NURS 310 HESI Review Exam Questions And 100%
Correct Answers A+ Graded
The client is a 75-year-old who has end stage renal failure and advanced lung cancer
and recently had a stroke. The healthcare provider stopped the client's dialysis two
days ago and told the family that death is imminent, but the client is confused and
refuses to sign a DNR order. Which is the highest priority nursing intervention?
Analyze the client's most recent laboratory studies
Refer the client and family members to hospice services.
Inform the hospital ethics committee about the client situation.
Identify who has legal authority to make decisions. - ANS Identify who has legal
authority to make decisions.
A male client has an infected wound and tells the nurse that he is on a macrobiotic diet.
What types of foods should the nurse teach the client to select from the hospital menu?
Low fat and low sodium foods.
Combination of plant proteins to provide essential amino acids.
LIMITED
Complex carbohydrates and fiber.
Increased amount of vitamin C and beta carotene rich foods. - ANSWER Combination of
plant proteins to provide essential amino acids.
A macrobiotic diet is high in whole-grain cereals, vegetables, sea vegetables, beans,
and vegetarian soups, and the client needs essential amino acids to provide complete
proteins to heal the infected wound. Although a macrobiotic diet contains no source of
animal protein, essential amino acids should be obtained by combining plant
(incomplete) proteins to provide complete (all essential amino acids) proteins (B) for
anabolic processes. (A, C, and D) do not provide the client with food choices consistent
,with a macrobiotic diet and protein needs.
The nurse is administering an antibiotic via intermittent infusion to a client who has
intravenous access via an antecubital saline lock. After the roller clamp on the IV tubing
is opened, the infusion pump alerts the nurse to an obstruction in the line. Which of the
following actions would the nurse take first?
Check for a blood return.
Reposition the client's arm.
Remove the IV site dressing.
Flush the lock with saline. - ANSWER Reposition the client's arm.
If the client's elbow is bent, the IV may not be able to infuse, causing an obstruction
alarm, so the nurse should initially try to reposition the client's arm to relieve an
obstruction
For a client who is unable to move, which of the following measures should the nurse
take in order to prevent a sacral ulcer?
Position for comfort. Maintain in a lateral position using protective wrist and vest
devices.
Prone position with a small pillow under the diaphragm
Elevate the head and knee gatch while in a supine position
Transfer to a wheelchair beside the nurse's station for observation. - ANSWER Prone
position with a small pillow under the diaphragm.
What is the intervention that the nurse should include in the plan of care for a client who
is receiving an Unna's paste boot for leg ulcers related to chronic venous insufficiency?
Check capillary refill of toes on lower extremity with Unna's paste boot.
Apply dressing to wound area before applying the Unna's paste boot.
, Wrap the leg from the knee down towards the foot.
Remove the Unna's paste boot q8h and assess wound healing. - ANWER Assess
capillary refill of toes on lower extremity that has an Unna's paste boot applied to the
extremity.
Choose the nursing intervention that is most helpful in preventing the development of
urosepsis for a hospitalized client who has an indwelling urinary catheter.
Keep the client's perineal area cleaned twice daily.
Keep a record of fluid intake and output.
Encourage frequent ambulation if allowed or regular turning if on bedrest.
Obtain a prescription for removal of the catheter as soon as possible. - ANSWER Obtain
a prescription for removal of the catheter as soon as possible.
The best answer is D. The most appropriate intervention to decrease the risk for
urosepsis-infection of an infectious agent from the urinary tract to systemic
circulation-is to remove the urinary catheter as soon as possible. Although options A, B,
and C are helpful in reducing the risk for infection, all are less important than option D
relative to reducing the risk for urosepsis.
A client provides information regarding the purpose of his care to the nurse. The nurse
identifies that the information regarding hospitalization history is missing. How would
the nurse gather this information?
Call the insurance company for information about the client's hospitalization history.
Retrieve the history of medical records from the client's archived hospital records.
Ask the client to provide you with information about any previous hospitalization that
occurred in the last 5 years.
