HESI 700 EXAM QUESTIONS &
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? - ANS Review with the client the need to avoid foods that are rich in milk and cream
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? - ANS Stroke secondary to hemorrhage
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? - ANS Instruct the UAP to obtain soft blankets to secure to the side
rails instead of pillows
An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12
days. Which assessment finding requires immediate follow-up - ANS Describes life without purpose
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 - ANS Further
evaluation involving surgery may be needed
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? - ANS Teach tracheal
suctioning techniques
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 - 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? - ANS Respiratory apnea of 30 seconds
During a home visit, the nurse observed an elderly client with diabetes slip and fall. What action should
the nurse take first? - ANS Check the client for lacerations or fractures
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? - ANS Inform the anesthesia care provider
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 - ANS Listen with the
bell at the same location
A 66-year-old woman is retiring and will no longer have a health insurance through her place of
employment. Which agency should the client be referred to by the employee health nurse for health
insurance needs? - ANS Medicare
A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset. What snack
should the nurse instruct the client to take with the tetracycline? - ANS Toasted wheat bread and jelly
Following a lumbar puncture, a client voices several complaints. What complaint indicated to the nurse
that the client is experiencing a complication? - ANS "I have a headache that gets worse when I sit up"
An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with
incontinence. Which action should the nurse implement - ANS Obtain a clean catch mid-stream
specimen
,The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are in
keeping with the child's dietary restrictions. Which foods are contraindicated for this child? - ANS Foods
sweetened with aspartame
Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the circulating
nurse if a 3 minute surgical hand scrub is adequate preparation for this client. Which response should
the circulating nurse provide? - ANS Direct the nurse to continue the surgical hand scrub for a 5 minute
duration
Which breakfast selection indicates that the client understands the nurse's instructions about the
dietary management of osteoporosis? - ANS Bagel with jelly and skim milk
The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal
number of registered nurses will be working that shift. In planning assignments, which client should
receive the most care hours by a registered nurse (RN) - ANS An 82-year-old client with Alzheimer's
disease newly-fractures femur who has a Foley catheter and soft wrist restrains applied
A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician's office.
Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the
child's foot. Which action should the nurse implement first? - ANS Cleanse the foot with soap and water
and apply an antibiotic ointment
The mother of an adolescent tells the clinic nurse, "My son has athlete's foot, I have been applying triple
antibiotic ointment for two days, but there has been no improvement." What instruction should the
nurse provide? - ANS Stop using the ointment and encourage complete drying of the feet and wearing
clean socks.
A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and
levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the
prescribed dosage is too high for this client? The client experiences - ANS Palpitations and shortness of
breath
, A client with a history of heart failure presents to the clinic with a nausea, vomiting, yellow vision and
palpitations. Which finding is most important for the nurse to assess to the client? - ANS Obtain a list of
medications taken for cardiac history
The healthcare provider prescribes an IV solution of isoproterenol (Isuprel) 1 mg in 250 ml of D5W at
300 mcg/hour. The nurse should program the infusion pump to deliver how many ml/hour? (Enter
numeric value only.) - ANS 75
Rationale: Convert mg to mcg and use the formula D/H x Q. 300 mcg/hour / 1,000 mcg x 250 ml = 3/1 x
25 = 75 ml/hour
The pathophysiological mechanism are responsible for ascites related to liver failure? (Select all that
apply) - ANS -Fluid shifts from intravascular to interstitial area due to decreased serum protein
-Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen
-Increased circulating aldosterone levels that increase sodium and water retention
The nurse is auscultating a client's heart sounds. Which description should the nurse use to document
this sound? (Please listen to the audio first to select the option that applies) - ANS Murmur
The healthcare provider prescribes celtazidime (Fortax) 35 mg every 8 hours IM for an infant. The 500
mg vial is labeled with the instruction to add 5.3 ml diluent to provide a concentration of 100 mg/ml.
How many ml should the nurse administered for each dose? (Enter numeric value only. If rounding is
required, round to the nearest tenth - ANS 0.4
rationale: 35mg/100mg x 1 = 0.35 = 0.4 ml
The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four days.
