HESI EXAM 3
Study online at https://quizlet.com/_bs7npj
1. A male client with stomach cancer returns to the unit d. Increase the infusion
following a total gastrectomy. He has a nasogastric rate of Lactated Ringer's
tube to suction and is receiving Lactated Ringer's solu- solution.
tion at 75 mL/hour IV. One hour after admission to the
unit, the nurse notes 300 mL of blood in the suction
canister, the client's heart rate is 155 beats/minute,
and his blood pressure is 78/48 mmHg. In addition
to reporting the finding to the surgeon. Which action
should the nurse implement first?
a. Measure and document the client's urinary output.
b. Request the client's reserved unit if packed red
blood cells.
c. Prepare the placement of a central venous catheter.
d. Increase the infusion rate of Lactated Ringer's solu-
tion.
2. An adult male who fell 20 feet from the roof of this
home has multiple injuries, including a right pneu-
mothorax. Chest tubes were inserted in the emer-
gency department prior to his transfer to the inten-
sive care unit (ICU). the nurse notes that the suction
control chamber is bubbling at the - 10 cm H2O mark,
with fluctuation in the water seal, and over the past
hour 75 ml of bright red blood is measured in the col-
lection chamber. Which intervention should the nurse
implement?
a. Add sterile water to the suction control chamber.
b. Give blood from the collection chamber as
auto-transfusion
c. Manipulate blood in tubing to drain into chamber.
d. Increase wall suction to eliminate fluctuation in wa-
ter seal.
, HESI EXAM 3
Study online at https://quizlet.com/_bs7npj
3. A client who received hemodialysis yesterday is ex-
periencing a blood pressure of 200/100 mmHg,
heart rate 110 beats/minute, and respiratory rate 36
breaths/minute. The client is manifesting shortness
of breath, bilateral 2+ pedal edema, and an oxygen
saturation on room air of 89%. Which action should
the nurse take first?
a. Elevate the foot of the bed.
b. Restrict the client's fluid.
c. Begin supplemental oxygen.
d. Prepare the client for hemodialysis.
4. A client with Addison's crisis is admitted for treatment a. Headache and tremors
with adrenal cortical supplementation. Based on the b. Irregular heart rate
client's admitting diagnosis, which findings require e. Pallor and diaphoresis
immediate action by the nurse? (Select all that apply)
a. Headache and tremors
b. Irregular heart rate
c. Skin hyperpigmentation
d. Postural hypotension
e. Pallor and diaphoresis
5. An older client is admitted with fluid volume deficit .d. Skin tenting occurs
and dehydration. Which assessment finding when the client's forearm
is the best indicator of hydration that the nurse should is pinched
report to the healthcare provider?
a. Urine specific gravity is 1.040b.
b. Systolic blood pressure decreases 10 points when
standing.
c. The client denies being thirsty.
, HESI EXAM 3
Study online at https://quizlet.com/_bs7npj
d. Skin tenting occurs when the client's forearm is
pinched.
6. After an inservice about electronic health record (EHR) a. File a detailed incident
security and safeguarding client information, the report with the specific
nurse observes a colleague going home with print- hiring facility.
ed copies of client information in a uniform pocket.
Which action should the nurse take?
a. File a detailed incident report with the specific hiring
facility.
b. Warn the colleague that their actions are unprofes-
sional.
c. Comment anonymously about the action of a staff
discussion board.
d. Communicate the colleague's actions to the unit
charge nurse.
7. The nurse is evaluating a tertiary prevention program c. Clients who in-
for clients with cardiovascular disease implemented curred disease complica-
in a rural health clinic. Which outcome indicate the tions promptly received
program is effective? rehabilitation.
a. At-risk clients received an increased number of rou-
tine health screenings.
b. Clients reported having new confidence in making
healthy food choices.
c. Clients who incurred disease complications prompt-
ly received rehabilitation.
d. Client relapse rate of 30% in a 5-year communi-
ty-wide anti-smoking campaign.
8. The nurse is caring for a client with chronic obstruc-
tive pulmonary disease (COPD) who uses oxygen at 2
, HESI EXAM 3
Study online at https://quizlet.com/_bs7npj
L/minute per nasal cannula continuously. The nurse d. Assess the delivery
observes that the client is having increased short- mechanism of the oxygen
ness of breath with respirations at 23 breaths/minute. tank, tubing, and cannula.
Which action should the nurse implement first?
a. Determine if the client is experiencing any anxiety.
b. Auscultate the client's bilateral lung sounds and
oxygen saturation.
c. Notify the healthcare provider about the client's
distress.
d. Assess the delivery mechanism of the oxygen tank,
tubing, and cannula.
9. Which statement by a client who is 24 hours a. "When I get out of bed
post-subtotal thyroidectomy requires an immediate quickly, I feel a little dizzy."
investigation by the nurse?
a. "When I get out of bed quickly, I feel a little dizzy."
b. "The dressing over my incision feels like it is too
tight."
c. "I'm most comfortable when the head of the bed is
raised."
d. "This IV infusion makes me urinate more often than
usual."
10. An older adult male who is in his early 70's is admitted b. Notify the healthcare
to the emergency department because of a COPD provider of the client's
exacerbation. This client is struggling to breathe and wishes.
the healthcare team is preparing for endotracheal in-
tubation. The spouse's wife, who is 30 years younger
than the client, asks the nurse to stop the procedure
and provide the nurse a copy of the client's living will.