Correct Answers A+ Graded
The client is a 75-year-old who has end stage renal failure and advanced lung cancer
and recently had a stroke. The healthcare provider stopped the client's dialysis two
days ago and told the family that death is imminent, but the client is confused and
refuses to sign a DNR order. Which is the highest priority nursing intervention?
Analyze the client's most recent laboratory studies
Refer the client and family members to hospice services.
Inform the hospital ethics committee about the client situation.
Identify who has legal authority to make decisions. - ANS Identify who has legal
authority to make decisions.
A male client has an infected wound and tells the nurse that he is on a macrobiotic diet.
What types of foods should the nurse teach the client to select from the hospital menu?
Low fat and low sodium foods.
Combination of plant proteins to provide essential amino acids.
LIMITED
Complex carbohydrates and fiber.
Increased amount of vitamin C and beta carotene rich foods. - ANSWER Combination of
plant proteins to provide essential amino acids.
A macrobiotic diet is high in whole-grain cereals, vegetables, sea vegetables, beans,
and vegetarian soups, and the client needs essential amino acids to provide complete
proteins to heal the infected wound. Although a macrobiotic diet contains no source of
animal protein, essential amino acids should be obtained by combining plant
(incomplete) proteins to provide complete (all essential amino acids) proteins (B) for
anabolic processes. (A, C, and D) do not provide the client with food choices consistent
,with a macrobiotic diet and protein needs.
The nurse is administering an antibiotic via intermittent infusion to a client who has
intravenous access via an antecubital saline lock. After the roller clamp on the IV tubing
is opened, the infusion pump alerts the nurse to an obstruction in the line. Which of the
following actions would the nurse take first?
Check for a blood return.
Reposition the client's arm.
Remove the IV site dressing.
Flush the lock with saline. - ANSWER Reposition the client's arm.
If the client's elbow is bent, the IV may not be able to infuse, causing an obstruction
alarm, so the nurse should initially try to reposition the client's arm to relieve an
obstruction
For a client who is unable to move, which of the following measures should the nurse
take in order to prevent a sacral ulcer?
Position for comfort. Maintain in a lateral position using protective wrist and vest
devices.
Prone position with a small pillow under the diaphragm
Elevate the head and knee gatch while in a supine position
Transfer to a wheelchair beside the nurse's station for observation. - ANSWER Prone
position with a small pillow under the diaphragm.
What is the intervention that the nurse should include in the plan of care for a client who
is receiving an Unna's paste boot for leg ulcers related to chronic venous insufficiency?
Check capillary refill of toes on lower extremity with Unna's paste boot.
Apply dressing to wound area before applying the Unna's paste boot.
, Wrap the leg from the knee down towards the foot.
Remove the Unna's paste boot q8h and assess wound healing. - ANWER Assess
capillary refill of toes on lower extremity that has an Unna's paste boot applied to the
extremity.
Choose the nursing intervention that is most helpful in preventing the development of
urosepsis for a hospitalized client who has an indwelling urinary catheter.
Keep the client's perineal area cleaned twice daily.
Keep a record of fluid intake and output.
Encourage frequent ambulation if allowed or regular turning if on bedrest.
Obtain a prescription for removal of the catheter as soon as possible. - ANSWER Obtain
a prescription for removal of the catheter as soon as possible.
The best answer is D. The most appropriate intervention to decrease the risk for
urosepsis-infection of an infectious agent from the urinary tract to systemic
circulation-is to remove the urinary catheter as soon as possible. Although options A, B,
and C are helpful in reducing the risk for infection, all are less important than option D
relative to reducing the risk for urosepsis.
A client provides information regarding the purpose of his care to the nurse. The nurse
identifies that the information regarding hospitalization history is missing. How would
the nurse gather this information?
Call the insurance company for information about the client's hospitalization history.
Retrieve the history of medical records from the client's archived hospital records.
Ask the client to provide you with information about any previous hospitalization that
occurred in the last 5 years.
