Hesi Level 2 Practice Questions with Complete Rationale

What assessment finding should the nurse identify that indicates a client with an acute asthma exacerbation is beginning to improve after treatment? A. Vesicular breath sounds decrease B. Bronchodilators stimulate coughing C. Cough remains unproductive D. Wheezing becomes louder - Answer : Wheezing becomes louder. In an acute asthma attack, air flow may be so significantly restricted that wheezing is diminished. If the client is successfully responding to bronchodilators and respiratory treatments, wheezing becomes louder (A) as air flow increases in the airways. As the airways open and mucous is mobilized in response to treatment, the cough becomes more productive, not (B). Vesicular sounds are soft, low-pitched, gentle, rustling sounds heard over lung fields (C) and is not an indicator of improvement during asthma treatment. Bronchodilators do not stimulate coughing (D). A client with sickle cell anemia is admitted with severe abdominal pain and the diagnosis is sickle cell crisis. What is the most important nursing action to implement? A. Evaluate the effectiveness of narcotic analgesics. B. Limit the client's intake of oral fluids and food. C. Teach the client about prevention of crises. D. Encourage the client to ambulate as tolerated. - Answer: Evaluate the effectiveness of narcotic analgesics. Pain management is the priority for a client during sickle cell crisis. Continuous narcotic analgesics are the mainstay of pain control, which should be evaluated (B) frequently to determine if the client's pain is adequately controlled. (A, C, and D) are not indicated at this time. The nurse is assessing a middle-aged male client for risk factors related to chronic illness. Which finding should the nurse assess further? A. Thinning hair and dry scalp. B. Increase in muscle tone but decreased muscle strength. C. Increase in abdominal fat deposits. D. Increase in appetite and taste-bud acuity. - Answer: Increase in abdominal fat deposits. An increase in the abdominal girth (D) may be indicative of the onset of metabolic syndrome, which places the client at risk for cardiac disease and requires further assessment. During middle adulthood, common findings include thinning hair, dry skin and scalp (A), changes in taste bud acuity (B), and muscle size and strength (C), which are consistent with normal system functioning during aging. The nurse is caring for a male client who had an inguinal herniorrhaphy 3 hours ago. The nurse determines the client's lower abdomen is distended and assesses dullness to percussion. What is the priority nursing action? A. Assessment of the client's vital signs. B. Determine the time the client last voided. C. Document the finding as the only action. D. Insert a rectal tube for the passage of flatus. - Answer: Determine the time the client last voided. Swelling at the surgical site in the immediate postoperative period can impact the bladder and prostate area causing the client to experience difficulty voiding due to pressure on the urethra. To provide additional data supporting bladder distention, the last time the client voided (C) should be determined next. Documentation (B) should be made, but the client's distended bladder requires additional intervention. (A and D) are not priority actions based on the client's abdominal findings. The nurse is giving discharge instructions to a client with chronic prostatitis. What instruction should the nurse provide the client to reduce the risk of spreading the infection to other areas of the client's urinary tract? A. Avoid consuming alcohol and caffeinated beverages. B. Wear a condom when having sexual intercourse. C. Have intercourse or masturbate at least twice a week. D. Empty the bladder completely with each voiding. - Answer: Have intercourse or masturbate at least twice a week. The prostate is not easily penetrated by antibiotics and can serve as a reservoir for microorganisms, which can infect other areas of the genitourinary tract. Draining the prostate regularly through intercourse or masturbation (D) decreases the number of microorganisms present and reduces the risk for further infection from stored contaminated fluids. (A, B, and C) do not reduce the risk of spreading the infection internally. A 3-year-old boy is brought to the emergency room because of a possible diazepam (Valium) overdose. He is lethargic and confused, and his vital signs are: pulse rate 100 beats/minute, respiratory rate 20 breaths/minute, and blood pressure 70/30. Which nursing intervention has the highest priority? A. Insert an orogastric tube for gastric lavage. B. Prepare a set-up for an endotracheal intubation. C.Draw blood for stat chemistries and blood gases. D. Insert a Foley catheter to monitor renal functioning. - Answer: Prepare a set-up for an endotracheal intubation. Diazepam causes respiratory depression, so preparation for intubation (B) to protect the airway is the priority intervention at this time. (A) may be necessary, but the child is lethargic and confused, with a lowered respiratory rate, so (B) takes priority. (C and D) are interventions that should be implemented, but they are both secondary to ensuring an open airway. The nurse is developing a plan of care for a newborn with a colostomy due to anal agenesis, and the infant has had three loose stools since surgery yesterday. Which nursing diagnosis has the highest priority? A. Pain related to postoperative condition. B. Potential for fluid volume deficit. C. Alteration in bowel elimination. D. Anxiety of parents related to newborn's condition. - Answer: Potential for fluid volume deficit. All stated nursing diagnoses are appropriate for a postoperative colostomy client. However, fluid balance is the priority concern (A) for any newborn infant. Though three loose stools in 24-hours is not significant, depending on the amount of fluid lost with each stool, potential for fluid volume deficit is always a concern for a postoperative infant. Newborns are extremely vulnerable to fluid imbalances due to immature body systems and a larger percentage of their body weight consisting of fluid. (B, C, and D) do not have the priority of (A). The community health nurse teaches the parents of school-aged children about the need for fluoride as part of a dental health program. Which statement by the parents indicates that they understand the teaching? A. "Having our children brush with fluoride toothpaste is not effective." B. "Excessive amounts of fluoride will make teeth turn brittle and yellow." C. "Use of fluoride in water is mostly effective during initial tooth formation." D. "Dental caries can be prevented through fluoridation of public water." - Answer: "Dental caries can be prevented through fluoridation of public water." Dental caries can be prevented through fluoridation of public water (D). Large amounts of fluoride (A) produces yellow and discolored teeth, not brittle teeth. (B) is effective for young teeth. Fluoride is effective throughout the life span, not just during initial tooth formation (C). A Spanish-speaking 5-year-old child starts kindergarten in an English-speaking school. The child cries most of the time, appears helpless and unable to function in the new situation. After assessing the child, how should the school nurse document the situation? A. Experiencing culture shock. B. Refuses to participate in school activities. C. Lacks the maturity needed in school. D. Going through minority group discrimination. - Answer: Experiencing culture shock. An inability to function may apply to persons of all ages undergoing transitions, such as moving to a new country and adjusting to a subculture within a larger culture that is unfamiliar. Culture shock (A) describes feelings of discomfort and disorientation when adapting to new cultural settings. Language barriers inhibit effective communication, so a child who is unable to communicate in the spoken language in the school environment may lack the skills necessary to participate, and is not refusing to participate (C). The child may be adequately mature (B), accepted by peers (D) within the environment, but continues to not join in because of the impact of culture shock. The nurse is assessing a child's skin turgor and grasps the skin on the abdomen between the thumb and index finger, pulls it taut, and quickly releases it. The tissue remains suspended and tented for a few seconds, then slowly falls back on the abdomen. How should the nurse document this finding? A. Assessment inconclusive. B. Poor skin turgor. C. Adequate hydration. D. Normal skin elasticity - Answer: Poor skin turgor Tissue turgor refers to the amount of elasticity in the skin and is one of the best estimates of adequate hydration and nutrition. Elastic tissue immediately resumes its normal position without residual marks or creases. In a child with poor turgor (B), the skin remains tented or suspended for a few seconds before returning to a normal position. (A, C and D) are inaccurate.