NUR 216 Hesi Review Questions

1. The nurse is caring for a client with heart failure. On assessment,
the nurse notes that the client is dyspneic, and crackles are audible
on auscultation. What additional manifestations would the nurse
expect to note in this client if excess fluid volume is present?
1/1

1. Weight loss and dry skin.
2. Flat neck and hand veins and decreased urinary output.
3. An increase in blood pressure and increased respirations.

4. Weakness and decreased central venous pressure (CVP).


2. Which client is at risk for the development of a potassium level of
5.5 mEq/L (5.5 mmol/L)?
1/1

1. The client with colitis
2. The client with Cushing’s syndrome
3. The client who has been overusing laxatives
4. The client who has sustained a traumatic burn



3. The nurse is caring for a client with heart failure who is receiving
high doses of a diuretic. On assessment, the nurse notes that the
client has flat neck veins, generalized muscle weakness, and
diminished deep tendon reflexes. The nurse suspects hyponatremia.
What additional signs would the nurse expect to note in a client
with hyponatremia?
0/1
1. Muscle twitches
2. Decreased urinary output

3. Hyperactive bowel sounds
4. Increased specific gravity of the urine

Correct answer
3. Hyperactive bowel sounds


4. Which client is at risk for the development of a sodium level at
130 mEq/L (130 mmol/L)?
0/1
1. The client who is taking diuretics
2. The client with hyperaldosteronism

,3. The client with Cushing’s syndrome

4. The client who is taking corticosteroids

Correct answer
1. The client who is taking diuretics


5. The nurse is assigned to care for a group of clients. On review of
the clients’ medical records, the nurse determines that which client
is most likely at risk for a fluid volume deficit?
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1. A client with an ileostomy
2. A client with heart failure
3. A client on long-term corticosteroid therapy

4. A client receiving frequent wound irrigations

Correct answer
1. A client with an ileostomy


6. On review of the clients’ medical records, the nurse determines
that which client is at risk for fluid volume excess?
0/1
1. The client taking diuretics and has tenting of the skin
2. The client with an ileostomy from a recent abdominal surgery
3. The client who requires intermittent gastrointestinal suctioning

4. The client with kidney disease and a 12-year history of diabetes mellitus

Correct answer
4. The client with kidney disease and a 12-year history of diabetes mellitus


7. The nurse is teaching a client who has iron deficiency anemia
about foods she should include in the diet. The nurse determines
that the client under- stands the dietary modifications if which
items are selected from the menu?
1/1

1. Nuts and milk
2. Coffee and tea
3. Cooked rolled oats and fish
4. Oranges and dark green leafy vegetables

,8. A client receiving parenteral nutrition (PN) com- plains of a
headache. The nurse notes that the client has an increased blood
pressure, bounding pulse, jugular vein distention, and crackles
bilaterally. The nurse determines that the client is experiencing
which complication of PN therapy?
1/1
1. Sepsis
2. Air embolism
3. Hypervolemia

4. Hyperglycemia


9. The nurse is making initial rounds on the nursing unit to assess
the condition of assigned clients. Which assessment findings are
consistent with infiltration? Select all that apply.
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1. Pain and erythema
2. Pallor and coolness

3. Numbness and pain
4. Edema and blanched skin
5. Formation of a red streak and purulent drainage


10. The health care provider has written these orders for a client
with a diagnosis of pulmonary edema. The client’s morning
assessment reveals bounding peripheral pulses, weight gain for
2 lb, pitting ankle edema, and bilateral moist crackles. Which order
takes priority at this time?
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1. Weight the client every morning.
2. Maintain accurate intake and output records.
3. Restrict fluids to 1500 mL/day.
4. Administer furosemide 40 mg IV push.



11. The nurse is caring for a client with a diagnosis of cancer who is
immunosuppressed. The nurse would consider implementing
neutropenic precautions if the client’s white blood cell count was
which value?
1/1

, 1. 2000mm3 (2.0:109/L)

2. 5800mm3 (5.8:109/L)
3. 8400mm3 (8.4:109/L)
4. 11,500mm3 (11.5:109/L)


12. The nurse reviewing a health care provider’s prescription for a
child with sickle cell anemia who was admitted to the hospital for
the treatment of Vaso-occlusive crisis. Which prescriptions
documented in the child’s record should the nurse question? Select
all that apply.
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1. Restrict fluid intake.
2. Position for comfort.

3. Avoid strain on painful joints.
4. Apply nasal oxygen at 2 L/minute.
5. Provide a high-calorie, high protein diet.
6. Give meperidine, 25 mg intravenously every 4 hours for pain.

Correct answers
1. Restrict fluid intake.
6. Give meperidine, 25 mg intravenously every 4 hours for pain.


13. A nurse is teaching a client with Hodgkin disease about
responses to whole-body radiation. Which clinical indicator increase
should the nurse include?
1/1
1. Blood viscosity.
2. Susceptibility to infection.

3. Red blood cell production.
4. Tendency for pathologic fracture.


14. Which of these patients who have just arrived at the emergency
department should the nurse assess first?
0/1
1. Patient who reports several dark, tarry stools and a history of peptic ulcer disease

2. Patient with hemophilia A who is experiencing thigh swelling after a fall
3. Patient who has pernicious anemia and reports paresthesia of the hands and feet
4. Patient with thalassemia major who needs a scheduled blood transfusion