BSN 266 Practice HESI
1. A male client receives a local anesthetic during surgery. During the
post-operative assessment, the nurse notices the client is slurring his speech.Which action should
the nurse take?
A. Determine the client is anxious and allow him to sleep.
B. Evaluate his blood pressure, pulse, and respiratory status.
C. Review the client's pre-operative history for alcohol abuse.
D. Continue to monitor the client for reactivity to anesthesia.: B. Evaluate hisblood pressure,
pulse, and respiratory status.
Rationale
Slurred speech in the post-operative client who received a local anesthetic is an atypical
finding and may indicate neurological deficits that require further assess-ment, so obtaining
the client's vital signs will provide information about possible cardiovascular complications,
such as stroke.
2. Which symptoms should the nurse expect a client to exhibit who is diag-nosed with a
pheochromocytoma?
A. Numbness, tingling, and cramps in the extremities.
B. Headache, diaphoresis, and palpitations.
C. Cyanosis, fever, and classic signs of shock.
D. Nausea, vomiting, and muscular weakness.: B. Headache, diaphoresis, andpalpitations.
Rationale
Pheochromocytoma is a catecholamine secreting non-cancerous tumor of the adrenal medulla,
and a headache, profuse sweating and palpitations is the typicaltriad of symptoms depending
upon the relative proportions of epinephrine and norepinephrine secretion. Surgical removal
of the tumor is the only treatment.
3. A client with diabetes mellitus is experiencing polyphagia. Which outcomestatement is the
priority for this client?
A. Fluid and electrolyte balance.
B. Prevention of water toxicity.
C. Reduced glucose in the urine.
D. Adequate cellular nourishment.: D. Adequate cellular nourishment.Rationale
Diabetes mellitus Type 1 is characterized by hyperglycemia that precipitates gluco-suria and
polyuria (frequent urination), polydipsia (excessive thirst), and polyphagia(excessive hunger).
,Polyphagia is a consequence of cellular malnourishment wheninsulin deficiency prevents
utilization of glucose into the cell for energy, so the outcome statement should include
stabilization of adequate cellular nutrition whichis done by providing the insulin supplement
the client needs.
4. The nurse is teaching a female client about the best time to plan sexual in-tercourse in order
to conceive. Which information should the nurse provide?
A. Two weeks before menstruation.
B. Vaginal mucous discharge is thick.
C. Low basal temperature.
D. First thing in the morning.: A. Two weeks before menstruation.Rationale
Ovulation typically occurs 14 days before menstruation begins during a typical28 day cycle.
Sexual intercourse should occur within 24 hours of ovulation foran increase chance of
conception to occur. High estrogen levels occur during
ovulation and increase the vaginal mucous membrane characteristics to become more
"slippery" and stretchy, along with a rise in basal temperature. The timing during the day is not
as significant in determining conception as the day before andafter ovulation.
5. Which intervention should the nurse plan to implement when caring for aclient who has
just undergone a right above-the-knee amputation?
A. Maintain the residual limb on three pillows at all times.
B. Place a large tourniquet at the client's bedside.
C. Apply constant, direct pressure to the residual limb.
D. Do not allow the client to lie in the prone position. Submit: B. Place a large tourniquet at
the client's bedside.Rationale
A large tourniquet should be placed in plain sight at the client's bedside, in the event severe
bleeding occurs. The purpose is to have the tourniquet available to applied to the residual limb to
control bleeding if hemorrhaging was to occur. The residual limb should not be placed on a
pillow because a flexion contracture of the hip may result
and the client should be encouraged to lie in the prone position to prevent flexion contracture
of the hip
6. Two days postoperative, a male client reports aching pain in his left leg. The nurse assesses
redness and warmth on the lower left calf. What intervention would be most helpful to this
client?
A. Apply sequential compression devices (SCDs) bilaterally.
B. Assess for a positive Homan's sign in each leg.
C. Pad all bony prominences on the affected leg.
,D. Advise the client to remain in bed with the leg elevated.: D. Advise the clientto remain in
bed with the leg elevated.
