HESI Health Assessment Exam 3 2024
A nurse who has recently completed orientation is beginning work in the labor and delivery
unit for the first time. When making assignments, which client should the charge nurse assign
to this new nurse? - A multiparous client who is dilated 5 cm and 50% effaced
A client with human immunodeficiency virus (HIV) infection has white lesions in the oral
cavity that resemble milk curds. Nystatin (Mycostatin) preparation is prescribed as a swish
and swallow. Which information is most important for the nurse to provide the client? - Oral
hygiene should be performed before the medication.
A client who is admitted with emphysema is having difficulty breathing. In which position
should the nurse place the client? - Sitting upright and forward with both arms supported on
an over the bed table
A client with chronic renal insufficiency (CRI) is taking 25 mg of hydrochlorothiazide
(HCTZ) PO and 40 mg of furosemide (Lasix) PO daily. Today, at a routine clinic visit, the
client's serum potassium level is 4 mEq/L. What is the most likely cause of this client's
potassium level? - The client's renal function has affected his potassium level.
A registered nurse (RN) delivers telehealth services to clients via electronic communication.
Which nursing action creates the greatest risk for professional liability and has the potential
for a malpractice lawsuit? - Sending medical records to health care providers via the Internet
Which pathophysiologic response supports the contraindication for opioids, such as
morphine, in clients with increased intracranial pressure (ICP)?
A.Sedation produced by opioids is a result of a prolonged half-life when the ICP is elevated.
B.Higher doses of opioids are required when cerebral blood flow is reduced by an elevated
ICP.
C.Dysphoria from opioids contributes to altered levels of consciousness with an elevated
ICP.
D.Opioids suppress respirations, which increases Pco2 and contributes to an elevated ICP. - D
The greatest risk associated with opioids such as morphine (D) is respiratory depression that
causes an increase in Pco2, which increases ICP and masks the early signs of intracranial
bleeding in head injury. (A, B, and C) do not support the risks associated with opioid use in a
client with increased ICP.
The charge nurse of a medical surgical unit is alerted to an impending disaster requiring
implementation of the hospital's disaster plan. Specific facts about the nature of this disaster
are not yet known. Which instruction should the charge nurse give to the other staff members
at this time?
A.Prepare to evacuate the unit, starting with the bedridden clients.
B.UAPs should report to the emergency center to handle transports.
C.The licensed staff should begin counting wheelchairs and IV poles on the unit.
, D.Continue with current assignments until more instructions are received. - D
When rfaced rwith ran rimpending rdisaster, rhospital rpersonnel rmay rbe ralerted rbut rshould
rcontinue rwith rcurrent rclient rcare rassignments runtil rfurther rinstructions rare rreceived r(D).
rEvacuation ris rtypically ra rresponse rof rlast rresort rthat rbegins rwith rclients rwho rare rmost
rable rto rambulate r(A). r(B) ris rpremature rand ris rlikely rto rincrease rthe rchaos rif rincoming
rcasualties rare ranticipated. r(C) ris rpoor rutilization rof rpersonnel. r
r
The rnurse rassesses ra rclient rwhile rthe rUAP rmeasures rthe rclient's rvital rsigns. rThe rclient's
rvital rsigns rchange rsuddenly, rand rthe rnurse rdetermines rthat rthe rclient's rcondition ris
rworsening. rThe rnurse ris runsure rof rthe rclient's rresuscitative rstatus rand rneeds rto rcheck rthe
rclient's rmedical rrecord rfor rany radvanced rdirectives. rWhich raction rshould rthe rnurse
rimplement? r
r
A.Ask rthe rUAP rto rcheck rfor rthe radvanced rdirective rwhile rthe rnurse rcompletes rthe
rassessment. r
B.Assign rthe rUAP rto rcomplete rthe rassessment rwhile rthe rnurse rchecks rfor rthe radvanced
rdirective. r
C.Check rthe rmedical rrecord rfor rthe radvanced rdirective rand rthen rcomplete rthe rclient
rassessment. r
rD.Call rfor rthe rcharge rnurse rto rcheck rthe radvanced rdirective rwhile rcontinuing rto rassess
rthe rclient. r- rD r
Because rthe rclient's rcondition ris rworsening, rthe rnurse rshould rremain rwith rthe rclient rand
rcontinue rthe rassessment rwhile rcalling rfor rhelp rfrom rthe rcharge rnurse rto rdetermine rthe
rclient's rresuscitative rstatus r(D). r(A rand rB) rare rtasks rthat rmust rbe rcompleted rby ra rnurse
rand rcannot rbe rdelegated rto rthe rUAP. r(C) ris rcontraindicated. r
r
The rnurse ris rpreparing ra rclient rfor rsurgery rscheduled rin r2 rhours. rA rUAP ris rhelping rthe
rnurse. r
Which rtask ris rimportant rfor rthe rnurse rto rperform, rrather rthan rthe r
rUAP?
