hesi inet version 5
1. After placing a 36-week-gesation new- b. Remove the wet blankets and linens from the
born in an isolette and drying the isolette.
infant with several blankets, what
Should the nurse implement next? Wet blankets can contribute to heat loss in
the newborn. Removing them and replacing
a. Administer the vitamin K injection. them with dry linens helps maintain the infant's
b. Remove the wet blankets and linens body temperature, which is crucial, especially for
from the isolette. preterm or near-term infants like a 36-week-ges-
c. Place erythromycin opthalmic oint- tation newborn.
ment in both eyes.
d. Open the door to assess the infant's
vital signs.
2. A client in the third trimester of preg- d. Record the respiratory findings in the clients
nancy com- plains of frequent nasal record as normal
stiffness and occasional nosebleeds.
Her chest circumference has increased
by 5 cm during the pregnancy, and
she uses thoracic breathing. Her di-
aphragm is elevated and she has an in-
creased costal angle. Which interven-
tion should the nurse implement?
3. A terminally ill male hospice client b. encourage family to speak often with the client
who is at home is showing decreased
awareness of his surroundings. His ap- Even if the client has decreased awareness, hear-
petite is poor and he often refuses oral ing familiar voices can be comforting. Family
intake of solids and liquids. For the members can share memories, express love, or
past several days he has been unable simply be present with the client, which can be
to get out of bed. Which action should emotionally supportive for everyone involved.
the hospice nurse implement?
, hesi inet version 5
a. Ask family to remain nearby, but in
another room.
b. Encourage family to speak often
with the client.
c. Teach family how to assist the client
to a wheelchair.
d. Instruct family to offer client only
soft, bland foods
4. A woman was admitted yesterday af- b. perform gastroccult test on the nasogastric
ternoon with severe abdominal pain. drainage
Her pregnancy test and ultrasound
were negative, so an exploratory la- A gastroccult test is used to detect the presence
parotomy was completed during the of blood in gastric contents. Performing this test
night. When coffee ground material is on the nasogastric drainage will help confirm
observed in the drainage from the na- whether the coffee ground material is indeed
sogastric tube (NGT), which blood, which is a crucial step in assessing the
Intervention should the nurse imple- patient's condition.
ment?
a. Verify correct placement of the na-
sogastric tube
b. Perform gastroccult test on the na-
sogastric drainage.
c. Listen for evidence of diminished
bowel sounds.
d. Irrigate the nasogastric tube with
water until clear.
5. The nurse Is reviewing the laboratory a. Lipase.
values for a client with acute pancreati-
tis who reports of the abdominal pain Lipase is an enzyme produced by the pancreas.
, hesi inet version 5
is not as severe as it was on admission. Elevated levels of lipase in the blood are indica-
Which laboratory test should the nurse tive of pancreatic inflammation and are commonly
review to evaluate the client's clinical used to diagnose and monitor acute pancreatitis.
recovery? A decreasing trend in lipase levels can indicate
clinical improvement and resolution of pancreati-
a. Lipase. tis symptoms.
b. Creatinine.
c. Bilirubin.
d. Glucose.
6. While assessing a client who had a la- a. Determine the clients vital signs
parotomy the previous day, the nurse
notices that 300 ml of dark red fluids Assessing the client's vital signs, especially blood
has drained from the nasogastric tube pressure and heart rate, is the most immediate
In the last hour. Which action should and essential action in this situation to determine
the nurse take first? if the client is experiencing hypovolemia (a sig-
nificant decrease in blood volume). The dark red
a. Determine the clients vital signs drainage may indicate bleeding, and vital signs
b. Monitor urinary output hourly. can help assess the client's overall hemodynamic
c. Notify the surgeon immediately. status.
d. Assess the client's level of pain.
