Hesi Version 2 Exam 160 Questions and Answers Graded A+ 2025

1. The school nurse is preparing a presentation for a elementary school teachers to inform teachers to inform them about when a child should be referred to the school clinic for further follow-up. The teachers should be instructed to report which situations to the school nurse? (Select all that apply) A. Refuses to complete written homework assignments. B. Thirst and frequent requests for bathroom breaks. C. Bruises on both knees after the weekend. D. Sunburn with blisters on the face, arms, and hands. E. Shaking that changes the child’s hand writing. ANS: B D E 2. When preparing a client for discharge from the hospital following a cystectomy and a urinary diversion to treat bladder cancer, which instruction is most important for the nurse to include in the client’s discharge teaching plan? A. Report any signs of cloudy urine output. B. Frequent empty bladder to avoid distention. C. Follow instructions for self-care toileting. D. Seek counselling for body image. ANS: A 3. A client with renal lithiasis is receiving morphine sulfate every four hours for pain and renal colic. Which assessment finding should prompt the nurse to administer a PRN dose of naloxone? A. Unresponsive to verbal or tactile stimuli. B. Respiratory rate of 12 breath/minute. C. Statements about visual hallucinations. D. Complaints of increasing flank pain. ANS: A lOMoAR cPSD| 4. The mother of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The mother reports no evidence of watery stools. Which nursing intervention should the nurse implement? A. Instruct the mother to change the child’s diaper more often. B. Encourage the mother to apply lotion with each diaper change. C. Ask the mother to decrease the infant’s intake of fruits for 24 hours. D. Tell the mother to cleanse with soap and water at each diaper change. ANS: A 5. The nurse is having difficulty palpating a client’s posterior tibial pulse while the client is lying in a supine position? A. Extend the client’s arm fully while supporting the elbow and attempt to repalpate. B. Apply less pressure when palpating over the middle of the dorsum of the foot. C. Use an ultrasound stethoscope place behind and below the medial bone. D. Help the client to a prone position with the knee slightly flexed and palpate again. ANS: D 6. The nurse implements a tertiary prevention program for type 2 diabetes in a rural health clinic. Which outcome indicates that the program was effective? A. Average client scores improved on specific risk factor knowledge tests. B. Only 30% of clients did not attend self-management education sessions. C. More that 50% of at-risk clients were diagnosed early in the disease process. D. Client who developed disease complications promptly received rehabilitation. ANS: D 7. A client is recovering in the critical care unit following a cardiac catheterization. IV nitroglycerin and heparin are infusing. The client is sedated but responds to verbal instructions. After changing positions, the client complains of pain at the right groin insertion site. What action should the nurse implement? A. Stimulate the client to take deep breaths. B. Evaluate the integrity of the IV insertion site. C. Assess distal lower extremity capillary refill. D. Check femoral site for hematoma formation. ANS: B lOMoAR cPSD| 8. A 7-year old is admitted to the hospital with persistent vomiting, and nasogastric tube attached to low intermittent suction is applied. Which finding is most important for the nurse to report to the healthcare provider? A. Shift intake of 640 ml IV fluids plus 30 ml PO ice chips. B. Serum pH of 7.45 C. Serum potassium of 3.0 mg/dl. D. Gastric output of 100 ml in the last 8 hours. ANS: C 9. A morbidly obese client is scheduled for gastric bypass surgery. The client completes the required preoperative nutritional counselling and signs the operative permit. To promote effective discharge planning, which intervention is most important for the nurse to implement? A. Discuss small, low fat, low sugar meal preparation techniques. B. Advise the client to arrange for dietary counselling after discharged. C. Encourage the client to keep a daily diary for two weeks. D. Suggest that the client’s spouse do the family grocery shopping. ANS: A 10. The nurse is admitting a client from the post anesthesia unit to the postoperative surgical care unit. Which prescription should the nurse implement first? A. Cefazolin 1-gram IVPB q6 hours. B. Complete blood cell count (CBC) in AM. C. Straight catherization if unable to void. D. Advance from clear liquid as tolerated. ANS: lOMoAR cPSD| 11. Which needle should the nurse use to administer intravenous fluids (IV) via a client’s implanted port? ANS: C 12. An older client is referred to a rehabilitation