r
A.Remove rthe rclient's rnail rpolish rand rdentures. r
rB.Assist rthe rclient rto rthe rrestroom rto rvoid. r
rC.Obtain rthe rclient's rheight rand rweight. r
rD.Offer rthe rclient remotional rsupport. r- rD r
By rusing rtherapeutic rtechniques rto roffer rsupport r(D), rthe rnurse rcan rdetermine rany rclient
rconcerns rthat rneed rto rbe raddressed. r(A, rB, rand rC) rare rall ractions rthat rcan rbe rperformed
rby rthe rUAP runder rthe rsupervision rof rthe rnurse. r
r
Until rthe rcensus ron rthe robstetrics r(OB) runit rincreases, ran runlicensed rassistive rpersonnel
r(UAP) rwho rusually rworks rin rlabor rand rdelivery rand rthe rnewborn rnursery ris rassigned rto
rwork ron rthe rpostoperative runit. rWhich rclient rwould rbe rbest rfor rthe rcharge rnurse rto
rassign rto rthis r
UAP? r
r
rA.An radolescent rwho rwas rreadmitted rto rthe rhospital rbecause rof ra rpostoperative rinfection
r
rB.A rwoman rwith ra rnew rcolostomy rwho rrequires rdischarge rteaching r
rC.A rwoman rwho rhad ra rhip rreplacement rand rmay rbe rtransferred rto rthe rhome rcare runit r
, rD.A rman rwho rhad ra rcholecystectomy rand rcurrently rhas ra rnasogastric rtube rset rto
rintermittent rsuction r- rC r
The rcharge rnurse rwill rbe rresponsible rfor rproviding ra rreport rto rthe rhome rcare runit rif rthe
rtransfer roccurs r(A). rThe rclient ris rinfected rand ran remployee rwho rworks ron ran rOB runit
rshould rbe rassigned rto rclean rcases rin rcase rthe remployee ris rrequired rto rreturn rto rthe rOB
runit r(B). rThis rrequires rthe rskills rof ra rregistered rnurse r(RN) rto rdo rdischarge rteaching rand
rprovide remotional rsupport r(D). rThis rmay rrequire rskills rbeyond rthe rlevel rof rthis rUAP. r
r
A rmale rclient ris radmitted rfor robservation rafter rbeing rhit ron rthe rhead rwith ra rbaseball rbat.
rSix rhours rafter radmission, rthe rclient rattempts rto rcrawl rout rof rbed rand rasks rthe rnurse
rwhy rthere rare rso rmany rbugs rin rhis rbed. rHis rvital rsigns rare rstable, rand rthe rpulse
roximeter rreading ris r98% ron rroom rair. rWhich rintervention rshould rthe rnurse rperform rfirst?