7. The nurse is reviewing the recom- c. get annual flu and pneumococcal vaccine poly-
mended preventative care for clients valent (PPSV23) vaccines
with asthma, chronic bronchitis, and
emphysema. Which health care mea- These vaccines help protect against influenza and
sure is most important for the nurse topneumococcal disease, both of which can cause
recommend to these clients? serious complications in people with respiratory
conditions. The flu can exacerbate these condi-
a. Ensure supplemental oxygen and tions, and pneumococcal pneumonia is a serious
respiratory medications are available bacterial infection that can be particularly harm-
at all times. ful.
b. Use nasal or cough tissues followed
, hesi inet version 5
by hand washing at all times.
c. Get annual flu and Pneumococcal
vaccine polyvalent (PPSV23) vaccines.
d. Avoid large crowded areas during
the colder months of the year
8. The mother of a one-month-old infant a. Position the infant on the stomach occasionally
calls the clinic to report that the back when awake and active.
of her infant's head is flat. How should
the nurse respond? This recommendation aligns with safe sleep
guidelines for infants. While the infant should be
a. Position the infant on the stomach placed on their back to sleep to reduce the risk
occasionally when awake and active. of sudden infant death syndrome (SIDS), super-
b. Turn the infant on the left side vised tummy time when the infant is awake and
braced against the crib when sleep- active can help prevent the development of a flat
ing. head (positional plagiocephaly) by allowing them
c. Prop the infant in a sitting position to strengthen neck muscles and change head po-
with a cushion when not sleeping. sitions.
d. Place a small pillow under the in-
fant's head while lying on the back.
9. A woman is brought to the labor and c. Massage the fundus and give an oxytocin
delivery unit after delivering a term in- agent
fant and the placenta in the hospital
parking lot 10 minutes ago. Which ac- The immediate concern after precipitous deliv-
tion should the nurse perform first? ery is to manage postpartum hemorrhage (PPH),
which can occur due to uterine atony. Massaging
a. Inspect the perineum for lacera- the fundus helps to stimulate uterine contrac-
tions. tions, and administering an oxytocin agent (such
b. Collect specimen for hemoglobin as oxytocin or methylergonovine) can further help
and hematocrit. control bleeding by causing the uterus to con-
c. Massage the fundus and give an oxy- tract.
1. After placing a 36-week-gesation new- b. Remove the wet blankets and linens from the
born in an isolette and drying the isolette.
infant with several blankets, what
Should the nurse implement next? Wet blankets can contribute to heat loss in
the newborn. Removing them and replacing
a. Administer the vitamin K injection. them with dry linens helps maintain the infant's
b. Remove the wet blankets and linens body temperature, which is crucial, especially for
from the isolette. preterm or near-term infants like a 36-week-ges-
c. Place erythromycin opthalmic oint- tation newborn.
ment in both eyes.
d. Open the door to assess the infant's
vital signs.
2. A client in the third trimester of preg- d. Record the respiratory findings in the clients
nancy com- plains of frequent nasal record as normal
stiffness and occasional nosebleeds.
Her chest circumference has increased
by 5 cm during the pregnancy, and
she uses thoracic breathing. Her di-
aphragm is elevated and she has an in-
creased costal angle. Which interven-
tion should the nurse implement?
3. A terminally ill male hospice client b. encourage family to speak often with the client
who is at home is showing decreased
awareness of his surroundings. His ap- Even if the client has decreased awareness, hear-
petite is poor and he often refuses oral ing familiar voices can be comforting. Family
intake of solids and liquids. For the members can share memories, express love, or
past several days he has been unable simply be present with the client, which can be
to get out of bed. Which action should emotionally supportive for everyone involved.
the hospice nurse implement?
, hesi inet version 5
a. Ask family to remain nearby, but in
another room.
b. Encourage family to speak often
with the client.
c. Teach family how to assist the client
to a wheelchair.
d. Instruct family to offer client only
soft, bland foods
4. A woman was admitted yesterday af- b. perform gastroccult test on the nasogastric
ternoon with severe abdominal pain. drainage
Her pregnancy test and ultrasound
were negative, so an exploratory la- A gastroccult test is used to detect the presence
parotomy was completed during the of blood in gastric contents. Performing this test
night. When coffee ground material is on the nasogastric drainage will help confirm
observed in the drainage from the na- whether the coffee ground material is indeed
sogastric tube (NGT), which blood, which is a crucial step in assessing the
Intervention should the nurse imple- patient's condition.
ment?
a. Verify correct placement of the na-
sogastric tube
b. Perform gastroccult test on the na-
sogastric drainage.
c. Listen for evidence of diminished
bowel sounds.
d. Irrigate the nasogastric tube with
water until clear.