Rationale
The client is exhibiting symptoms of deep vein thrombosis (DVT), a complication of
immobility. The initial care includes bedrest and elevation of the extremity.
7. A client is admitted for further testing to confirm sarcoidosis. Which diag- nostic test
provides definitive information that the nurse should report to thehealthcare provider?
A. Lung tissue biopsy.
B. Positive blood cultures.
C. Magnetic resonance imaging (MRI).
D. Computerized tomography (CT) of the thorax.Submit: A. Lung tissue biopsy.
Rationale
Sarcoidosis is an inflammatory condition that is characterized by the formation ofwidespread
granulomatous lesions involving a pulmonary primary site. Although chest radiography
identifies sarcoidosis, lung tissue biopsy obtained by bron- choscopy or bronchoalveolar
lavage provides definitive confirmation.
8. Small bowel obstruction is a condition characterized by which finding?
A. Severe fluid and electrolyte imbalances.
B. Metabolic acidosis.
C. Ribbon-like stools.
D. Intermittent lower abdominal cramping.: A. Severe fluid and electrolyte imbal-ances.
Rationale
Among the findings characteristic of a small bowel obstruction is the presence ofsevere fluid
and electrolyte imbalances.
9. The nurse is assessing a client with chronic kidney disease (CKD). Whichfinding is most
important for the nurse to respond to first?
A. Potassium 6.0 mEq.
B. Daily urine output of 400 ml.
C. Peripheral neuropathy.
D. Uremic fetor.: A. Potassium 6.0 mEq.Rationale
Hyperkalemia (normal serum level, 3.5 to 5.5 mEq) is a serious electrolyte disorder that can
cause fatal arrhythmias, so the elevation of the potassium level is a nursingpriority.
10. A middle-aged male client with diabetes continues to eat an abundance offoods that are
, high in sugar and fat. According to the Health Belief Model, which event is most likely to
increase the client's willingness to become compliant with the prescribed diet?
A. He visits his diabetic brother who just had surgery to amputate an infectedfoot.
B. He is provided with the most current information about the dangers ofuntreated diabetes.
C. He comments on the community service announcements about preventingcomplications
associated with diabetes.
D. His wife expresses a sincere willingness to prepare meals that are within his prescribed diet.:
A. He visits his diabetic brother who just had surgery to amputatean infected foot.
Rationale
The loss of a limb due to diabetes by a family member should be the strongest event or "cue to
action" and is most likely to increase the client's perceived seriousness ofthe disease.
11. A female client requests information about using the calendar method ofcontraception.
Which assessment is most important for the nurse to obtain?
A. Amount of weight gain or weight loss during the previous year.
B. An accurate menstrual cycle diary for the past 6 to 12 months.
C. Skin pigmentation and hair texture for evidence of hormonal changes.
D. Previous birth-control methods and beliefs about the calendar method.: B.An accurate
menstrual cycle diary for the past 6 to 12 months.
Rationale
The fertile period, which occurs 2 weeks prior to the onset of menses, is determined using an
accurate record of the number of days of the menstrual cycles for the past 6 months, so it is
most important to emphasize to the client that accuracy and being compliant in recording the
menstrual diary is the basis of the calendar method.
12. The nurse assesses a client with advanced cirrhosis of the liver for signs of hepatic
encephalopathy. Which finding would the nurse consider an indication of progressive hepatic
encephalopathy?
A. An increase in abdominal girth.
B. Hypertension and a bounding pulse.
C. Decreased bowel sounds.
D. Difficulty in handwriting.: D. Difficulty in handwriting.Rationale
A daily record in handwriting may provide evidence of progression or reversal of hepatic
encephalopathy leading to coma (D). (A) is a sign of ascites. (B) are not seenwith hepatic
encephalopathy. (C) does not indicate an increase in serum ammonialevel which is the
primary cause of hepatic encephalopathy.