r
r
A.Administer roxygen rper rnasal rcannula rat r2 rL/min. r
B.Plan rto rcheck rhis rvital rsigns ragain rin r30 rminutes. r
C.Notify rthe rhealth rcare rprovider rof rthe rchange rin rmental rstatus. r
D.Ask rthe rclient rwhy rhe rthinks rthere rare rbugs rin rthe rbed. r- rC r
One rof rthe rearliest rsigns rof rincreased rintracranial rpressure r(ICP) ris ra rchange rin rmental
rstatus r(C). rIt ris rimportant rto ract rearly rand rquickly rwhen rsymptoms rof rincreased rICP
roccur. rBecause rhis roxygen rsaturation ris rnormal, rthe radministration rof roxygen r(A) ris rnot
rthe rtop rpriority. rVital rsigns rshould rbe rmonitored rfrequently r(B), rbut rthe rclient's
rconfusion rshould rbe rreported rimmediately. r(D) ris rnot ra ruseful rintervention. r
r
The rnurse ris rmonitoring ra rclient rwho ris rreceiving rbedside rconscious rsedation rwith
rmidazolam r
hydrochloride r(Versed). rIn rassessing rthe rclient, rthe rnurse rdetermines rthat rthe rclient r
r
rhas
slurred rspeech rwith rdiplopia. rBased ron rthis rfinding, rwhat raction rshould rthe rnurse
rtake?
r
rA.Open rthe rairway rwith ra rchin rlift-head rtilt rmaneuver. r
rB.Obtain ra rfingerstick rglucose rreading. r
rC.Administer rflumazenil r(Romazicon). r
rD.Continue rto rmonitor rthe rclient. r- rD r
The rdesired rlevel rIII rin rconscious rsedation rincludes rslurred rspeech, rglazed reyes, rand
rmarked rdiplopia. rBecause rthis ris rthe rdesired routcome rof rthe rmedication rregimen, rno
raction ris rneeded rbut rcontinuing rto rmonitor rthe rclient r(D). rThe rairway ris ropen rif rthe
rclient ris rable rto rtalk r(A). rThere rare rno rsigns rof rhypoglycemia r(B). rNo rreversal ris
rnecessary rfor rthe rbenzodiazepine r(Versed) rwithout rsigns rof roversedation, rsuch ras
rrespiratory rdepression r(C). r
r
The rnurse ris rassessing ra rclient rusing rthe rSnellen rchart rand rdetermines rthat rthe rclient's
rvisual r
acuity ris rthe rsame ras rin ra rprevious rexamination, rwhich rwas rrecorded ras r20/100. rWhen r
rthe
client rasks rthe rmeaning rof rthis, rwhich rinformation rshould rthe rnurse r
rprovide?
r
A nurse who has recently completed orientation is beginning work in the labor and delivery
unit for the first time. When making assignments, which client should the charge nurse assign
to this new nurse? - A multiparous client who is dilated 5 cm and 50% effaced
A client with human immunodeficiency virus (HIV) infection has white lesions in the oral
cavity that resemble milk curds. Nystatin (Mycostatin) preparation is prescribed as a swish
and swallow. Which information is most important for the nurse to provide the client? - Oral
hygiene should be performed before the medication.
A client who is admitted with emphysema is having difficulty breathing. In which position
should the nurse place the client? - Sitting upright and forward with both arms supported on
an over the bed table
A client with chronic renal insufficiency (CRI) is taking 25 mg of hydrochlorothiazide
(HCTZ) PO and 40 mg of furosemide (Lasix) PO daily. Today, at a routine clinic visit, the
client's serum potassium level is 4 mEq/L. What is the most likely cause of this client's
potassium level? - The client's renal function has affected his potassium level.
A registered nurse (RN) delivers telehealth services to clients via electronic communication.
Which nursing action creates the greatest risk for professional liability and has the potential
for a malpractice lawsuit? - Sending medical records to health care providers via the Internet
Which pathophysiologic response supports the contraindication for opioids, such as
morphine, in clients with increased intracranial pressure (ICP)?
A.Sedation produced by opioids is a result of a prolonged half-life when the ICP is elevated.
B.Higher doses of opioids are required when cerebral blood flow is reduced by an elevated
ICP.
C.Dysphoria from opioids contributes to altered levels of consciousness with an elevated
ICP.
D.Opioids suppress respirations, which increases Pco2 and contributes to an elevated ICP. - D
The greatest risk associated with opioids such as morphine (D) is respiratory depression that
causes an increase in Pco2, which increases ICP and masks the early signs of intracranial
bleeding in head injury. (A, B, and C) do not support the risks associated with opioid use in a
client with increased ICP.
