HESI LEVEL 2 (NSG 170) 182 QUESTIONS WITH COMPLETE SOLU-
TIONS/NEWEST UPDATE
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1. A client with acute appendicitis is B. Achieve a sense of control.
experiencing anxiety and loss of
sleep about missing final examina- The experience of psychological discomfort may be
tion week at college. Which outcome as real as physical pain for the client and
is most important for the nurse to should be seen as a priority in care. Because the
include in the plan of care? client is experiencing anxiety, achieving a sense of
control is a key need (B) before (A, C and D) are
A. Sleeping six to eight hours. addressed.
B. Achieve a sense of control.
C. Utilize problem solving skills.
D. Increased focus of attention.
2. A 57-year-old male client is sched- D. "The test you are having tomorrow requires that
uled to have a stress-thallium test you have nothing by mouth tonight."
the following morning and is NPO
after midnight. At 0130, he is agi- Being direct and explaining to the client that the
tated because he cannot eat and is test requires him to be NPO, is the most therapeutic
demanding food. Which response is statement because the nurse is responding to the
best for the nurse to provide to this client's question and providing him the reason why.
client?
A) I'm sorry sir, you have a prescrip-
tion for nothing by mouth from mid-
night tonight.
B) I will let you have one cracker, but
that is all you can have for the rest of
tonight.
C) What did the healthcare provider
tell you about the test you are hav-
ing tomorrow?
D) The test you are having tomorrow
, HESI LEVEL 2 (NSG 170) 182 QUESTIONS WITH COMPLETE SOLU-
TIONS/NEWEST UPDATE
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requires that you have nothing by
mouth tonight.
3. A male client who smokes two packs B, C, D
of cigarettes a day states he un-
derstands that smoking cigarettes is Use of tobacco, alcohol, and marijuana may affect
contributing to the difficulty that he sperm counts. Sperm count is also negatively affect-
and his wife are having in getting ed by low testosterone levels and obesity.
pregnant and wants to know if oth-
er factors could be contributing to
their difficulty. What information is
best for the nurse to provide? (Select
all that apply.)
A.Marijuana cigarettes do not affect
sperm count.
B.Alcohol consumption can cause
erectile dysfunction.
C.Low testosterone levels affect
sperm production.
D.Cessation of smoking improves
general health and fertility.
E.Obesity has no effect on sperm
production.
4. Which response by a client with a C.Accepts that punishment from God is not related to
nursing diagnosis of Spiritual dis- illness
tress indicates to the nurse that a
desired outcome measure has been Acceptance that her illness is not God punishing her,
met? indicates a desired outcome for some degree of res-
A.Expresses concern about the olution of spiritual distress
meaning and importance of life.
, HESI LEVEL 2 (NSG 170) 182 QUESTIONS WITH COMPLETE SOLU-
TIONS/NEWEST UPDATE
Study online at https://quizlet.com/_h7dlak
B.Remains angry at God for the con-
tinuation of the illness.
C.Accepts that punishment from
God is not related to illness.
D.Refuses to participate in religious
rituals that have no meaning.
5. A mother brings her 4-month-old C.Ask the mother to talk about the options she has
infant to the clinic for a well-child been considering.
checkup. She asks if she should go
back to work now or stay at home It is common for mothers to feel ambivalent about
with the baby. How should the nurse returning to work and caring full time for children at
respond to the mother? home. The nurse should assist the mother to explore
A.Mothers can promote healthy her feelings on the subject while focusing on the
bonding by staying at home during optimal, appropriate, safe, and available options for
the child's first years. her child
B.Determine if other family relatives
can stay at home with the baby.
C.Ask the mother to talk about the
options she has been considering.
D.Returning to work when an infant
is young helps the baby to adjust to
other children.
6. A 4-year-old boy who is scheduled D. "It may hurt but we'll give you medicine to help
for a tonsillectomy and adenoidec- you feel better."
tomy asks the nurse, "Will it hurt to
have my tonsils and adenoids taken Answering questions simply and directly provides
out?" Which response is best for the comfort for the preschool-age child and builds con-
nurse to provide? fidence in the healthcare team.
A. "It may hurt a little because of the
, HESI LEVEL 2 (NSG 170) 182 QUESTIONS WITH COMPLETE SOLU-
TIONS/NEWEST UPDATE
Study online at https://quizlet.com/_h7dlak
incision made in your throat."
B. "It won't hurt because you're such
a big boy."
C. "It won't hurt because we put you
to sleep."
D. "It may hurt but we'll give you
medicine to help you feel better."
7. A postoperative client has been re- C.Decrease the IV infusion rate of the meperidine
ceiving a continuous IV infusion of (Demerol) per protocol.
meperidine (Demerol) 35 mg/hr for
four days. The client has a PRN pre- The client is exhibiting symptoms of Demerol toxicity
scription for Demerol 100 mg PO which is consistent with the large doses of Demerol
q3h. The nurse notes that the client received over four days. Decreasing the infusion rate
has become increasingly restless, ir- of the Demerol as per protocol is the most effective
ritable and confused, stating that action to immediately decrease the amount of serum
there are bugs all over the walls. Demerol. The next nursing action is for the nurse to
What action should the nurse take notify the healthcare provider.
first?
A..Administer a PRN dose of the PO
meperidine (Demerol).
B.Administer naloxone (Narcan) IV
per PRN protocol.
C.Decrease the IV infusion rate of
the meperidine (Demerol) per proto-
col.
D.Notify the healthcare provider of
the client's confusion and hallucina-
tions.