5. The nurse Is reviewing the laboratory a. Lipase.
values for a client with acute pancreati-
tis who reports of the abdominal pain Lipase is an enzyme produced by the pancreas.
, hesi inet version 5
is not as severe as it was on admission. Elevated levels of lipase in the blood are indica-
Which laboratory test should the nurse tive of pancreatic inflammation and are commonly
review to evaluate the client's clinical used to diagnose and monitor acute pancreatitis.
recovery? A decreasing trend in lipase levels can indicate
clinical improvement and resolution of pancreati-
a. Lipase. tis symptoms.
b. Creatinine.
c. Bilirubin.
d. Glucose.
6. While assessing a client who had a la- a. Determine the clients vital signs
parotomy the previous day, the nurse
notices that 300 ml of dark red fluids Assessing the client's vital signs, especially blood
has drained from the nasogastric tube pressure and heart rate, is the most immediate
In the last hour. Which action should and essential action in this situation to determine
the nurse take first? if the client is experiencing hypovolemia (a sig-
nificant decrease in blood volume). The dark red
a. Determine the clients vital signs drainage may indicate bleeding, and vital signs
b. Monitor urinary output hourly. can help assess the client's overall hemodynamic
c. Notify the surgeon immediately. status.
d. Assess the client's level of pain.
7. The nurse is reviewing the recom- c. get annual flu and pneumococcal vaccine poly-
mended preventative care for clients valent (PPSV23) vaccines
with asthma, chronic bronchitis, and
emphysema. Which health care mea- These vaccines help protect against influenza and
sure is most important for the nurse topneumococcal disease, both of which can cause
recommend to these clients? serious complications in people with respiratory
conditions. The flu can exacerbate these condi-
a. Ensure supplemental oxygen and tions, and pneumococcal pneumonia is a serious
respiratory medications are available bacterial infection that can be particularly harm-
at all times. ful.
b. Use nasal or cough tissues followed
, hesi inet version 5
by hand washing at all times.
c. Get annual flu and Pneumococcal
vaccine polyvalent (PPSV23) vaccines.
d. Avoid large crowded areas during
the colder months of the year
8. The mother of a one-month-old infant a. Position the infant on the stomach occasionally
calls the clinic to report that the back when awake and active.
of her infant's head is flat. How should
the nurse respond? This recommendation aligns with safe sleep
guidelines for infants. While the infant should be
a. Position the infant on the stomach placed on their back to sleep to reduce the risk
occasionally when awake and active. of sudden infant death syndrome (SIDS), super-
b. Turn the infant on the left side vised tummy time when the infant is awake and
braced against the crib when sleep- active can help prevent the development of a flat
ing. head (positional plagiocephaly) by allowing them
c. Prop the infant in a sitting position to strengthen neck muscles and change head po-
with a cushion when not sleeping. sitions.
d. Place a small pillow under the in-
fant's head while lying on the back.
9. A woman is brought to the labor and c. Massage the fundus and give an oxytocin
delivery unit after delivering a term in- agent
fant and the placenta in the hospital
parking lot 10 minutes ago. Which ac- The immediate concern after precipitous deliv-
tion should the nurse perform first? ery is to manage postpartum hemorrhage (PPH),
which can occur due to uterine atony. Massaging
a. Inspect the perineum for lacera- the fundus helps to stimulate uterine contrac-
tions. tions, and administering an oxytocin agent (such
b. Collect specimen for hemoglobin as oxytocin or methylergonovine) can further help
and hematocrit. control bleeding by causing the uterus to con-
c. Massage the fundus and give an oxy- tract.
