BSN 266 HESI REVIEW
1. The nurse is caring for a client scheduled to undergo insertion of a percu- taneous
endoscopic gastrostomy (PEG) tube. The client asks the nurse to ex- plain how a PEG tube
differs from a gastrostomy tube (GT). Which explanationbest describes how they are different?
A. Method of insertion.
B. Location of the tubes.
C. Diameter of the tubes.
D. Procedure for feedings.: ARationale
The best explanation of how a PEG tube differs from a GT is by the method of
insertion. GT insertion involves making an incision in the wall of the abdomen and suturing
the tube to the gastric wall. A PEG tube is more commonly used due to thefact it does not
require general anesthesia and less invasive due to being inserted with endoscopic
visualization through the esophagus into the stomach and then pulled through a small incision
in the abdominal wall and held in place by a tiny plasticdevice called a "bumper" that holds the
g-tube in place inside the stomach and a small water-filled balloon which keeps the stomach
in place against the abdominal wall
2. A client with a recent history of blood in his stools is scheduled for a proc-
tosigmoidoscopy. The nurse should implement which protocols to prepare the client for this
procedure? (Select all that apply.)
Select all that apply
A. Obtain consent for the procedure.
B. Initiate preoperative sedation.
C. Begin fast the morning of the procedure.
D. Administer an enema before the procedure.
E. Provide a clear-liquid diet 48 hours before the procedure: D,ERationale
The usual preoperative preparation for proctosigmoidoscopy entails obtaining the client's
consent to the procedure, a clear-liquid diet for 24 to 48 hours prior to the procedure,
administration of an enema, and fasting on the morning of the procedure.
3. A female client with type 2 diabetes mellitus reports dysuria. Which as- sessment finding
is most important for the nurse to report to the healthcareprovider?
A. Suprapublic pain and distention.
B. Bounding pulse at 100 beats/minute.
C. Fingerstick glucose of 300 mg/dl.
D. Small vesicular perineal lesions.: CRationale
,Elevated fingerstick glucose levels need to be reported to the healthcare provider, so a plan of
care can be adjusted to treat the elevated glucose level. Also, elevatedglucose levels spill into
the urine and provide a medium for bacterial growth
4. When planning care for a client with right renal calculi, which nursingdiagnosis has the
highest priority?
A. Acute pain related to movement of the stone.
B. Impaired urinary elimination related to obstructed flow of urine.
C. Risk for infection related to urinary stasis.
D. Deficient knowledge related to need for prevention of recurrence of calculi.-
:A
Rationale
The nursing diagnosis of the highest priority is "Acute pain related the the renal calculi's
movement".
5. A client asks the nurse about the purpose of beginning chemotherapy (CT) because the
tumor is still very small. Which information supports the explanation that the nurse should
provide?
A. Side effects are less likely if therapy is started early.
B. Collateral circulation increases as the tumor grows.
C. The sensitivity of cancer cells to CT is based on cell cycle rate.
D. The cell count of the tumor reduces by half with each dose: DRationale
Initiating chemotherapy while the tumor is small provides a better chance of erad-icating all
cancer cells because 50% of cancer cells or tumor cells are killed with each dose.
6. The nurse is caring for a client with end stage liver disease who is being assessed for the
presence of asterixis. To assess the client for asterixis, whatposition should the nurse ask the
client to demonstrate?
A. Extend the left arm laterally with the left palm upward.
B. Extend the arm, dorsiflex the wrist, and extend the fingers.
C. Extend the arms and hold this position for 30 seconds.
D. Extend arms with both legs adducted to shoulder width.: BRationale
Asterixis (flapping tremor, liver flap) is a hand-flapping tremor that is often seen frequently in
hepatic encephalopathy. The tremor is induced by extending the armand dorsiflexing the wrist
causing rapid, non-rhythmic extension and flexion of thewrist while attempting to hold
position.
7. The nurse is caring for a client who is two days postoperative. Which observation should
,alert the nurse to call the Rapid Response Team (RRT)?