facility following a cerebrovascular accident (CVA). The client is aphasic with left-side paresis and is having difficulty swallowing. Which intervention is most important for the nurse to include in the client’s plan of care? A. Use pictures and gestures to communicate. B. Arrange for daily home care assistance. C. Facilitate a consultation for speech therapy. D. Initiate passive range of motion exercises. ANS: C 13. A client has had several episodes of clear, watery diarrhea that started yesterday. What action should the nurse implement? A. Assess the client for the presence of hemorrhoids. B. Administer a prescribed PRN antiemetic. C. Check the client’s hemoglobin level. D. Review the client’s current list of medications ANS: D lOMoAR cPSD| 14. A mother runs into the emergency department with a toddler in her arms and tells the nurse that her child got into some cleaning products. The child smells of chemicals on hands, face, and on the front of the child's clothes. After ensuring the airway is patent, what action should the nurse implement first? A. Call poison control emergency number. B. Determine type of chemical exposure. C. Obtain equipment for gastric lavage. D. Assess child for altered sensorium. ANS: D 15. When should the nurse conduct an Allen’s test? A. Prior to attempting a cardiac output calculation. B. When pulmonary artery pressures are obtained. C. Just before arterial blood gasses are drawn peripherally. D. To assess for presence of deep vein thrombus in the leg. ANS: C 16. A nurse with 10 years experience working in the emergency room is reassigned to the perinatal unit to work an 8 hour shift. Which client is best to assign to this nurse? A. A mother with an infected episiotomy B. A client who is leaking clear fluid. C. A client at 28-weeks gestation in pre-term labor. D. A mother who just delivered a 9-pound baby. ANS: A 17. A 300 ml unit of packed red blood cells is prescribed for a client with heart failure (HF) who has 3+ pitting edema, shortness of breath with any activity, and activity, and crackles in both lung bases. What rate should the nurse administer the blood? A. 150 ml/hour. B. 75 ml/hour. C. 300 ml/hour. D. 50 ml/hour. ANS: A lOMoAR cPSD| 18. The nurse enters the room of a client with Parkinson’s disease who is taking carbidopa levodopa. The client is arising slowly from the chair while the unlicensed assistive personnel (UAP) stands next to the chair. What action should the nurse take? A. Tell the UAP to assist the client in moving more quickly. B. Offer PRN analgesic to reduce painful movement. C. Affirm that the client should arise slowly from the chair. D. Demonstrate how to help the client move more efficiently. ANS: C 19. Which assessment is more important for the nurse to include in the daily plan of care for a client with a burned extremity? A. Range of Motion B. Distal pulse intensity C. Extremity sensation D. Presence of exudate ANS: B 20. Client is receiving continuous ambulatory peritoneal dialysis since the arteriovenous (AV) graft in the right arm is no longer available for use for hemodialysis. The client has lost weight, has increasing peripheral edema, and has a serum albumin level of 1.5 g/dl (15 g/L). Which intervention is the priority for the nurse to implement? A. Instruct the client to continue to follow the prescribed rigid fluid restriction amount. B. Evaluate patency of the AV graft for resumption of hemodialysis. C. Ensure the client receives frequent small meals containing complete proteins. D. Recommend the use of support stocking to enhance venous return. ANS: C lOMoAR cPSD| 21. An older adult client with systemic inflammatory response syndrome (SIRS) has a temperature of 101.8 F (38.8 C), heart rate of 110 beats/minute, and a respiratory rate of 24 breaths/minute. Which additional finding is most important to report to the healthcare provider? A. Capillary glucose reading of 110 mg/dl (6.1 mmol/L SI) B. Serum creatine of 2.0 mg/dl (176.8 micromol/L SI) C. Hemoglobin of 12. g/dl (120 g/dl SI) D. Blood pressure of 130/88 mm hg. ANS: B 22. The nurse completes auscultation of the thoracic region of an older adult client. Which finding is considered normal for this older adult client? A. High pitched wheezing. B. Hyperresonance. C. Medium crackles. D. Vesicular sounds. ANS: D 23. A client who is admitted for primary hypothyroidism has early signs of myxedema coma. In assessing the client, in which sequence should the nurse completes these actions? (Rank the first action at the top with the remainder in descending order) 1. Observe breathing patterns. 2. Assess blood pressure. 3. Measure body temperature. 4. Palpate for pedal edema. 