HESI
The nurse notices that the hispanic parents of a toddler who returns from surgery offer the child
only the broth that comes on the clear liquid tray. Other liquids, including gelatin, popsicles, and
juices, remain untouched. What explanation is most appropriate for this behavior? - CORRECT
ANSWER-"hot" remedies restore balance after surgery, which is considered a "cold" condition.
common parental practices and health beliefs among hispanic, Chinese, filipino, and arab cultures
classify diseases, areas of the body, and illnesses as "hot" or "cold" and must be balanced to
maintain health and prevent illness. The perception that surgery is a "cold" condition implies that
only "hot" remedies such as soup, should be used to restore the healthy balance within the body
20 minutes after beginning a heat application, the client states that the heating pad no longer feels
warm enough. What is the best response by the nurse? - CORRECT ANSWER-"The body's
receptors adapt over time as they are exposed to heat"
--thermal adaptation, which occurs 20-30 minutes after heat application
An african-american grandmother tells the nurse that her 4-year-old grandson is suffering with
"Miseries". based on this statement, which focused assessment should the nurse conduct? -
CORRECT ANSWER-Inquire about the source and type of pain
Different cultural groups often have their own terms for health conditions. African-American clients
may refer to pain as "miseries"
A female client with a nasogastric tube attached to low suction states that she is nauseated. The
nurse assess that there has been no drainage through the NG tube in the last two hours. What
action should the nurse take first? - CORRECT ANSWER-Reposition the client on her side
The immediate priority is to determine if the tube is functioning correctly, which would then relieve
the client's nausea. The least invasive intervention should be attempted first, followed by irrigating
the NG tube with sterile normal saline and advancing the NG tube an additional 5cm, unless
contraindicated. If these procedures do not work, the client may require an antiemetic.
A hospitalized male client is receiving NG tube feedings via a small-bore tube and a continuous
pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels
fine now. What action is best for the nurse to take? - CORRECT ANSWER-After clearing the tube
with 30ml of air, check the pH of fluid withdrawn from the tube.
coughing, vomitting, and suctioning can precipitate displacement of the tip of the small bore
feeding tube upward into the esophagus, placing the client at increased risk for aspiration.
Checking the sample of fluid withdrawn from the tube (after clearing the tube with 30ml of air) for
acidic (stomach) or alkaline (intestine) values is a more sensitive method for these tubes, and the
nurse should assess tube placement in this way prior to taking any other action
A sub-saharan african widowed immigrant woman lives with her deceased husband's brother and
his family, which includes the brother-in-law's children and the widow's adult children. each family
member speaks fluent english. surgery was recommended for the client. What is the best plan to
obtain consent for surgery for this client? - CORRECT ANSWER-Tell the surgeon that the
, brother-in-law will decide after explanation of the proposed surgery is provided to him an the
widow
Customary law in some sub-saharan countries encompasses wife inheritance and polygamy; the
widow becomes the inherited wife of her husband's brother. In those rural areas women live in
patriarchal family where decision are made by men. Most likely, the brother-in-law will make the
decision for his inherited wife.
An older client who is a resident in a long term care facility has been bedridden for a week. Which
finding should the nurse ID as a client risk factor for pressure ulcers? - CORRECT
ANSWER-Rashes in axillary, groin, and skin fold regions.
immobility, constant contact with bed clothing, and excessive heat and moisture in areas where air
flow is limited contributes to bacterial and fungal growth, which increases the risk for rashes, skin
breakdown, an the development of pressure ulcers.
The nurse is teaching a client proper use of an inhaler. When should the client administer the
inhaler-delivered medication to demonstrate correct use of the inhaler? - CORRECT
ANSWER-during the inhalation
the client should be instructed to deliver the medication during the last part of inhalation. After
medication is delivered, the client should remove the mouthpiece, keeping their lips closed and
breath held for several seconds to allow for distribution of the medication. The client should deliver
no more than two inhalations at a time.
an unlicensed UAP places a client in a left lateral position prior to administering a soap suds
enema. Which instruction should the nurse provide the UAP? - CORRECT ANSWER-Reposition
in Sim's position with the client's weight on the anterior ilium.
The left sided Sim's position allows the enema solution to follow the anatomical course of the
intestines and allows the best overall results, so the UAP should resposition the client in the Sim's
position, which distributes the client's weight to the anterior ilium.
Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an
adolescent? - CORRECT ANSWER-Upper arm circumference is an indirect measure of muscle
mass.
Abnormal heart sounds are best heard with the bell of the stethoscope, which picks up
lower-pitched sounds, that is placed at points on the anterior chest. - CORRECT ANSWER-
A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating.
Based on these findings, which intervention should the nurse implement first? - CORRECT
ANSWER-Assist the ambulating client back to bed.
An oxygen saturation below 90% indicates inadequate oxygenation. First, the client should be
assisted to return to bed to minimize oxygen demands. Ambulation increases aeration of the lungs
to prevent pooling of respiratory secretions, but the client's activity at this time is depleting oxygen
saturation of the blood. Oxygen levels at different sites should be evaluated after the client returns
to bed.