A. Fresh bleeding noted on abdominal surgical wound dressing.
B. Pulse change from 85 to160 beats/minute lasting more than 10 minutes.
C. Temperature of 103.1 F and white blood cell (WBC) count of 16,000 mm3.
D. Weakness, diaphoresis, complaints of feeling faint. BP 100/56 mm Hg.: BRationale
The RRT should be called to intervene for a client with an acute life-threatening change, such
as a pulse change resulting in tachycardia for a prolonged time in apost-operative client.
8. The nurse is caring for a client who is admitted with a hemorrhagic stroke.Which nursing
action should be included in the plan of care?
A. Perform active range of motion three times daily.
B. Monitor for Battle's sign every four hours.
C. Teach measures to avoid the Valsalva maneuver.Maintain the head of bed in a flat position:
C Rationale
The Valsalva maneuver, straining with bowel movements while holding one's breath,increases
intracerebral pressure (ICP) which may induce bleeding or rupture of cerebral blood vessels
9. A client who has just tested positive for human immunodeficiency virus (HIV) does not
appear to hear what the nurse is saying during post-test counseling. Which information should
the nurse offer to facilitate the client'sadjustment to HIV infection?
A. Inform the client how to protect sexual and needle-sharing partners.
B. Teach the client about the medications that are available for treatment.
C. Identify the need to test others who have had risky contact with the client.
D. Discuss retesting to verify the results, which will ensure continuing con-tact.: D
Rationale
Encouraging retesting supports hope and gives the client time to cope with the diag- nosis.
Although post-test counseling should include education, retesting encourages the client to
maintain medical follow-up and management.
10. The nurse is preparing a client for orthopedic surgery on the left leg andcompleting a
safety checklist before transport to the operating room. Whichitems should the nurse remove
from the client? (Select all that apply.) Select all that apply
A. Nail polish.
B. Hearing aid.
C. Wedding band.
D. Left leg brace.
, E. Contact lenses.
F. Partial dentures.: AB,E,FRationale
The removal of nail polish provides a more accurate pulse oximetry readings and evaluation
of capillary refill. Hearing aids, contact lenses, and partial dentures are removed to prevent
damage, loss or misplacement, or injury during surgery. Ideally,give the client's significant
other the contact lenses if they are not the disposable ones, hearing aids and partial dentures
once placed in an appropriate labeled container to hold for safe keeping. If no significant other
is not able to hold onto theitems, then secured them in an appropriate and safe place
11. What instruction should the nurse include in the discharge teaching for aclient who needs
to perform self-catheterization technique at home?
A. Catheterize every 3 to 4 hours.
B. Maintain sterile technique.
C. Use the Cred maneuver before catheterization.
D. Drink 500 ml of fluid within 2 hours of catheterization.: ARationale
The average interval between catheterizations for adults is every 3 to 4 hours. Although sterile
technique is indicated in healthcare facilities, clean technique isoften followed by the client
when performing self-catheterization at home
12. The nurse assesses a long-term resident of a nursing home and finds theclient has a fungal
infection (candidiasis) beneath both breasts. To prevent nosocomial infection, which protocol
should the nurse review with the rest ofthe staff?
A. Follow contact isolation procedures.
B. Wash hands after caring for the client.
C. Wear gloves when providing personal care.
D. Restrict pregnant staff or visitors into the room.: BRationale
The organism Candida albicans, which causes this infection, is part of the normal flora on the
skin of most adults. Good handwashing is all that is needed to preventnosocomial spread.
13. What assessment finding should the nurse identify that indicates a clientwith an acute
asthma exacerbation is beginning to improve after treatment?
A. Wheezing becomes louder.
B. Cough remains unproductive.
C. Vesicular breath sounds decrease.
D. Bronchodilators stimulate coughing.: ARationale
In an acute asthma attack, air flow may be so significantly restricted that breath sounds and
wheezing is diminished. If the client is successfully responding to bronchodilators and
1. The nurse is caring for a client scheduled to undergo insertion of a percu- taneous
endoscopic gastrostomy (PEG) tube. The client asks the nurse to ex- plain how a PEG tube
differs from a gastrostomy tube (GT). Which explanationbest describes how they are different?
