266 HESI Study Guide Questions & Answers 100% Solved.
HESI STUDY GUIDE
( = was on my 266 HESI V1)
1. A client who underwent cardiac stent placement four days ago
arrives to the emergency department reporting a sudden onset of
chest pressure and shortness of breath. Which action should the nurse
take next?
a. Listen for extra heart sounds, murmurs, and rhythm with
the bell of the stethoscope.
b. Evaluate upper and lower extremities for perfusion, pulse
volume, and pitting edema.
c. Verify troponin level assessments are scheduled every
3-6 hours for a series of three.
d. Obtain a 12- lead electrocardiogram and begin
continuous cardiac monitoring.
3. a client with type 2 diabetes mellitus arrives to the clinic reporting
episodes of weakness and palpitations. Which finding should the
nurse recognize as a possible complication?
a. anxiety and sighing
b. myalgia in wrists and hands
c. hyperactive bowel sounds
d. dark yellow urine
4. While completing a health assessment for a client with migraine
headaches, the nurse assesses bilateral weakness in the clients
hand grips. The client reports joint pain and trouble twisting a door
knob due to weaknesses. Which action should the nurses take in
response to these figures?
a. Implement fall precautions to reduce the clients risk of
injury.
b. Explain that relief of the migraine pain will
reduce related symptoms.
c. Gather additional assessment data about the pain and
weakness.
d. Consult with the occupational therapist for a functional
assessment
Explanation: The nurse should gather additional assessment data about the
pain and weakness to better understand the client's condition and to
determine if there is an underlying issue or if the symptoms are related to
the migraine headaches.
5. A client who has developed acute kidney injury (AKI) due to
aminoglycoside antibiotics has moved from the oliguric phase to the
diuretic phase of AKI. Which parameters are most important for the
nurse to plan to carefully monitor?
a. Uremic irritation of mucous membranes and skin surfaces.
,b. Hypovolemia and electrocardiographic (ECG) changes.
c. Side effects of total parental nutrition (TPN) and Intralipids.
d. Elevated creatinine and blood urea nitrogen (BUN).
, Explanation: During the diuretic phase of AKI, the client may experience increased
urine output, which can lead to hypovolemia and electrolyte imbalances.
Monitoring for hypovolemia and ECG changes can help detect any
complications or worsening of the client's condition.
6. The nurse is caring for a client diagnosed with psoriasis vulgaris
who is receiving psoralen and ultraviolet A light (PUVA) treatment.
Which assessment finding indicates that the client has been
overexposed to the treatment?
a. Thick skin plaques topped by silvery white scales
b. Tenderness upon palpation and generalized erythema
c. Brown, rough, greasy, wart-like papules on the face
d. Requires sunglasses because sunlight hurts eyes
Explanation: Overexposure to PUVA treatment can cause skin irritation,
tenderness, and erythema. If the client exhibits these symptoms, the nurse
should notify the healthcare provider for possible treatment modifications.
7. An adult client who had a gastric bypass surgery 2 weeks ago, is
admitted with possible anastomosis leakage. The client's abdomen is
tender to touch, and the vital signs are temperature 101* F (38 3* C).
heart rate 130 beats/minute, respiratory rate 26 breaths/minute, and
blood pressure 100/50 mmHg. Which intervention is most important
for the nurse to include in the client's plan of care?
a. Encourage regular turning.
b. Monitor skin for breakdown.
c. Strict IV fluid replacement.
d. Assess wound drainage daily.
Explanation: The client's vital signs indicate possible sepsis or systemic infection.
Strict IV fluid replacement is important to maintain adequate circulation,
support blood pressure, and treat potential sepsis. The other interventions
are also essential but not as critical as fluid replacement in this situation.
8. A client who was recently diagnosed with Raynaud’s disease is
concerned about pain management. Which nursing instructions
should the nurse provide?
a. Painful areas should be rubbed gently until the pain
subsides.
b. Return appointments will be needed for IV pain
medications.
c. Enrolling in a pain clinic can provide relief alternatives.
d. Wearing gloves when handling cold items guards
against painful spasms.
Explanation: For clients with Raynaud's disease, cold temperatures can trigger
painful episodes. Instructing the client to wear gloves when handling cold
items can help protect against these episodes and manage pain.