The charge nurse of a medical surgical unit is alerted to an impending disaster requiring
implementation of the hospital's disaster plan. Specific facts about the nature of this disaster
are not yet known. Which instruction should the charge nurse give to the other staff members
at this time?
A.Prepare to evacuate the unit, starting with the bedridden clients.
B.UAPs should report to the emergency center to handle transports.
C.The licensed staff should begin counting wheelchairs and IV poles on the unit.
, D.Continue with current assignments until more instructions are received. - D
When rfaced rwith ran rimpending rdisaster, rhospital rpersonnel rmay rbe ralerted rbut rshould
rcontinue rwith rcurrent rclient rcare rassignments runtil rfurther rinstructions rare rreceived r(D).
rEvacuation ris rtypically ra rresponse rof rlast rresort rthat rbegins rwith rclients rwho rare rmost
rable rto rambulate r(A). r(B) ris rpremature rand ris rlikely rto rincrease rthe rchaos rif rincoming
rcasualties rare ranticipated. r(C) ris rpoor rutilization rof rpersonnel. r
r
The rnurse rassesses ra rclient rwhile rthe rUAP rmeasures rthe rclient's rvital rsigns. rThe rclient's
rvital rsigns rchange rsuddenly, rand rthe rnurse rdetermines rthat rthe rclient's rcondition ris
rworsening. rThe rnurse ris runsure rof rthe rclient's rresuscitative rstatus rand rneeds rto rcheck rthe
rclient's rmedical rrecord rfor rany radvanced rdirectives. rWhich raction rshould rthe rnurse
rimplement? r
r
A.Ask rthe rUAP rto rcheck rfor rthe radvanced rdirective rwhile rthe rnurse rcompletes rthe
rassessment. r
B.Assign rthe rUAP rto rcomplete rthe rassessment rwhile rthe rnurse rchecks rfor rthe radvanced
rdirective. r
C.Check rthe rmedical rrecord rfor rthe radvanced rdirective rand rthen rcomplete rthe rclient
rassessment. r
rD.Call rfor rthe rcharge rnurse rto rcheck rthe radvanced rdirective rwhile rcontinuing rto rassess
rthe rclient. r- rD r
Because rthe rclient's rcondition ris rworsening, rthe rnurse rshould rremain rwith rthe rclient rand
rcontinue rthe rassessment rwhile rcalling rfor rhelp rfrom rthe rcharge rnurse rto rdetermine rthe
rclient's rresuscitative rstatus r(D). r(A rand rB) rare rtasks rthat rmust rbe rcompleted rby ra rnurse
rand rcannot rbe rdelegated rto rthe rUAP. r(C) ris rcontraindicated. r
r
The rnurse ris rpreparing ra rclient rfor rsurgery rscheduled rin r2 rhours. rA rUAP ris rhelping rthe
rnurse. r
Which rtask ris rimportant rfor rthe rnurse rto rperform, rrather rthan rthe r
rUAP?
r
A.Remove rthe rclient's rnail rpolish rand rdentures. r
rB.Assist rthe rclient rto rthe rrestroom rto rvoid. r
rC.Obtain rthe rclient's rheight rand rweight. r
rD.Offer rthe rclient remotional rsupport. r- rD r
By rusing rtherapeutic rtechniques rto roffer rsupport r(D), rthe rnurse rcan rdetermine rany rclient
rconcerns rthat rneed rto rbe raddressed. r(A, rB, rand rC) rare rall ractions rthat rcan rbe rperformed
rby rthe rUAP runder rthe rsupervision rof rthe rnurse. r
r
Until rthe rcensus ron rthe robstetrics r(OB) runit rincreases, ran runlicensed rassistive rpersonnel
r(UAP) rwho rusually rworks rin rlabor rand rdelivery rand rthe rnewborn rnursery ris rassigned rto
rwork ron rthe rpostoperative runit. rWhich rclient rwould rbe rbest rfor rthe rcharge rnurse rto
rassign rto rthis r
UAP? r
r
rA.An radolescent rwho rwas rreadmitted rto rthe rhospital rbecause rof ra rpostoperative rinfection
r
rB.A rwoman rwith ra rnew rcolostomy rwho rrequires rdischarge rteaching r
rC.A rwoman rwho rhad ra rhip rreplacement rand rmay rbe rtransferred rto rthe rhome rcare runit r
, rD.A rman rwho rhad ra rcholecystectomy rand rcurrently rhas ra rnasogastric rtube rset rto
rintermittent rsuction r- rC r
The rcharge rnurse rwill rbe rresponsible rfor rproviding ra rreport rto rthe rhome rcare runit rif rthe
rtransfer roccurs r(A). rThe rclient ris rinfected rand ran remployee rwho rworks ron ran rOB runit
rshould rbe rassigned rto rclean rcases rin rcase rthe remployee ris rrequired rto rreturn rto rthe rOB
runit r(B). rThis rrequires rthe rskills rof ra rregistered rnurse r(RN) rto rdo rdischarge rteaching rand
rprovide remotional rsupport r(D). rThis rmay rrequire rskills rbeyond rthe rlevel rof rthis rUAP. r
r
A rmale rclient ris radmitted rfor robservation rafter rbeing rhit ron rthe rhead rwith ra rbaseball rbat.