The nurse notices that the hispanic parents of a toddler who returns from surgery offer the child
only the broth that comes on the clear liquid tray. Other liquids, including gelatin, popsicles, and
juices, remain untouched. What explanation is most appropriate for this behavior? - CORRECT
ANSWER-"hot" remedies restore balance after surgery, which is considered a "cold" condition.
common parental practices and health beliefs among hispanic, Chinese, filipino, and arab cultures
classify diseases, areas of the body, and illnesses as "hot" or "cold" and must be balanced to
maintain health and prevent illness. The perception that surgery is a "cold" condition implies that
only "hot" remedies such as soup, should be used to restore the healthy balance within the body
20 minutes after beginning a heat application, the client states that the heating pad no longer feels
warm enough. What is the best response by the nurse? - CORRECT ANSWER-"The body's
receptors adapt over time as they are exposed to heat"
--thermal adaptation, which occurs 20-30 minutes after heat application
An african-american grandmother tells the nurse that her 4-year-old grandson is suffering with
"Miseries". based on this statement, which focused assessment should the nurse conduct? -
CORRECT ANSWER-Inquire about the source and type of pain
Different cultural groups often have their own terms for health conditions. African-American clients
may refer to pain as "miseries"
A female client with a nasogastric tube attached to low suction states that she is nauseated. The
nurse assess that there has been no drainage through the NG tube in the last two hours. What
action should the nurse take first? - CORRECT ANSWER-Reposition the client on her side
The immediate priority is to determine if the tube is functioning correctly, which would then relieve
the client's nausea. The least invasive intervention should be attempted first, followed by irrigating
the NG tube with sterile normal saline and advancing the NG tube an additional 5cm, unless
contraindicated. If these procedures do not work, the client may require an antiemetic.
A hospitalized male client is receiving NG tube feedings via a small-bore tube and a continuous
pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels
fine now. What action is best for the nurse to take? - CORRECT ANSWER-After clearing the tube
with 30ml of air, check the pH of fluid withdrawn from the tube.
coughing, vomitting, and suctioning can precipitate displacement of the tip of the small bore
feeding tube upward into the esophagus, placing the client at increased risk for aspiration.
Checking the sample of fluid withdrawn from the tube (after clearing the tube with 30ml of air) for
acidic (stomach) or alkaline (intestine) values is a more sensitive method for these tubes, and the
nurse should assess tube placement in this way prior to taking any other action
A sub-saharan african widowed immigrant woman lives with her deceased husband's brother and
his family, which includes the brother-in-law's children and the widow's adult children. each family
member speaks fluent english. surgery was recommended for the client. What is the best plan to
obtain consent for surgery for this client? - CORRECT ANSWER-Tell the surgeon that the
, brother-in-law will decide after explanation of the proposed surgery is provided to him an the
widow
Customary law in some sub-saharan countries encompasses wife inheritance and polygamy; the
widow becomes the inherited wife of her husband's brother. In those rural areas women live in
patriarchal family where decision are made by men. Most likely, the brother-in-law will make the
decision for his inherited wife.
An older client who is a resident in a long term care facility has been bedridden for a week. Which
finding should the nurse ID as a client risk factor for pressure ulcers? - CORRECT
ANSWER-Rashes in axillary, groin, and skin fold regions.
immobility, constant contact with bed clothing, and excessive heat and moisture in areas where air
flow is limited contributes to bacterial and fungal growth, which increases the risk for rashes, skin
breakdown, an the development of pressure ulcers.
The nurse is teaching a client proper use of an inhaler. When should the client administer the
inhaler-delivered medication to demonstrate correct use of the inhaler? - CORRECT
ANSWER-during the inhalation
the client should be instructed to deliver the medication during the last part of inhalation. After
medication is delivered, the client should remove the mouthpiece, keeping their lips closed and
breath held for several seconds to allow for distribution of the medication. The client should deliver
no more than two inhalations at a time.
an unlicensed UAP places a client in a left lateral position prior to administering a soap suds
enema. Which instruction should the nurse provide the UAP? - CORRECT ANSWER-Reposition
in Sim's position with the client's weight on the anterior ilium.
The left sided Sim's position allows the enema solution to follow the anatomical course of the
intestines and allows the best overall results, so the UAP should resposition the client in the Sim's
position, which distributes the client's weight to the anterior ilium.
Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an
adolescent? - CORRECT ANSWER-Upper arm circumference is an indirect measure of muscle
mass.
Abnormal heart sounds are best heard with the bell of the stethoscope, which picks up
lower-pitched sounds, that is placed at points on the anterior chest. - CORRECT ANSWER-
A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating.
Based on these findings, which intervention should the nurse implement first? - CORRECT
ANSWER-Assist the ambulating client back to bed.
An oxygen saturation below 90% indicates inadequate oxygenation. First, the client should be
assisted to return to bed to minimize oxygen demands. Ambulation increases aeration of the lungs
to prevent pooling of respiratory secretions, but the client's activity at this time is depleting oxygen
saturation of the blood. Oxygen levels at different sites should be evaluated after the client returns
to bed.