A. Method of insertion.
B. Location of the tubes.
C. Diameter of the tubes.
D. Procedure for feedings.: ARationale
The best explanation of how a PEG tube differs from a GT is by the method of
insertion. GT insertion involves making an incision in the wall of the abdomen and suturing
the tube to the gastric wall. A PEG tube is more commonly used due to thefact it does not
require general anesthesia and less invasive due to being inserted with endoscopic
visualization through the esophagus into the stomach and then pulled through a small incision
in the abdominal wall and held in place by a tiny plasticdevice called a "bumper" that holds the
g-tube in place inside the stomach and a small water-filled balloon which keeps the stomach
in place against the abdominal wall
2. A client with a recent history of blood in his stools is scheduled for a proc-
tosigmoidoscopy. The nurse should implement which protocols to prepare the client for this
procedure? (Select all that apply.)
Select all that apply
A. Obtain consent for the procedure.
B. Initiate preoperative sedation.
C. Begin fast the morning of the procedure.
D. Administer an enema before the procedure.
E. Provide a clear-liquid diet 48 hours before the procedure: D,ERationale
The usual preoperative preparation for proctosigmoidoscopy entails obtaining the client's
consent to the procedure, a clear-liquid diet for 24 to 48 hours prior to the procedure,
administration of an enema, and fasting on the morning of the procedure.
3. A female client with type 2 diabetes mellitus reports dysuria. Which as- sessment finding
is most important for the nurse to report to the healthcareprovider?
A. Suprapublic pain and distention.
B. Bounding pulse at 100 beats/minute.
C. Fingerstick glucose of 300 mg/dl.
D. Small vesicular perineal lesions.: CRationale
,Elevated fingerstick glucose levels need to be reported to the healthcare provider, so a plan of
care can be adjusted to treat the elevated glucose level. Also, elevatedglucose levels spill into
the urine and provide a medium for bacterial growth
4. When planning care for a client with right renal calculi, which nursingdiagnosis has the
highest priority?
A. Acute pain related to movement of the stone.
B. Impaired urinary elimination related to obstructed flow of urine.
C. Risk for infection related to urinary stasis.
D. Deficient knowledge related to need for prevention of recurrence of calculi.-
:A
Rationale
The nursing diagnosis of the highest priority is "Acute pain related the the renal calculi's
movement".
5. A client asks the nurse about the purpose of beginning chemotherapy (CT) because the
tumor is still very small. Which information supports the explanation that the nurse should
provide?
A. Side effects are less likely if therapy is started early.
B. Collateral circulation increases as the tumor grows.
C. The sensitivity of cancer cells to CT is based on cell cycle rate.
D. The cell count of the tumor reduces by half with each dose: DRationale
Initiating chemotherapy while the tumor is small provides a better chance of erad-icating all
cancer cells because 50% of cancer cells or tumor cells are killed with each dose.
6. The nurse is caring for a client with end stage liver disease who is being assessed for the
presence of asterixis. To assess the client for asterixis, whatposition should the nurse ask the
client to demonstrate?
A. Extend the left arm laterally with the left palm upward.
B. Extend the arm, dorsiflex the wrist, and extend the fingers.
C. Extend the arms and hold this position for 30 seconds.
D. Extend arms with both legs adducted to shoulder width.: BRationale
Asterixis (flapping tremor, liver flap) is a hand-flapping tremor that is often seen frequently in
hepatic encephalopathy. The tremor is induced by extending the armand dorsiflexing the wrist
causing rapid, non-rhythmic extension and flexion of thewrist while attempting to hold
position.
7. The nurse is caring for a client who is two days postoperative. Which observation should
,alert the nurse to call the Rapid Response Team (RRT)?