rSix rhours rafter radmission, rthe rclient rattempts rto rcrawl rout rof rbed rand rasks rthe rnurse
rwhy rthere rare rso rmany rbugs rin rhis rbed. rHis rvital rsigns rare rstable, rand rthe rpulse
roximeter rreading ris r98% ron rroom rair. rWhich rintervention rshould rthe rnurse rperform rfirst?
r
r
A.Administer roxygen rper rnasal rcannula rat r2 rL/min. r
B.Plan rto rcheck rhis rvital rsigns ragain rin r30 rminutes. r
C.Notify rthe rhealth rcare rprovider rof rthe rchange rin rmental rstatus. r
D.Ask rthe rclient rwhy rhe rthinks rthere rare rbugs rin rthe rbed. r- rC r
One rof rthe rearliest rsigns rof rincreased rintracranial rpressure r(ICP) ris ra rchange rin rmental
rstatus r(C). rIt ris rimportant rto ract rearly rand rquickly rwhen rsymptoms rof rincreased rICP
roccur. rBecause rhis roxygen rsaturation ris rnormal, rthe radministration rof roxygen r(A) ris rnot
rthe rtop rpriority. rVital rsigns rshould rbe rmonitored rfrequently r(B), rbut rthe rclient's
rconfusion rshould rbe rreported rimmediately. r(D) ris rnot ra ruseful rintervention. r
r
The rnurse ris rmonitoring ra rclient rwho ris rreceiving rbedside rconscious rsedation rwith
rmidazolam r
hydrochloride r(Versed). rIn rassessing rthe rclient, rthe rnurse rdetermines rthat rthe rclient r
r
rhas
slurred rspeech rwith rdiplopia. rBased ron rthis rfinding, rwhat raction rshould rthe rnurse
rtake?
r
rA.Open rthe rairway rwith ra rchin rlift-head rtilt rmaneuver. r
rB.Obtain ra rfingerstick rglucose rreading. r
rC.Administer rflumazenil r(Romazicon). r
rD.Continue rto rmonitor rthe rclient. r- rD r
The rdesired rlevel rIII rin rconscious rsedation rincludes rslurred rspeech, rglazed reyes, rand
rmarked rdiplopia. rBecause rthis ris rthe rdesired routcome rof rthe rmedication rregimen, rno
raction ris rneeded rbut rcontinuing rto rmonitor rthe rclient r(D). rThe rairway ris ropen rif rthe
rclient ris rable rto rtalk r(A). rThere rare rno rsigns rof rhypoglycemia r(B). rNo rreversal ris
rnecessary rfor rthe rbenzodiazepine r(Versed) rwithout rsigns rof roversedation, rsuch ras
rrespiratory rdepression r(C). r
r
The rnurse ris rassessing ra rclient rusing rthe rSnellen rchart rand rdetermines rthat rthe rclient's
rvisual r
acuity ris rthe rsame ras rin ra rprevious rexamination, rwhich rwas rrecorded ras r20/100. rWhen r
rthe
client rasks rthe rmeaning rof rthis, rwhich rinformation rshould rthe rnurse r
rprovide?
r