What assessment is most important for the nurse to complete? - ANS Auscultate the client's bowel
sounds
Rationale: hydromorphone is a potent opioid analgesic that slows peristalsis and frequently causes
constipation, so it is most important to Auscultate the client's bowel sounds
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? - ANS Review with the client the need to avoid foods that are rich in milk and cream
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? - ANS Stroke secondary to hemorrhage
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? - ANS Instruct the UAP to obtain soft blankets to secure to the side
rails instead of pillows
An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12
days. Which assessment finding requires immediate follow-up - ANS Describes life without purpose
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 - ANS Further
evaluation involving surgery may be needed
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? - ANS Teach tracheal
suctioning techniques
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 - 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? - ANS Respiratory apnea of 30 seconds
During a home visit, the nurse observed an elderly client with diabetes slip and fall. What action should
the nurse take first? - ANS Check the client for lacerations or fractures
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? - ANS Inform the anesthesia care provider
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 - ANS Listen with the
bell at the same location
A 66-year-old woman is retiring and will no longer have a health insurance through her place of
employment. Which agency should the client be referred to by the employee health nurse for health
insurance needs? - ANS Medicare
A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset. What snack
should the nurse instruct the client to take with the tetracycline? - ANS Toasted wheat bread and jelly
Following a lumbar puncture, a client voices several complaints. What complaint indicated to the nurse
that the client is experiencing a complication? - ANS "I have a headache that gets worse when I sit up"
An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with
incontinence. Which action should the nurse implement - ANS Obtain a clean catch mid-stream
specimen
,The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are in
keeping with the child's dietary restrictions. Which foods are contraindicated for this child? - ANS Foods
sweetened with aspartame
Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the circulating
nurse if a 3 minute surgical hand scrub is adequate preparation for this client. Which response should
the circulating nurse provide? - ANS Direct the nurse to continue the surgical hand scrub for a 5 minute
duration
Which breakfast selection indicates that the client understands the nurse's instructions about the
dietary management of osteoporosis? - ANS Bagel with jelly and skim milk
The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal
number of registered nurses will be working that shift. In planning assignments, which client should
receive the most care hours by a registered nurse (RN) - ANS An 82-year-old client with Alzheimer's
disease newly-fractures femur who has a Foley catheter and soft wrist restrains applied
A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician's office.
Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the
child's foot. Which action should the nurse implement first? - ANS Cleanse the foot with soap and water
and apply an antibiotic ointment
The mother of an adolescent tells the clinic nurse, "My son has athlete's foot, I have been applying triple
antibiotic ointment for two days, but there has been no improvement." What instruction should the
nurse provide? - ANS Stop using the ointment and encourage complete drying of the feet and wearing
clean socks.
A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and
levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the
prescribed dosage is too high for this client? The client experiences - ANS Palpitations and shortness of
breath
, A client with a history of heart failure presents to the clinic with a nausea, vomiting, yellow vision and
palpitations. Which finding is most important for the nurse to assess to the client? - ANS Obtain a list of
medications taken for cardiac history
The healthcare provider prescribes an IV solution of isoproterenol (Isuprel) 1 mg in 250 ml of D5W at
300 mcg/hour. The nurse should program the infusion pump to deliver how many ml/hour? (Enter
numeric value only.) - ANS 75
Rationale: Convert mg to mcg and use the formula D/H x Q. 300 mcg/hour / 1,000 mcg x 250 ml = 3/1 x
25 = 75 ml/hour
The pathophysiological mechanism are responsible for ascites related to liver failure? (Select all that
apply) - ANS -Fluid shifts from intravascular to interstitial area due to decreased serum protein
-Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen
-Increased circulating aldosterone levels that increase sodium and water retention
The nurse is auscultating a client's heart sounds. Which description should the nurse use to document
this sound? (Please listen to the audio first to select the option that applies) - ANS Murmur
The healthcare provider prescribes celtazidime (Fortax) 35 mg every 8 hours IM for an infant. The 500
mg vial is labeled with the instruction to add 5.3 ml diluent to provide a concentration of 100 mg/ml.
How many ml should the nurse administered for each dose? (Enter numeric value only. If rounding is
required, round to the nearest tenth - ANS 0.4
rationale: 35mg/100mg x 1 = 0.35 = 0.4 ml
The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four days.
What assessment is most important for the nurse to complete? - ANS Auscultate the client's bowel
sounds
Rationale: hydromorphone is a potent opioid analgesic that slows peristalsis and frequently causes
constipation, so it is most important to Auscultate the client's bowel sounds