A. Fresh bleeding noted on abdominal surgical wound dressing.
B. Pulse change from 85 to160 beats/minute lasting more than 10 minutes.
C. Temperature of 103.1 F and white blood cell (WBC) count of 16,000 mm3.
D. Weakness, diaphoresis, complaints of feeling faint. BP 100/56 mm Hg.: BRationale
The RRT should be called to intervene for a client with an acute life-threatening change, such
as a pulse change resulting in tachycardia for a prolonged time in apost-operative client.
8. The nurse is caring for a client who is admitted with a hemorrhagic stroke.Which nursing
action should be included in the plan of care?
A. Perform active range of motion three times daily.
B. Monitor for Battle's sign every four hours.
C. Teach measures to avoid the Valsalva maneuver.Maintain the head of bed in a flat position:
C Rationale
The Valsalva maneuver, straining with bowel movements while holding one's breath,increases
intracerebral pressure (ICP) which may induce bleeding or rupture of cerebral blood vessels
9. A client who has just tested positive for human immunodeficiency virus (HIV) does not
appear to hear what the nurse is saying during post-test counseling. Which information should
the nurse offer to facilitate the client'sadjustment to HIV infection?
A. Inform the client how to protect sexual and needle-sharing partners.
B. Teach the client about the medications that are available for treatment.
C. Identify the need to test others who have had risky contact with the client.
D. Discuss retesting to verify the results, which will ensure continuing con-tact.: D
Rationale
Encouraging retesting supports hope and gives the client time to cope with the diag- nosis.
Although post-test counseling should include education, retesting encourages the client to
maintain medical follow-up and management.
10. The nurse is preparing a client for orthopedic surgery on the left leg andcompleting a
safety checklist before transport to the operating room. Whichitems should the nurse remove
from the client? (Select all that apply.) Select all that apply
A. Nail polish.
B. Hearing aid.
C. Wedding band.
D. Left leg brace.
, E. Contact lenses.
F. Partial dentures.: AB,E,FRationale
The removal of nail polish provides a more accurate pulse oximetry readings and evaluation
of capillary refill. Hearing aids, contact lenses, and partial dentures are removed to prevent
damage, loss or misplacement, or injury during surgery. Ideally,give the client's significant
other the contact lenses if they are not the disposable ones, hearing aids and partial dentures
once placed in an appropriate labeled container to hold for safe keeping. If no significant other
is not able to hold onto theitems, then secured them in an appropriate and safe place
11. What instruction should the nurse include in the discharge teaching for aclient who needs
to perform self-catheterization technique at home?
A. Catheterize every 3 to 4 hours.
B. Maintain sterile technique.
C. Use the Cred maneuver before catheterization.
D. Drink 500 ml of fluid within 2 hours of catheterization.: ARationale
The average interval between catheterizations for adults is every 3 to 4 hours. Although sterile
technique is indicated in healthcare facilities, clean technique isoften followed by the client
when performing self-catheterization at home
12. The nurse assesses a long-term resident of a nursing home and finds theclient has a fungal
infection (candidiasis) beneath both breasts. To prevent nosocomial infection, which protocol
should the nurse review with the rest ofthe staff?
A. Follow contact isolation procedures.
B. Wash hands after caring for the client.
C. Wear gloves when providing personal care.
D. Restrict pregnant staff or visitors into the room.: BRationale
The organism Candida albicans, which causes this infection, is part of the normal flora on the
skin of most adults. Good handwashing is all that is needed to preventnosocomial spread.
13. What assessment finding should the nurse identify that indicates a clientwith an acute
asthma exacerbation is beginning to improve after treatment?
A. Wheezing becomes louder.
B. Cough remains unproductive.
C. Vesicular breath sounds decrease.
D. Bronchodilators stimulate coughing.: ARationale
In an acute asthma attack, air flow may be so significantly restricted that breath sounds and
wheezing is diminished. If the client is successfully responding to bronchodilators and
