.
What
the steps
nurse willnext? (Select all that
take
apply.)
A.
Place the client in the bed next to the nurse's
station.
B
.
Instruct the client not to get out
of
C.bed.
Place the call bell within the client's
reach.
D
.
Place the side rails up, according to institutional
policy.
E.
Assist the client to the bathroom. correct
answersthe
Instruct B. client not to get out
of
C. bed.
Place the call bell within the client's
reach.
D
Place
. the side rails up, according to institutional
policy.
When emptying 350 mL of pale yellow urine from a client's urinal, the
nurse
this is notes that
the first time the client has voided in 4 hours. Which action should the
nurse take
next
?
A.
Record the amount on the client's fluid output
record.
B
.
Encourage the client to increase oral fluid
intake.
C.
Notify the health care provider of the
findings.
D.
Palpate the client's bladder for distention. correct
answersthe
Record A. amount on the client's fluid output
record.
, The nurse is providing care to clients at a day treatment center. One of the
clients who is usually talkative and eats well is now confused and did not eat
lunch. The nurse learns these are new findings as of today. What are the
next nursing actions? (Select all that apply.)
A.
Obtain a clean catch urine
sample. B.
Take the client's vital
signs. C.
Assess for the initiation of any new
medications. D.
Obtain an oxygen
saturation. E.
Call the client's children to report the
confusion. F.
Call the facility's bus service to return the client home. correct
answers A. Obtain a clean catch urine sample.
B.
Take the client's vital
signs. C.
Assess for the initiation of any new
medications. D.
Obtain an oxygen saturation.
A 65-year-old client who attends an adult daycare program and is
wheelchair
has rednessmobile
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
frequently"
C.
"Increase daily intake of water or other oral
fluids."
D
.
"Purchase a newer model wheelchair." correct
answers B.
"Change positions in the chair
frequently"
By rolling contaminated gloves inside-out, the nurse is affecting which step
in the chain
of
infection?
A.
Mode of
transmission
B
.
Portal of
entry
C.
Reservoi
rD.
NCLEX-RN Examination
In assisting an older adult client prepare to take a tub bath, which nursing
action is most
importan
t?
A.
Check the bath water
temperature.
B.
Shut the bathroom
door.
C.
Ensure that the client has
voided.
D
.
Provide extra towels. correct
answers
Check A.bath water
the
temperature.
The nurse determines that a postoperative client's respiratory rate has
increased
18 from
to 24 breaths/min. Based on this assessment finding, what is the
priority nursing
action
?
A.
Encourage the client to increase ambulation in
the
B. room.
Offer the client a high-carbohydrate snack for
energy.
C.
Force fluids to thin the client's pulmonary
secretions.
D
Determine
. if pain is causing the client's tachypnea. correct
answers D. if pain is causing the client's
Determine
tachypnea.
The nurse is aware that malnutrition is a common problem among clients
served by a health clinic for the homeless. Which laboratory value is the
community
most reliable
indicator of chronic protein
A.
malnutrition?
Low serum albumin
level
B
.
Low serum transferrin
level
C.
High hemoglobin
level
D
.
High cholesterol level correct
answers
Low serumA. albumin
level
,During a routine assessment, an obese 50-year-old client states, "I feel so
unlovable
because of my weight." Which is the best response by
the nurse?
A.
Reassure the client that many obese people have concerns
about
B. sex.
Remind the client that sexual relationships need not be affected
by
C. obesity.
Determine the frequency of sexual
intercourse.
D
.
Ask the client to talk about specific concerns. correct
answers
Ask D.
the client to talk about specific
concerns.
The nurse is evaluating measures implemented for the non-responsive
client. Which
findings indicate the effectiveness of the care delivered? (Select all
that apply.)
A.
Footboard at the end of the
bed
B
.
Heals without redness
bilaterally
C.
Skin intact on the
back
D
.
Sheepskin booties in
place
E.
Elbow joint fully flexes and
extends.
F.
Ankle joint rotates 360 degrees freely. correct
answers
Heals B.
without redness
bilaterally
C.
Skin intact on the
back
E.
Elbow joint fully flexes and
extends.
F.
Ankle joint rotates 360 degrees
freely.
The mental health nurse plans to discuss a client's depression with the
health care
provider in the emergency department. There are two clients sitting
across from department
emergency the desk. Which nursing action
is best?
A.
Only refer to the client by
gender.
B
.
Identify the client only by
age.
C.
Avoid using the client's
name.
D.
Discuss the client another time. correct
answersthe
Discuss D. client another
time.
,The nurse is teaching a client how to perform progressive muscle relaxation
techniques
to relieve insomnia. A week later the client reports, "I am still unable to
sleep, despite
following the same routine every night." Which action should the nurse
take next?
A.
Instruct the client to add regular exercise as a daily
routine.
B.
Determine if the client has been keeping a
sleep
C. diary.
Encourage the client to continue the routine until sleep is
achieved.
D
.
Ask the client to describe the routine he is currently following. correct
answers
Ask D.
the client to describe the routine he is currently
following.
The nurse administered 10 mg of diazepam to the preoperative client.
What
the steps
nurse willnext? (Select all that
take
apply.)
A.
Place the client in the bed next to the nurse's
station.
B
.
Instruct the client not to get out
of
C.bed.
Place the call bell within the client's
reach.
D
.
Place the side rails up, according to institutional
policy.
E.
Assist the client to the bathroom. correct
answersthe
Instruct B. client not to get out
of
C. bed.
Place the call bell within the client's
reach.
D
Place
. the side rails up, according to institutional
policy.
When emptying 350 mL of pale yellow urine from a client's urinal, the
nurse
this is notes that
the first time the client has voided in 4 hours. Which action should the
nurse take
next
?
A.
Record the amount on the client's fluid output
record.
B
.
Encourage the client to increase oral fluid
intake.
C.
Notify the health care provider of the
findings.
D.
Palpate the client's bladder for distention. correct
answersthe
Record A. amount on the client's fluid output
record.
, The nurse is providing care to clients at a day treatment center. One of the
clients who is usually talkative and eats well is now confused and did not eat
lunch. The nurse learns these are new findings as of today. What are the
next nursing actions? (Select all that apply.)
A.
Obtain a clean catch urine
sample. B.
Take the client's vital
signs. C.
Assess for the initiation of any new
medications. D.
Obtain an oxygen
saturation. E.
Call the client's children to report the
confusion. F.
Call the facility's bus service to return the client home. correct
answers A. Obtain a clean catch urine sample.
B.
Take the client's vital
signs. C.
Assess for the initiation of any new
medications. D.
Obtain an oxygen saturation.
A 65-year-old client who attends an adult daycare program and is
wheelchair
has rednessmobile
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
frequently"
C.
"Increase daily intake of water or other oral
fluids."
D
.
"Purchase a newer model wheelchair." correct
answers B.
"Change positions in the chair
frequently"
By rolling contaminated gloves inside-out, the nurse is affecting which step
in the chain
of
infection?
A.
Mode of
transmission
B
.
Portal of
entry
C.
Reservoi
rD.
