HEALTH ASSESSMENT HESI 2024-2025 FINAL EXAM
COMPLETE QUESTIONS AND CORRECT ANSWERS
GRADED A+
The nurse is caring for a client who was admitted two hours ago with confusion, Kussmaul
respirations, and warm, flushed skin. The healthcare provider determines the client is in acute
renal failure (ARF). Which intervention is most important for the nurse to include in this clients
plan of care?
Hourly neurological assessments.
The nurse observes a 2cm area of non-blanchable erythema on the sacrum of an immobile
client. What documentation of this finding is best for the nurse to enter into the client's record?
Stage 1 pressure ulcer on sacrum.
A client diagnosed with major depression is being allowed a weekend pass from the psychiatric
unit. Which instruction should the nurse provide to the client's family?
Involve the client in usual at home activities
A 14-year-old male client arrives at the emergency room in status epilepticus. He was
diagnosed with a seizure disorder in childhood. What is the most likely cause of his present
condition?
Acute withdrawal from anticonvulsant medication.
,A client with gestational diabetes at 39-weeks gestation is in the second stage of labor. After
delivery of the fetal head, the nurse recognizes that shoulder dystocia is occurring. What
intervention should the nurse implement first?
Assist the client to sharply flex her thighs up against the abdomen
The nurse is teaching a childbirth education class t prospective parents and describing possible
signs of labor. Class participants should be taught that which sign should be reported to the
healthcare provider immediately?
Leaking of fluid from the vagina
During the first trimester of pregnancy, a client who was treated for genital herpes with acyclovir
(Zovirax) prior to this pregnancy tells the nurse that she is experiencing an episode of genital
herpes. Which nursing intervention has the highest priority?
The highest priority in this situation is to determine if the client has taken the drug Zoviarax,
because Acyclovir has been associated with birth defects.
. The nurse is obtaining a medication history for a client with a new prescription for paroxetine
(Paxil). The client reports current use of the MAO inhibitor isocarboxazid (Marplan). What
intervention is most important for the nurse to implement?
Notify the healthcare provider that the client is currently taking Marplan.
After administering a medication through a nasogastric tube connected to suction, what action
should the nurse take first?
Clamp the tube
What action should the nurse implement first when delegating nursing activities to an unlicensed
assistive personnel (UAP)?
Evaluate the experience of the UAP.
, The nurse is caring for four clients: Client A 94% o2 saturation, Client B, hemoglobin of 8.;
Client C, potassium level of 3.8 and Client D appendectomy who has a white blood cell count of
15,000. What
should the nurse implement?
Determine if Client B has two units of packed cells available in the blood bank.
A 40-year-old client with type 1 diabetes developed chronic kidney (CKD) disease 6 months
ago. Because of secondary complications often associated with this illness the nurse plans to
carefully assess for signs of what condition?
Anemia
A client diagnosed with acute epididymitis secondary to a sexually transmitted disease receives
a prescription for ceftriaxone (Rocephin). Prior to administering the prescription, which question
should the nurse ask the client?
"Have you ever had an allergic reaction to any other antibiotics?"
A client at 38 weeks gestation is in active labor, and a vaginal birth after Cesarean section
(VBAC) is planned. Vaginal exam indicates that the client is 6cm dilated, 90% effaced, and the
station 0 with intact membranes. As the client's contraction become stronger, the fetal heart rate
decelerates during the contraction but returns to baseline. What action should be taken?
Continue to monitor the client's labor progress.
An elderly client with limited mobility reports frequent episodes of nocturia. To reduce the risk for
urinary incontinence, what action should the nurse implement?
Keep the call bell button within the client's reach.
COMPLETE QUESTIONS AND CORRECT ANSWERS
GRADED A+
The nurse is caring for a client who was admitted two hours ago with confusion, Kussmaul
respirations, and warm, flushed skin. The healthcare provider determines the client is in acute
renal failure (ARF). Which intervention is most important for the nurse to include in this clients
plan of care?
Hourly neurological assessments.
The nurse observes a 2cm area of non-blanchable erythema on the sacrum of an immobile
client. What documentation of this finding is best for the nurse to enter into the client's record?
Stage 1 pressure ulcer on sacrum.
A client diagnosed with major depression is being allowed a weekend pass from the psychiatric
unit. Which instruction should the nurse provide to the client's family?
Involve the client in usual at home activities
A 14-year-old male client arrives at the emergency room in status epilepticus. He was
diagnosed with a seizure disorder in childhood. What is the most likely cause of his present
condition?
Acute withdrawal from anticonvulsant medication.
,A client with gestational diabetes at 39-weeks gestation is in the second stage of labor. After
delivery of the fetal head, the nurse recognizes that shoulder dystocia is occurring. What
intervention should the nurse implement first?
Assist the client to sharply flex her thighs up against the abdomen
The nurse is teaching a childbirth education class t prospective parents and describing possible
signs of labor. Class participants should be taught that which sign should be reported to the
healthcare provider immediately?
Leaking of fluid from the vagina
During the first trimester of pregnancy, a client who was treated for genital herpes with acyclovir
(Zovirax) prior to this pregnancy tells the nurse that she is experiencing an episode of genital
herpes. Which nursing intervention has the highest priority?
The highest priority in this situation is to determine if the client has taken the drug Zoviarax,
because Acyclovir has been associated with birth defects.
. The nurse is obtaining a medication history for a client with a new prescription for paroxetine
(Paxil). The client reports current use of the MAO inhibitor isocarboxazid (Marplan). What
intervention is most important for the nurse to implement?
Notify the healthcare provider that the client is currently taking Marplan.
After administering a medication through a nasogastric tube connected to suction, what action
should the nurse take first?
Clamp the tube
What action should the nurse implement first when delegating nursing activities to an unlicensed
assistive personnel (UAP)?
Evaluate the experience of the UAP.
, The nurse is caring for four clients: Client A 94% o2 saturation, Client B, hemoglobin of 8.;
Client C, potassium level of 3.8 and Client D appendectomy who has a white blood cell count of
15,000. What
should the nurse implement?
Determine if Client B has two units of packed cells available in the blood bank.
A 40-year-old client with type 1 diabetes developed chronic kidney (CKD) disease 6 months
ago. Because of secondary complications often associated with this illness the nurse plans to
carefully assess for signs of what condition?
Anemia
A client diagnosed with acute epididymitis secondary to a sexually transmitted disease receives
a prescription for ceftriaxone (Rocephin). Prior to administering the prescription, which question
should the nurse ask the client?
"Have you ever had an allergic reaction to any other antibiotics?"
A client at 38 weeks gestation is in active labor, and a vaginal birth after Cesarean section
(VBAC) is planned. Vaginal exam indicates that the client is 6cm dilated, 90% effaced, and the
station 0 with intact membranes. As the client's contraction become stronger, the fetal heart rate
decelerates during the contraction but returns to baseline. What action should be taken?
Continue to monitor the client's labor progress.
An elderly client with limited mobility reports frequent episodes of nocturia. To reduce the risk for
urinary incontinence, what action should the nurse implement?
Keep the call bell button within the client's reach.