1. A male client receives a local anesthetic during surgery. During the
post-operative assessment, the nurse notices the client is slurring his speech.Which action should
the nurse take?
A. Determine the client is anxious and allow him to sleep.
B. Evaluate his blood pressure, pulse, and respiratory status.
C. Review the client's pre-operative history for alcohol abuse.
D. Continue to monitor the client for reactivity to anesthesia.: B. Evaluate hisblood pressure,
pulse, and respiratory status.
Rationale
Slurred speech in the post-operative client who received a local anesthetic is an atypical
finding and may indicate neurological deficits that require further assess-ment, so obtaining
the client's vital signs will provide information about possible cardiovascular complications,
such as stroke.
2. Which symptoms should the nurse expect a client to exhibit who is diag-nosed with a
pheochromocytoma?
A. Numbness, tingling, and cramps in the extremities.
B. Headache, diaphoresis, and palpitations.
C. Cyanosis, fever, and classic signs of shock.
D. Nausea, vomiting, and muscular weakness.: B. Headache, diaphoresis, andpalpitations.
Rationale
Pheochromocytoma is a catecholamine secreting non-cancerous tumor of the adrenal medulla,
and a headache, profuse sweating and palpitations is the typicaltriad of symptoms depending
upon the relative proportions of epinephrine and norepinephrine secretion. Surgical removal
of the tumor is the only treatment.
3. A client with diabetes mellitus is experiencing polyphagia. Which outcomestatement is the
priority for this client?
A. Fluid and electrolyte balance.
B. Prevention of water toxicity.
C. Reduced glucose in the urine.
D. Adequate cellular nourishment.: D. Adequate cellular nourishment.Rationale
Diabetes mellitus Type 1 is characterized by hyperglycemia that precipitates gluco-suria and
polyuria (frequent urination), polydipsia (excessive thirst), and polyphagia(excessive hunger).
,Polyphagia is a consequence of cellular malnourishment wheninsulin deficiency prevents
utilization of glucose into the cell for energy, so the outcome statement should include
stabilization of adequate cellular nutrition whichis done by providing the insulin supplement
the client needs.
4. The nurse is teaching a female client about the best time to plan sexual in-tercourse in order
to conceive. Which information should the nurse provide?
A. Two weeks before menstruation.
B. Vaginal mucous discharge is thick.
C. Low basal temperature.
D. First thing in the morning.: A. Two weeks before menstruation.Rationale
Ovulation typically occurs 14 days before menstruation begins during a typical28 day cycle.
Sexual intercourse should occur within 24 hours of ovulation foran increase chance of
conception to occur. High estrogen levels occur during
ovulation and increase the vaginal mucous membrane characteristics to become more
"slippery" and stretchy, along with a rise in basal temperature. The timing during the day is not
as significant in determining conception as the day before andafter ovulation.
5. Which intervention should the nurse plan to implement when caring for aclient who has
just undergone a right above-the-knee amputation?
A. Maintain the residual limb on three pillows at all times.
B. Place a large tourniquet at the client's bedside.
C. Apply constant, direct pressure to the residual limb.
D. Do not allow the client to lie in the prone position. Submit: B. Place a large tourniquet at
the client's bedside.Rationale
A large tourniquet should be placed in plain sight at the client's bedside, in the event severe
bleeding occurs. The purpose is to have the tourniquet available to applied to the residual limb to
control bleeding if hemorrhaging was to occur. The residual limb should not be placed on a
pillow because a flexion contracture of the hip may result
and the client should be encouraged to lie in the prone position to prevent flexion contracture
of the hip
6. Two days postoperative, a male client reports aching pain in his left leg. The nurse assesses
redness and warmth on the lower left calf. What intervention would be most helpful to this
client?
A. Apply sequential compression devices (SCDs) bilaterally.
B. Assess for a positive Homan's sign in each leg.
C. Pad all bony prominences on the affected leg.
,D. Advise the client to remain in bed with the leg elevated.: D. Advise the clientto remain in
bed with the leg elevated.