Which actionshould the nurse take?
a. Facilitate a family meeting with the palliative care
Study online at https://quizlet.com/_bs7npj
1. A male client with stomach cancer returns to the unit d. Increase the infusion
following a total gastrectomy. He has a nasogastric rate of Lactated Ringer's
tube to suction and is receiving Lactated Ringer's solu- solution.
tion at 75 mL/hour IV. One hour after admission to the
unit, the nurse notes 300 mL of blood in the suction
canister, the client's heart rate is 155 beats/minute,
and his blood pressure is 78/48 mmHg. In addition
to reporting the finding to the surgeon. Which action
should the nurse implement first?
a. Measure and document the client's urinary output.
b. Request the client's reserved unit if packed red
blood cells.
c. Prepare the placement of a central venous catheter.
d. Increase the infusion rate of Lactated Ringer's solu-
tion.
2. An adult male who fell 20 feet from the roof of this
home has multiple injuries, including a right pneu-
mothorax. Chest tubes were inserted in the emer-
gency department prior to his transfer to the inten-
sive care unit (ICU). the nurse notes that the suction
control chamber is bubbling at the - 10 cm H2O mark,
with fluctuation in the water seal, and over the past
hour 75 ml of bright red blood is measured in the col-
lection chamber. Which intervention should the nurse
implement?
a. Add sterile water to the suction control chamber.
b. Give blood from the collection chamber as
auto-transfusion
c. Manipulate blood in tubing to drain into chamber.
d. Increase wall suction to eliminate fluctuation in wa-
ter seal.
, HESI EXAM 3
Study online at https://quizlet.com/_bs7npj
3. A client who received hemodialysis yesterday is ex-
periencing a blood pressure of 200/100 mmHg,
heart rate 110 beats/minute, and respiratory rate 36
breaths/minute. The client is manifesting shortness
of breath, bilateral 2+ pedal edema, and an oxygen
saturation on room air of 89%. Which action should
the nurse take first?
a. Elevate the foot of the bed.
b. Restrict the client's fluid.
c. Begin supplemental oxygen.
d. Prepare the client for hemodialysis.
4. A client with Addison's crisis is admitted for treatment a. Headache and tremors
with adrenal cortical supplementation. Based on the b. Irregular heart rate
client's admitting diagnosis, which findings require e. Pallor and diaphoresis
immediate action by the nurse? (Select all that apply)
a. Headache and tremors
b. Irregular heart rate
c. Skin hyperpigmentation
d. Postural hypotension
e. Pallor and diaphoresis
5. An older client is admitted with fluid volume deficit .d. Skin tenting occurs
and dehydration. Which assessment finding when the client's forearm
is the best indicator of hydration that the nurse should is pinched
report to the healthcare provider?
a. Urine specific gravity is 1.040b.
b. Systolic blood pressure decreases 10 points when
standing.
c. The client denies being thirsty.
, HESI EXAM 3
Study online at https://quizlet.com/_bs7npj
d. Skin tenting occurs when the client's forearm is
pinched.
6. After an inservice about electronic health record (EHR) a. File a detailed incident
security and safeguarding client information, the report with the specific
nurse observes a colleague going home with print- hiring facility.
ed copies of client information in a uniform pocket.
Which action should the nurse take?
a. File a detailed incident report with the specific hiring
facility.
b. Warn the colleague that their actions are unprofes-
sional.
c. Comment anonymously about the action of a staff
discussion board.
d. Communicate the colleague's actions to the unit
charge nurse.
7. The nurse is evaluating a tertiary prevention program c. Clients who in-
for clients with cardiovascular disease implemented curred disease complica-
in a rural health clinic. Which outcome indicate the tions promptly received
program is effective? rehabilitation.
a. At-risk clients received an increased number of rou-
tine health screenings.
b. Clients reported having new confidence in making
healthy food choices.
c. Clients who incurred disease complications prompt-
ly received rehabilitation.
d. Client relapse rate of 30% in a 5-year communi-
ty-wide anti-smoking campaign.
8. The nurse is caring for a client with chronic obstruc-
tive pulmonary disease (COPD) who uses oxygen at 2
, HESI EXAM 3
Study online at https://quizlet.com/_bs7npj
L/minute per nasal cannula continuously. The nurse d. Assess the delivery
observes that the client is having increased short- mechanism of the oxygen
ness of breath with respirations at 23 breaths/minute. tank, tubing, and cannula.
Which action should the nurse implement first?
a. Determine if the client is experiencing any anxiety.
b. Auscultate the client's bilateral lung sounds and
oxygen saturation.
c. Notify the healthcare provider about the client's
distress.
d. Assess the delivery mechanism of the oxygen tank,
tubing, and cannula.
9. Which statement by a client who is 24 hours a. "When I get out of bed
post-subtotal thyroidectomy requires an immediate quickly, I feel a little dizzy."
investigation by the nurse?
a. "When I get out of bed quickly, I feel a little dizzy."
b. "The dressing over my incision feels like it is too
tight."
c. "I'm most comfortable when the head of the bed is
raised."
d. "This IV infusion makes me urinate more often than
usual."
10. An older adult male who is in his early 70's is admitted b. Notify the healthcare
to the emergency department because of a COPD provider of the client's
exacerbation. This client is struggling to breathe and wishes.
the healthcare team is preparing for endotracheal in-
tubation. The spouse's wife, who is 30 years younger
than the client, asks the nurse to stop the procedure
and provide the nurse a copy of the client's living will.
Which actionshould the nurse take?
a. Facilitate a family meeting with the palliative care
