100% ACCURATE ANSWERS
NAXLEX-HESI
STUDYGLOBAL 5/15/25 NAXLEX-HESI
,The client is an 81-year-old male with a history of hypertension, heart failure, and seasonal allergies. He
was admitted for pneumonia 3 days ago and is currently in the intensive care unit. The client lives with
his daughter and her family, who report that he is compliant with his medication regimen. The client
walks every morning but has shown cognitive decline at home and has no signs of improvement. The
client has been experiencing increased confusion, lethargy, and decreased appetite.
He has also developed a persistent cough with greenish sputum and shortness of breath.
Complete the diagram by specifying which condition the client is most likely experiencing, two actions
the nurse should take to address that condition, and two parameters the nurse should monitor to assess
the client's progress. - Accurate answers Actions to Take:
Administer diuretics as prescribed
Perform chest physiotherapy
Potential Condition: Hospital-acquired pneumonia
Parameters to Monitor:
Oxygen saturation
White blood cell count.
Rationale: The client is most likely experiencing Hospital-acquired pneumonia. This is indicated by the
recent admission for pneumonia, persistent cough with greenish sputum, increased WBC count, and
bilateral infiltrates on the chest X-ray.
The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute
via nasal cannula. The oxygen saturation is 89%. Which action should the nurse implement?
A. Verify placement of pulse oximeter.
B. Increase the oxygen to 3 L/minute.
C. Remove nasal cannula.
D. Switch to a non-rebreather mask. - Accurate answers A
Rationale: Verifying the placement of the pulse oximeter is the first step to ensure accurate readings.
Incorrect placement can lead to false low oxygen saturation readings.
The nurse is caring for a client with type 2 diabetes mellitus who had surgery for a large bowel resection
with a colostomy placement. The client has now developed hyperglycemia which requires self-injections
of insulin after discharge. When designing the postoperative plan of care, which outcome statement
should the nurse use?
A. The client will demonstrate the ability to change the ostomy bag in two days.
B. The client attempts to self-administer insulin but is unable to perform the injection.
C. The client's breath sounds will be auscultated by the nurse every 4 hours.
D. The client's breath sounds will be auscultated by the nurse every 4 hours.
, E. The client will adhere to the medication regimen after discharge. - Accurate answers E
When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is
most important for the nurse to implement?
A. Assess strength of deep tendon reflexes.
B. Determine apical pulse rate and rhythm.
C. Observe color and amount of urine.
D. Remind the UAP to lubricate the thermometer before gently inserting it in the ear. - Accurate
answers B
Rationale: Hyperkalemia directly affects the heart and can lead to dangerous arrhythmias, such as
ventricular fibrillation or asystole. Assessing the apical pulse and rhythm is crucial to identify
irregularities early.
The patient is a 36-year-old female who is in the clinic today for insomnia. She reports that she started
having trouble sleeping over a year ago after her father's death. She has no medical problems and has
never had surgery. She takes an oral contraceptive and a multivitamin daily. She does not smoke but
drinks one to two glasses of wine every evening.
What other recommendations could the nurse give to help the patient have better sleep? (Select all that
apply.)
A. Exercise in the evening.
B. Watch television in bed to fall asleep.
C. Take an analgesic before bed.
D. Avoid alcohol in the evening.
E. Try to go to bed and awaken at the same time every day.
F. Avoid naps.
G. Eat a heavy meal before bed. - Accurate answers D, E, and F
The nurse is assessing a client's pain experience. Which nursing intervention is most effective in
determining the severity of a client's pain?
A. Review the client's medical history and admission assessment.
B. Compare the client's current vital signs to the admission baseline.
C. Note how frequently doses of analgesics have been administered.
D. Ask the client to describe the intensity of the pain being experienced. - Accurate answers D
Which explanation is best for the nurse to provide a client who asks the purpose of using the log rolling
technique for turning?