8.
TIONS/NEWEST UPDATE
Study online at https://quizlet.com/_h7dlak
1. A client with acute appendicitis is B. Achieve a sense of control.
experiencing anxiety and loss of
sleep about missing final examina- The experience of psychological discomfort may be
tion week at college. Which outcome as real as physical pain for the client and
is most important for the nurse to should be seen as a priority in care. Because the
include in the plan of care? client is experiencing anxiety, achieving a sense of
control is a key need (B) before (A, C and D) are
A. Sleeping six to eight hours. addressed.
B. Achieve a sense of control.
C. Utilize problem solving skills.
D. Increased focus of attention.
2. A 57-year-old male client is sched- D. "The test you are having tomorrow requires that
uled to have a stress-thallium test you have nothing by mouth tonight."
the following morning and is NPO
after midnight. At 0130, he is agi- Being direct and explaining to the client that the
tated because he cannot eat and is test requires him to be NPO, is the most therapeutic
demanding food. Which response is statement because the nurse is responding to the
best for the nurse to provide to this client's question and providing him the reason why.
client?
A) I'm sorry sir, you have a prescrip-
tion for nothing by mouth from mid-
night tonight.
B) I will let you have one cracker, but
that is all you can have for the rest of
tonight.
C) What did the healthcare provider
tell you about the test you are hav-
ing tomorrow?
D) The test you are having tomorrow
, HESI LEVEL 2 (NSG 170) 182 QUESTIONS WITH COMPLETE SOLU-
TIONS/NEWEST UPDATE
Study online at https://quizlet.com/_h7dlak
requires that you have nothing by
mouth tonight.
3. A male client who smokes two packs B, C, D
of cigarettes a day states he un-
derstands that smoking cigarettes is Use of tobacco, alcohol, and marijuana may affect
contributing to the difficulty that he sperm counts. Sperm count is also negatively affect-
and his wife are having in getting ed by low testosterone levels and obesity.
pregnant and wants to know if oth-
er factors could be contributing to
their difficulty. What information is
best for the nurse to provide? (Select
all that apply.)
A.Marijuana cigarettes do not affect
sperm count.
B.Alcohol consumption can cause
erectile dysfunction.
C.Low testosterone levels affect
sperm production.
D.Cessation of smoking improves
general health and fertility.
E.Obesity has no effect on sperm
production.
4. Which response by a client with a C.Accepts that punishment from God is not related to
nursing diagnosis of Spiritual dis- illness
tress indicates to the nurse that a
desired outcome measure has been Acceptance that her illness is not God punishing her,
met? indicates a desired outcome for some degree of res-
A.Expresses concern about the olution of spiritual distress
meaning and importance of life.
, HESI LEVEL 2 (NSG 170) 182 QUESTIONS WITH COMPLETE SOLU-
TIONS/NEWEST UPDATE
Study online at https://quizlet.com/_h7dlak
B.Remains angry at God for the con-
tinuation of the illness.
C.Accepts that punishment from
God is not related to illness.
D.Refuses to participate in religious
rituals that have no meaning.
5. A mother brings her 4-month-old C.Ask the mother to talk about the options she has
infant to the clinic for a well-child been considering.
checkup. She asks if she should go
back to work now or stay at home It is common for mothers to feel ambivalent about
with the baby. How should the nurse returning to work and caring full time for children at
respond to the mother? home. The nurse should assist the mother to explore
A.Mothers can promote healthy her feelings on the subject while focusing on the
bonding by staying at home during optimal, appropriate, safe, and available options for
the child's first years. her child
B.Determine if other family relatives
can stay at home with the baby.
C.Ask the mother to talk about the
options she has been considering.
D.Returning to work when an infant
is young helps the baby to adjust to
other children.
6. A 4-year-old boy who is scheduled D. "It may hurt but we'll give you medicine to help
for a tonsillectomy and adenoidec- you feel better."
tomy asks the nurse, "Will it hurt to
have my tonsils and adenoids taken Answering questions simply and directly provides
out?" Which response is best for the comfort for the preschool-age child and builds con-
nurse to provide? fidence in the healthcare team.
A. "It may hurt a little because of the
, HESI LEVEL 2 (NSG 170) 182 QUESTIONS WITH COMPLETE SOLU-
TIONS/NEWEST UPDATE
Study online at https://quizlet.com/_h7dlak
incision made in your throat."
B. "It won't hurt because you're such
a big boy."
C. "It won't hurt because we put you
to sleep."
D. "It may hurt but we'll give you
medicine to help you feel better."
7. A postoperative client has been re- C.Decrease the IV infusion rate of the meperidine
ceiving a continuous IV infusion of (Demerol) per protocol.
meperidine (Demerol) 35 mg/hr for
four days. The client has a PRN pre- The client is exhibiting symptoms of Demerol toxicity
scription for Demerol 100 mg PO which is consistent with the large doses of Demerol
q3h. The nurse notes that the client received over four days. Decreasing the infusion rate
has become increasingly restless, ir- of the Demerol as per protocol is the most effective
ritable and confused, stating that action to immediately decrease the amount of serum
there are bugs all over the walls. Demerol. The next nursing action is for the nurse to
What action should the nurse take notify the healthcare provider.
first?
A..Administer a PRN dose of the PO
meperidine (Demerol).
B.Administer naloxone (Narcan) IV
per PRN protocol.
C.Decrease the IV infusion rate of
the meperidine (Demerol) per proto-
col.
D.Notify the healthcare provider of
the client's confusion and hallucina-
tions.
8.