24. What is the primary goal when planning nursing care for a client with degenerative joint disease (DJD)? A. Achieve satisfactory pain control. B. Obtain adequate rest and sleep. C. Improve stress management skills. D. Reducer risk of infection. ANS: A lOMoAR cPSD| 25. The home care nurse provide self-care instruction for a client chronic venous insufficiency cause by deep vein thrombosis. Which instructions should the nurse include in the client’s discharge teaching plan? (Select all that apply) A. Avoid prolonged standing or sitting B. Use recliner for long period of sitting C. Continue wearing elastic stocking D. Maintain the bed flat while sleeping E. Cross legs at knee but not at ankle ANS: A B C 26. One hour after a lung biopsy, a client returns to the surgical unit. The client is drowsy but easily aroused and follows commands accurately. Which intervention is most important for the nurse to implement? A. Encourage range of motion exercises. B. Notify family of a client’s return to the room. C. Reinforce use of incentive spirometry. D. Offer fluids if gag reflex is intact. ANS: C 27. An older woman who was recently diagnosed with end stage metastatic breast cancer is admitted because she is experiencing shortness of breath and confusion. The client refuses to eat and continuously asks to go home. Arterial blood gases indicate hypoxia. Which intervention is most important for the nurse to implement? A. Prepare for emergent oral intubation B. Offer sips of favorite beverages C. Clarify end of life desires D. Initiate comfort measures ANS: C lOMoAR cPSD| 28. The healthcare provider prescribes the antibiotic Cefdinir 300 mg PO every 12 hours for a client with a postoperative wound infection. Which foods should the nurse encourage this client to eat? A. Yogurt and/or buttermilk. B. Avocados and cheese C. Green leafy vegetables D. Fresh fruits ANS: A 29. A client with cirrhosis of the liver is having numerous, liquid, incontinent stools, and continues to be confused. In reviewing the client’s laboratory studies, the nurse identifies an elevated serum ammonia level. Based on this finding, which prescription is most important for this client to receive? A. Loperamide. B. IV human albumin. C. Lactulose. D. Furosemide. ANS: c 30. After a routine physical examination, the healthcare admits a woman with a history of Systemic Lupus Erythematous (SLE) to the hospital because she has 3+ pitting ankle edema and blood in her urine. Which assessment finding warrants immediate intervention by the nurse? A. Blood pressure 170/98 B. Joint and muscle aches C. Urine output 300 ml/hr D. Dark, rust-colored urine ANS: A 31. The nurse is preparing a client with an acoustic neuroma for a magnetic resonance image (MRI). Which client complaint is life-threatening and should be reported to the healthcare provider immediately? A. Intensifying headache. B. Facial numbness. C. Difficulty with balance. D. Right ear hearing loss. ANS: B lOMoAR cPSD| 32. A nurse changing the dressing of a client with a (UNABLE TO READ), the nurse observes purulent drainage at (UNABLE TO READ). Before reporting this finding to the healthcare provider, the nurse should client’s laboratory values? A. Blood pH level. B. Serum blood glucose level (BG) level. C. Hematocrit. D. Neutrophil count. ANS: 33. An unresponsive male victim of a diving accident is brought to the emergency department where it is determined that immediate surgery is required to save his life. The client is accompanied by a close friend, but no family member are available. What action should the nurse take first? A. Ask the man’s friend to sign the informed consent since the client is unresponsive. B. Notify the unit manager that an emergency court order is needed to allow the surgery. C. Continue to provide life support until a thorough search for a guardian is completed. D. Carry on with the surgical preparation of the client without a signed informed consent ANS: D 34. A young adult female with chronic kidney disease (CKD) due to recurring pyelonephritis is hospitalized with basilar crackles and peripheral edema. She is complaining of severe nausea and the cardiac monitor indicates sinus tachycardia with frequent premature ventricular contraction. Her blood pressure is 200 /110 mm Hg, and her temperature is 101 F which PRN medication should the nurse administers first? A. Enalapril B. Furosemide C. Acetaminophen D. Promethazine ANS: B lOMoAR cPSD| 35.35. The nurse assesses a client who has just returned from a diagnostic study, as seen in the picture. The client has a prescription for a nasogastric tube to low intermittent suction and reports feelings of nausea. What action should the nurse implement first? A. Remove tape from the cheek. B. Administer an IV antiemetic. C. Auscultate bowel sounds. D. Connect the tube to suction. ANS: A 36. Following breakfast, the nurse is preparing to administer 0900 medications to clients on a