HESI Practice Exam Q&A Verified A Pass 2023

HESI Practice Exam When making the bed of a client who needs to be cradle, which action should the nurse include? A - Teach the client to call for help before getting out of bed. B - Keep both the upper & lower side rails in a raised position. C - Keep the bed in the lowest position while changing the sheets. D - Drape the top sheet & covers loosely over the bed cradle. - D The nurse notes that a client consistently coughs while eating & drinking. Which nursing diagnosis is most important for the nurse to include in this client's plan of care? A - Ineffective breathing pattern B - Impaired gas exchange C - Risk for aspiration D - Ineffective airway clearance - C A client in hospice care develops audible gurgling sounds on inspiration. What nursing action has the highest priority? A - Ensure cultural outcomes are observed B - Increase oxygen flow to 4L/minute C - Auscultate bilateral lung fields. D - Inform the family that death is imminent. - D As the nurse prepares the equipment to be used to start an IV on a 4yr old boy in the treatment room, he cries continuously. What intervention should the nurse implement? A - Take the child back to his room. B - Recruit other to restrain child. C - Ask the mother to be present to soothe the child. D - Show the child how to manipulate the equipment. - C A male nurse is assigned to care for a female Muslim client. When the nurse offers to bathe, the client requests that a female nurse perform this task. How should the male nurse respond? A - "May I ask your daughter to help you with your personal hygiene?" B -"I will ask one of the female nurses to bathe you" C - "A staff member on the next shift will help you" D - "I will keep you draped & hand you the supplies as you need them" - B The nurse determines a client's IV solution is infusing at 250 mL/hr. The prescribed rate is 125 mL/hr. What action should the nurse take first? A - Determine when the IV solution was started. B - Slow the IV infusion to keep vein open rate. C - Assess the IV insertion site for swelling. D - Report the finding to the healthcare provider. - B When teaching a female client to perform intermittent self-catheterization, the nurse should ensure the client's ability to perform which action? A - Locate the perineum B - Transfer to a commode. C - Attach the catheter to a drainage bag. D - Manipulate a syringe to inflate the balloon. - A Prior to administering a newly prescribed medication to a client, the nurse reviews the adverse effects of the medication listed in a drug reference guide & determines the priority risks to the client. While performing this action, the nurse is an engaged in which step of the nursing process? A - Assessment B - Analysis C - Implementation D - Evaluation - B When assessing a client with a nursing diagnosis of fluid volume deficit, the nurse notes that the client's skin over the sternum "tents" when gently pinched. Which action should the nurse implement? A - Confirm the finding by further assessing the client for jugular vein distention. B - Offer the client high protein snacks between regularly scheduled mealtimes. C - Continue the planned nursing interventions to restore the client's fluid volume. D - Change the plan of care to include a nursing diagnosis of impaired skin integrity. - C In evaluating client care, which action should the nurse take first? A - Determine if the excepted outcomes of care were achieved. B - Review the rationales used as the basis of nursing actions. C - Document the care plan goals that were successfully met. D - Prioritize interventions to be added to the client's plan of care. - A Which nursing intervention is most beneficial in reducing the risk of urosepsis in a hospitalized client with an indwelling urinary catheter? A - Ensure that the client's perineal area is cleansed twice a day. B - Maintain accurate documentation of the fluid intake & output. C - Encourage frequent ambulation if allowed or regular turning if on bedrest. D - Obtain a prescription for removal of the catheter as soon as possible. - D The nurse is administering an intermittent infusion of an antibiotic to a client whose intravenous (IV) access is an antecubital saline lock. After the nurse opens the roller clamp on the IV tubing, the alarm on the infusion pump indicates an obstruction. What action should the nurse take first? A - Check for a blood return B - Reposition the client's arm C - Remove the IV site dressing D - Flush the lock with saline - B Which client assessment data is most important for the nurse to consider before ambulating a postoperative client? A - Respiratory rate B - Wound location C - Pedal pulse D - Pain rating - A When preparing to administer an intravenous medication through a central venous catheter, the nurse aspirates a blood return in one of the lumens of the triple catheter. Which action should the nurse implement? A - Flush the lumen with the saline solution & administer the medication through the lumen. B - Determine if a PRN prescription for a thrombolytic agent is listed on the medication record. C - Clamp the lumen & obtain a syringe of a dilute heparin solution to flush through the tubing. D - Withdraw the aspirated blood into the syringe & use a new syringe to administer the medication. - A A client is demonstrating positive Chvostek's sign. What action should the nurse take? A - Observe the client's pupil size & response to light. B - Ask the client about numbness or tingling in the hands. C - Assess the client's serum potassium level. D - Restrict dietary intake of calcium-rich foods. - B The nurse encounters a slight resistance when inserting the tubing into a client's rectum for a tap water enema. What action should the nurse implement? A - Withdraw the tube & apply additional lubricant to the tip of the tubing. B - Encourage the client to bear down & continue to insert the tube. C - Remove the tube & reposition the client to reinsert the tube. D - Ask the client to relax & twist the tube gently though the sphincter. - D When the nurse enters a client's room to do an initial assessment, the client shouts, "Get out of my room! I'm tired of being bothered!" How should the nurse respond? A - "There is no reason to be so angry" B - "Why do I need to leave your room" C - "What is most concerning you this morning?" D - "Let me call the client advocate for you." - C The nurse is preparing a male client who has an indwelling catheter & an IV infusion to ambulate to ambulate from the bed to a chair for the first time following abdominal surgery. What action(s) should the nurse implement prior to assisting the client to the chair? (select all that apply) A - pre-medicate the client with an analgesic B - inform the client of the plan for moving to the chair C - obtain & place a portable commode by the bed D - ask the client to push the IV pole to the chair E - clamp the indwelling catheter F - assess the client - A, B , D, F