HESI STUDY GUIDE
( = was on my 266 HESI V1)
1. A client who underwent cardiac stent placement four days ago
arrives to the emergency department reporting a sudden onset of
chest pressure and shortness of breath. Which action should the nurse
take next?
a. Listen for extra heart sounds, murmurs, and rhythm with
the bell of the stethoscope.
b. Evaluate upper and lower extremities for perfusion, pulse
volume, and pitting edema.
c. Verify troponin level assessments are scheduled every
3-6 hours for a series of three.
d. Obtain a 12- lead electrocardiogram and begin
continuous cardiac monitoring.
3. a client with type 2 diabetes mellitus arrives to the clinic reporting
episodes of weakness and palpitations. Which finding should the
nurse recognize as a possible complication?
a. anxiety and sighing
b. myalgia in wrists and hands
c. hyperactive bowel sounds
d. dark yellow urine
4. While completing a health assessment for a client with migraine
headaches, the nurse assesses bilateral weakness in the clients
hand grips. The client reports joint pain and trouble twisting a door
knob due to weaknesses. Which action should the nurses take in
response to these figures?
a. Implement fall precautions to reduce the clients risk of
injury.
b. Explain that relief of the migraine pain will
reduce related symptoms.
c. Gather additional assessment data about the pain and
weakness.
d. Consult with the occupational therapist for a functional
assessment
Explanation: The nurse should gather additional assessment data about the
pain and weakness to better understand the client's condition and to
determine if there is an underlying issue or if the symptoms are related to
the migraine headaches.
5. A client who has developed acute kidney injury (AKI) due to
aminoglycoside antibiotics has moved from the oliguric phase to the
diuretic phase of AKI. Which parameters are most important for the
nurse to plan to carefully monitor?
a. Uremic irritation of mucous membranes and skin surfaces.
,b. Hypovolemia and electrocardiographic (ECG) changes.
c. Side effects of total parental nutrition (TPN) and Intralipids.
d. Elevated creatinine and blood urea nitrogen (BUN).
, Explanation: During the diuretic phase of AKI, the client may experience increased
urine output, which can lead to hypovolemia and electrolyte imbalances.
Monitoring for hypovolemia and ECG changes can help detect any
complications or worsening of the client's condition.
6. The nurse is caring for a client diagnosed with psoriasis vulgaris
who is receiving psoralen and ultraviolet A light (PUVA) treatment.
Which assessment finding indicates that the client has been
overexposed to the treatment?
a. Thick skin plaques topped by silvery white scales
b. Tenderness upon palpation and generalized erythema
c. Brown, rough, greasy, wart-like papules on the face
d. Requires sunglasses because sunlight hurts eyes
Explanation: Overexposure to PUVA treatment can cause skin irritation,
tenderness, and erythema. If the client exhibits these symptoms, the nurse
should notify the healthcare provider for possible treatment modifications.
7. An adult client who had a gastric bypass surgery 2 weeks ago, is
admitted with possible anastomosis leakage. The client's abdomen is
tender to touch, and the vital signs are temperature 101* F (38 3* C).
heart rate 130 beats/minute, respiratory rate 26 breaths/minute, and
blood pressure 100/50 mmHg. Which intervention is most important
for the nurse to include in the client's plan of care?
a. Encourage regular turning.
b. Monitor skin for breakdown.
c. Strict IV fluid replacement.
d. Assess wound drainage daily.
Explanation: The client's vital signs indicate possible sepsis or systemic infection.
Strict IV fluid replacement is important to maintain adequate circulation,
support blood pressure, and treat potential sepsis. The other interventions
are also essential but not as critical as fluid replacement in this situation.
8. A client who was recently diagnosed with Raynaud’s disease is
concerned about pain management. Which nursing instructions
should the nurse provide?
a. Painful areas should be rubbed gently until the pain
subsides.
b. Return appointments will be needed for IV pain
medications.
c. Enrolling in a pain clinic can provide relief alternatives.
d. Wearing gloves when handling cold items guards
against painful spasms.
Explanation: For clients with Raynaud's disease, cold temperatures can trigger
painful episodes. Instructing the client to wear gloves when handling cold
items can help protect against these episodes and manage pain.