Rationale
The client is exhibiting symptoms of deep vein thrombosis (DVT), a complication of
immobility. The initial care includes bedrest and elevation of the extremity.
7. A client is admitted for further testing to confirm sarcoidosis. Which diag- nostic test
provides definitive information that the nurse should report to thehealthcare provider?
A. Lung tissue biopsy.
B. Positive blood cultures.
C. Magnetic resonance imaging (MRI).
D. Computerized tomography (CT) of the thorax.Submit: A. Lung tissue biopsy.
Rationale
Sarcoidosis is an inflammatory condition that is characterized by the formation ofwidespread
granulomatous lesions involving a pulmonary primary site. Although chest radiography
identifies sarcoidosis, lung tissue biopsy obtained by bron- choscopy or bronchoalveolar
lavage provides definitive confirmation.
8. Small bowel obstruction is a condition characterized by which finding?
A. Severe fluid and electrolyte imbalances.
B. Metabolic acidosis.
C. Ribbon-like stools.
D. Intermittent lower abdominal cramping.: A. Severe fluid and electrolyte imbal-ances.
Rationale
Among the findings characteristic of a small bowel obstruction is the presence ofsevere fluid
and electrolyte imbalances.
9. The nurse is assessing a client with chronic kidney disease (CKD). Whichfinding is most
important for the nurse to respond to first?
A. Potassium 6.0 mEq.
B. Daily urine output of 400 ml.
C. Peripheral neuropathy.
D. Uremic fetor.: A. Potassium 6.0 mEq.Rationale
Hyperkalemia (normal serum level, 3.5 to 5.5 mEq) is a serious electrolyte disorder that can
cause fatal arrhythmias, so the elevation of the potassium level is a nursingpriority.
10. A middle-aged male client with diabetes continues to eat an abundance offoods that are
, high in sugar and fat. According to the Health Belief Model, which event is most likely to
increase the client's willingness to become compliant with the prescribed diet?
A. He visits his diabetic brother who just had surgery to amputate an infectedfoot.
B. He is provided with the most current information about the dangers ofuntreated diabetes.
C. He comments on the community service announcements about preventingcomplications
associated with diabetes.
D. His wife expresses a sincere willingness to prepare meals that are within his prescribed diet.:
A. He visits his diabetic brother who just had surgery to amputatean infected foot.
Rationale
The loss of a limb due to diabetes by a family member should be the strongest event or "cue to
action" and is most likely to increase the client's perceived seriousness ofthe disease.
11. A female client requests information about using the calendar method ofcontraception.
Which assessment is most important for the nurse to obtain?
A. Amount of weight gain or weight loss during the previous year.
B. An accurate menstrual cycle diary for the past 6 to 12 months.
C. Skin pigmentation and hair texture for evidence of hormonal changes.
D. Previous birth-control methods and beliefs about the calendar method.: B.An accurate
menstrual cycle diary for the past 6 to 12 months.
Rationale
The fertile period, which occurs 2 weeks prior to the onset of menses, is determined using an
accurate record of the number of days of the menstrual cycles for the past 6 months, so it is
most important to emphasize to the client that accuracy and being compliant in recording the
menstrual diary is the basis of the calendar method.
12. The nurse assesses a client with advanced cirrhosis of the liver for signs of hepatic
encephalopathy. Which finding would the nurse consider an indication of progressive hepatic
encephalopathy?
A. An increase in abdominal girth.
B. Hypertension and a bounding pulse.
C. Decreased bowel sounds.
D. Difficulty in handwriting.: D. Difficulty in handwriting.Rationale
A daily record in handwriting may provide evidence of progression or reversal of hepatic
encephalopathy leading to coma (D). (A) is a sign of ascites. (B) are not seenwith hepatic
encephalopathy. (C) does not indicate an increase in serum ammonialevel which is the
primary cause of hepatic encephalopathy.