medical floor. Which medication should be held until a later time? A. The mucosal barrier, sucralfate (Carafate), for a client diagnosed with peptic ulcer disease. B. The antiplatelet agent aspirin, for a client who is scheduled to be discharged within an hour. C. The antifungal nystatin suspension for a client who has just brushed his teeth. D. The loop diuretic furosemide, for a client with a serum potassium level of 4.2 mEqL (4.2 mmol) ANS: A lOMoAR cPSD| 37. A client with a history of upper respiratory symptoms is admitted with chest tightness, a productive cough, and difficulty breathing. The client’s arterial blood gases (ABGs) indicate respiratory acidosis. An increase in which laboratory test results supports this finding? A. Arterial pH. B. PaCO2 C. PaO2 D. HCO3 ANS: B 38. One week after an above the knee amputation (AKA) of the left leg, a male client seems upset and reports that his left foot feels <numb.= What action should the nurse implement? A. Assess wound for signs of inflammation or drainage. B. Assess the right foot for signs of diminished circulation. C. Offer assurance that the numb feeling is temporary. D. Reinforce learning about the cause of this sensation. ANS: C 39. When providing client care, the nurse identifies a problem and develops a related clinical question. Next, the nurse intends to gather evidence so that the decision-making process in response to the problem and clinical question is evidence-based. When gathering evidence, which consideration is most important? A. Frequency that the problem occurs. B. Past experience with similar problems. C. Relevance to the situation. D. Related personal values. ANS: A 40. When obtaining isolation supplies needed to care for a client, which information is most important for the nurse to obtain? A. Antimicrobial medication administration schedule. B. Client’s most recent white blood cell count. C. Mode of transmission of the infectious organism. D. Initial portal of entry. ANS: C lOMoAR cPSD| 41. An older adult who lives alone in a two-story house is admitted after falling while shopping. X-rays revealed a fractured left hip. With no immediate family in the area, the client is concerned about pets at home. Which interventions should the nurse implement first? (Select all that apply) A. Alert social worker of client’s concerns. B. Palpate and mark pedal pulses. C. Assess ability to bear weight when standing. D. Support left leg with two pillows. E. Evaluate pain using a standard pain scale. ANS: B C D E 42. A client with a history of heavy alcohol intake is admitted with acute pancreatitis. The client reports severe abdominal pain, radiating to the back. In positioning the client, which instruction should the nurse provide to the unlicensed assistive personnel (UAP)? A. Motivate the client to stimulate peristalsis. B. Maintain the client in a supine position. C. Assist the client to his side with his knees to his chest. D. Tell client to deep breath and cough every 2 hours. ANS: C 43. A client is admitted to a medical unit with the diagnosis of gastritis and chronic heavy alcohol abuse. What should the nurse administered to prevent the development of Wernicke's syndrome? A. Lorazepam (Ativan) B. Famotidine (Pepcid) C. Thiamine (Vitamin B1) D. Atenolol (Tenormin) ANS: C 44.44. A. B. C. D. ANS: lOMoAR cPSD| 45. For the second time in four months, an overweight client is seen in the clinic because of vulvovaginitis resulting from a Candida infection. Which intervention should the nurse implement first? A. Ask the client about recent sexual activity. B. Determine the client’s typical menstrual cycle. C. Obtain the client’s blood glucose level. D. Review the client’s results for a complete blood count. ANS: A 46. The nurse is providing discharge teaching for a client admitted with diverticulitis. Which type of diet should the nurse recommend? A. Low fat. B. Low protein. C. High fiber. D. Low residue. ANS: C 47. The nurse is caring for a one-week old infant who has a ventriculoperitoneal (VP) shunt that was placed 2 days after birth. Which findings are an indication of a postoperative complication? (Select all that apply) A. Poor feeding and vomiting B. Leakage of CSF from the incisional site C. Hyperactive bowel sound D. Abdominal distention E. White Blood Count of 10000/mm3 ANS: A B D 48. A client who is in active labor and is receiving an infusion of magnesium sulfate becomes confused. Her respiratory rate drops to 4 breaths/minute, and her deep tendon reflexes (DTRs) are absent. After stopping the magnesium infusion, what action should the nurse implement first? A. Administer a STAT does of calcium gluconate. B. Replace the IV solution with normal saline. C. Assess the client’s reflexes every 15 minutes. D. Obtain a sample for serum magnesium levels. ANS: A