HESI 700 QUESTIONS AND ANSWERS
Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will drink
plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best follow-up
action by the nurse? WHY?
a. Remind the client that it is also important to switch to decaffeinated coffee and tea.
b. Suggest that the client also plan to eat frequent small meals to reduce discomfort
c. Review with the client the need to avoid foods that are rich in milk and cream.
d. Reinforce this teaching by asking the client to list a dairy food that he might select. - ANS Review
with the client the need to avoid foods that are rich in milk and cream
Rationale: Diets rich in milk and cream stimulate gastric acid secretion and should be avoided.
A male client with hypertension, who received new antihypertensive prescriptions at his last visit
returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and he
admits that he has not been taking the prescribed medication because the drugs make him "feel
bad". In explaining the need for hypertension control, the nurse should stress that an elevated BP
places the client at risk for which pathophysiological condition?
a. Blindness secondary to cataracts
b. Acute kidney injury due to glomerular damage
c. Stroke secondary to hemorrhage
d. Heart block due to myocardial damage - ANS Stroke secondary to hemorrhage
Rationale: Stroke related to cerebral hemorrhage is major risk for uncontrolled hypertension.
The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who
has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails.
What action should the nurse implement?
a. Ensure that the UAP has placed the pillows effectively to protect the client.
b. Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows.
,c. Assume responsibility for placing the pillows while the UAP completes another task.
d. Ask the UAP to use some of the pillows to prop the client in a side lying position. - ANS Instruct the
UAP to obtain soft blankets to secure to the side rails instead of pillows
Rationale: The nurse should instruct the UAP to pad the side rails with soft blankest because the use
of pillows could result in suffocation and would need to be removed at the onset of the seizure. The
nurse can delegate paddling the side rails to the UAP
An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12
days. Which assessment finding requires immediate follow-up
a. Describes life without purpose
b. Complains of nausea and loss of appetite
c. States is often fatigued and drowsy
d. Exhibits an increase in sweating. - ANS Describes life without purpose
Rationale: Cymbalta is a selective serotonin and norepinephrine reuptake inhibitor that is known to
increase the risk of suicidal thinking in adolescents and young adults with major depressive disorder.
B, C and D are side effects
A 60-year-old female client with a positive family history of ovarian cancer has developed an
abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear
results are negative. What information should the nurse include in the client's teaching plan
a. Further evaluation involving surgery may be needed
b. A pelvic exam is also needed before cancer is ruled out
c. Pap smear evaluation should be continued every six month
d. One additional negative pap smear in six months is needed. - ANS Further evaluation involving
surgery may be needed
Rationale: An abdominal mass in a client with a family history for ovarian cancer should be evaluated
carefully
A client who recently underwent a tracheostomy is being prepared for discharge to home. Which
instructions is most important for the nurse to include in the discharge plan?
,a. Explain how to use communication tools.
b. Teach tracheal suctioning techniques
c. Encourage self-care and independence.
d. Demonstrate how to clean tracheostomy site. - ANS Teach tracheal suctioning techniques
Rationale: Suctioning helps to clear secretions and maintain an open airway, which is critical.
In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir
bag does not deflate completely during inspiration and the client's respiratory rate is 14 breaths /
minute. What action should the nurse implement
a. Encourage the client to take deep breaths
b. Remove the mask to deflate the bag
c. Increase the liter flow of oxygen
d. Document the assessment data - ANS Document the assessment data
Rational: reservoir bag should not deflate completely during inspiration and the client's respiratory
rate is within normal limits.
During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client
alarm should the nurse investigate first?
a. Respiratory apnea of 30 seconds
b. Oxygen saturation rate of 88%
c. Eight premature ventricular beats every minute
d. Disconnected monitor signal for the last 6 minutes. - ANS Respiratory apnea of 30 seconds
Rationale: The priority is the client whose alarm indicating respiratory apnea that should be assessed
first.
During a home visit, the nurse observed an elderly client with diabetes slip and fall. What action
should the nurse take first?
, a. Give the client 4 ounces of orange juice
b. Call 911 to summon emergency assistance
c. Check the client for lacerations or fractures
d. Asses clients blood sugar level - ANS Check the client for lacerations or fractures
Rationale: After the client falls, the nurse should immediately assess for the possibility of injuries and
provide first aid as needed
At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section), the client tells
the nurse that she drank a cup a coffee at 0400 because she wanted to avoid getting a headache.
Which action should the nurse take first?
a. Ensure preoperative lab results are available
b. Start prescribed IV with lactated Ringer's
c. Inform the anesthesia care provider
d. Contact the client's obstetrician. - ANS Inform the anesthesia care provider
Rationale: Surgical preoperative instruction includes NPO after midnight the day of surgery to
decrease the risk of aspiration should vomiting occur during anesthesia. While it is possible the C-
section will be done on schedule or rescheduled for later in the day, the anesthesia provider should
be notified first.
After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds. To
determine if an S3 heart sound is present, what action should the nurse take first
a. Side the stethoscope across the sternum.
b. Move the stethoscope to the mitral site
c. Listen with the bell at the same location
d. Observe the cardiac telemetry monitor - ANS Listen with the bell at the same location
Rationale: The nurse uses the bell of the stethoscope to hear low-pitched sounds such as S3 and S4.
The nurse listens at the same site using the diaphragm the diaphragm and bell before moving
systematically to the next sites.
Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will drink
plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best follow-up
action by the nurse? WHY?
a. Remind the client that it is also important to switch to decaffeinated coffee and tea.
b. Suggest that the client also plan to eat frequent small meals to reduce discomfort
c. Review with the client the need to avoid foods that are rich in milk and cream.
d. Reinforce this teaching by asking the client to list a dairy food that he might select. - ANS Review
with the client the need to avoid foods that are rich in milk and cream
Rationale: Diets rich in milk and cream stimulate gastric acid secretion and should be avoided.
A male client with hypertension, who received new antihypertensive prescriptions at his last visit
returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and he
admits that he has not been taking the prescribed medication because the drugs make him "feel
bad". In explaining the need for hypertension control, the nurse should stress that an elevated BP
places the client at risk for which pathophysiological condition?
a. Blindness secondary to cataracts
b. Acute kidney injury due to glomerular damage
c. Stroke secondary to hemorrhage
d. Heart block due to myocardial damage - ANS Stroke secondary to hemorrhage
Rationale: Stroke related to cerebral hemorrhage is major risk for uncontrolled hypertension.
The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who
has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails.
What action should the nurse implement?
a. Ensure that the UAP has placed the pillows effectively to protect the client.
b. Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows.
,c. Assume responsibility for placing the pillows while the UAP completes another task.
d. Ask the UAP to use some of the pillows to prop the client in a side lying position. - ANS Instruct the
UAP to obtain soft blankets to secure to the side rails instead of pillows
Rationale: The nurse should instruct the UAP to pad the side rails with soft blankest because the use
of pillows could result in suffocation and would need to be removed at the onset of the seizure. The
nurse can delegate paddling the side rails to the UAP
An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12
days. Which assessment finding requires immediate follow-up
a. Describes life without purpose
b. Complains of nausea and loss of appetite
c. States is often fatigued and drowsy
d. Exhibits an increase in sweating. - ANS Describes life without purpose
Rationale: Cymbalta is a selective serotonin and norepinephrine reuptake inhibitor that is known to
increase the risk of suicidal thinking in adolescents and young adults with major depressive disorder.
B, C and D are side effects
A 60-year-old female client with a positive family history of ovarian cancer has developed an
abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear
results are negative. What information should the nurse include in the client's teaching plan
a. Further evaluation involving surgery may be needed
b. A pelvic exam is also needed before cancer is ruled out
c. Pap smear evaluation should be continued every six month
d. One additional negative pap smear in six months is needed. - ANS Further evaluation involving
surgery may be needed
Rationale: An abdominal mass in a client with a family history for ovarian cancer should be evaluated
carefully
A client who recently underwent a tracheostomy is being prepared for discharge to home. Which
instructions is most important for the nurse to include in the discharge plan?
,a. Explain how to use communication tools.
b. Teach tracheal suctioning techniques
c. Encourage self-care and independence.
d. Demonstrate how to clean tracheostomy site. - ANS Teach tracheal suctioning techniques
Rationale: Suctioning helps to clear secretions and maintain an open airway, which is critical.
In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir
bag does not deflate completely during inspiration and the client's respiratory rate is 14 breaths /
minute. What action should the nurse implement
a. Encourage the client to take deep breaths
b. Remove the mask to deflate the bag
c. Increase the liter flow of oxygen
d. Document the assessment data - ANS Document the assessment data
Rational: reservoir bag should not deflate completely during inspiration and the client's respiratory
rate is within normal limits.
During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client
alarm should the nurse investigate first?
a. Respiratory apnea of 30 seconds
b. Oxygen saturation rate of 88%
c. Eight premature ventricular beats every minute
d. Disconnected monitor signal for the last 6 minutes. - ANS Respiratory apnea of 30 seconds
Rationale: The priority is the client whose alarm indicating respiratory apnea that should be assessed
first.
During a home visit, the nurse observed an elderly client with diabetes slip and fall. What action
should the nurse take first?
, a. Give the client 4 ounces of orange juice
b. Call 911 to summon emergency assistance
c. Check the client for lacerations or fractures
d. Asses clients blood sugar level - ANS Check the client for lacerations or fractures
Rationale: After the client falls, the nurse should immediately assess for the possibility of injuries and
provide first aid as needed
At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section), the client tells
the nurse that she drank a cup a coffee at 0400 because she wanted to avoid getting a headache.
Which action should the nurse take first?
a. Ensure preoperative lab results are available
b. Start prescribed IV with lactated Ringer's
c. Inform the anesthesia care provider
d. Contact the client's obstetrician. - ANS Inform the anesthesia care provider
Rationale: Surgical preoperative instruction includes NPO after midnight the day of surgery to
decrease the risk of aspiration should vomiting occur during anesthesia. While it is possible the C-
section will be done on schedule or rescheduled for later in the day, the anesthesia provider should
be notified first.
After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds. To
determine if an S3 heart sound is present, what action should the nurse take first
a. Side the stethoscope across the sternum.
b. Move the stethoscope to the mitral site
c. Listen with the bell at the same location
d. Observe the cardiac telemetry monitor - ANS Listen with the bell at the same location
Rationale: The nurse uses the bell of the stethoscope to hear low-pitched sounds such as S3 and S4.
The nurse listens at the same site using the diaphragm the diaphragm and bell before moving
systematically to the next sites.
