BSN 225 HESI Practice Test 2 | Nightingale College 2026 |
Questions & Verified Answers | Latest Update | Graded A+
1. If a nurse finds that a client with protein malnutrition has consumed very few
protein-rich foods in the last 24 hours, what should be the nurse's next step in
patient care?
Initiate a fluid restriction protocol.
Develop a tailored nutrition plan to increase protein intake.
Schedule a follow-up appointment for medication review.
Refer the client to a physical therapist.
2. Which of the following is a correctly structured nursing diagnosis statement?
Altered tissue perfusion related to congestive heart failure.
Ineffective coping related to response to positive biopsy test
results.
Risk for impaired tissue integrity related to client's refusal to turn.
Altered urinary elimination related to urinary tract infection.
3. A client is positive for Chvostek's sign. The client is likely experiencing:
Hypocalcemia
Hyponatremia
Hyperkalemia
Hypercalcemia
,4. A nurse is evaluating a unlicensed assistive personnel (UAP) for proper body
mechanics while lifting a heavy object off the floor. Which action by the UAP
requires follow up?
Test the object's weight to determine if additional assistance is
needed.
Keep feet shoulder width apart.
Hold object close to body upon rising.
Bend from the waist to pick up the object.
5. Why is it important for a nurse to first determine if expected outcomes of
care were achieved during evaluation?
It allows the nurse to document all actions taken during the care.
It ensures that all interventions are prioritized correctly.
It provides a basis for reviewing the rationales behind nursing actions.
It helps assess the effectiveness of the care provided and guides
future nursing actions.
6. A client has an Unna boot applied for treatment of a venous stasis leg ulcer.
The nurse notes that the client's toes are mottled and cool, and the client
verbalizes some numbness and tingling of the foot. The nurse interprets that
the boot:
Has not yet dried
Is improving venous return
Has been applied too tightly
Is controlling leg edema
, 7. In a scenario where a client with spiritual distress refuses to discuss their
feelings about impending death, what should the nurse do to support the
client effectively?
Insist that the client talk about their feelings immediately.
Redirect the conversation to more positive topics.
Encourage the client to express their feelings at their own pace
while providing emotional support.
Tell the client that they should not worry about death.
8. In a scenario where a patient with an indwelling urinary catheter shows signs
of infection, what immediate action should the nurse take to address the
situation?
Increase the patient's fluid intake.
Assess the catheter site for signs of infection.
Notify the physician without assessing the patient.
Remove the catheter immediately.
9. What does a positive Chvostek's sign indicate in a patient?
Hypocalcemia
Dehydration
Hypercalcemia
Hyperkalemia
10. If a patient exhibits a decrease in pulse rate during a fecal impaction
removal, what should the nurse's immediate action be?
Administer oxygen to the patient.
Questions & Verified Answers | Latest Update | Graded A+
1. If a nurse finds that a client with protein malnutrition has consumed very few
protein-rich foods in the last 24 hours, what should be the nurse's next step in
patient care?
Initiate a fluid restriction protocol.
Develop a tailored nutrition plan to increase protein intake.
Schedule a follow-up appointment for medication review.
Refer the client to a physical therapist.
2. Which of the following is a correctly structured nursing diagnosis statement?
Altered tissue perfusion related to congestive heart failure.
Ineffective coping related to response to positive biopsy test
results.
Risk for impaired tissue integrity related to client's refusal to turn.
Altered urinary elimination related to urinary tract infection.
3. A client is positive for Chvostek's sign. The client is likely experiencing:
Hypocalcemia
Hyponatremia
Hyperkalemia
Hypercalcemia
,4. A nurse is evaluating a unlicensed assistive personnel (UAP) for proper body
mechanics while lifting a heavy object off the floor. Which action by the UAP
requires follow up?
Test the object's weight to determine if additional assistance is
needed.
Keep feet shoulder width apart.
Hold object close to body upon rising.
Bend from the waist to pick up the object.
5. Why is it important for a nurse to first determine if expected outcomes of
care were achieved during evaluation?
It allows the nurse to document all actions taken during the care.
It ensures that all interventions are prioritized correctly.
It provides a basis for reviewing the rationales behind nursing actions.
It helps assess the effectiveness of the care provided and guides
future nursing actions.
6. A client has an Unna boot applied for treatment of a venous stasis leg ulcer.
The nurse notes that the client's toes are mottled and cool, and the client
verbalizes some numbness and tingling of the foot. The nurse interprets that
the boot:
Has not yet dried
Is improving venous return
Has been applied too tightly
Is controlling leg edema
, 7. In a scenario where a client with spiritual distress refuses to discuss their
feelings about impending death, what should the nurse do to support the
client effectively?
Insist that the client talk about their feelings immediately.
Redirect the conversation to more positive topics.
Encourage the client to express their feelings at their own pace
while providing emotional support.
Tell the client that they should not worry about death.
8. In a scenario where a patient with an indwelling urinary catheter shows signs
of infection, what immediate action should the nurse take to address the
situation?
Increase the patient's fluid intake.
Assess the catheter site for signs of infection.
Notify the physician without assessing the patient.
Remove the catheter immediately.
9. What does a positive Chvostek's sign indicate in a patient?
Hypocalcemia
Dehydration
Hypercalcemia
Hyperkalemia
10. If a patient exhibits a decrease in pulse rate during a fecal impaction
removal, what should the nurse's immediate action be?
Administer oxygen to the patient.
