NURS 310 HESI Review with Complete Solutions
A 75-year-old client who has a history of end stage renal failure and advanced lung cancer,
recently had a stroke. Two days ago the healthcare provider discontinued the client's dialysis
Page | 1
treatments, stating that death is inevitable, but the client is disoriented and will not sign a DNR
directive. What is the priority nursing intervention?
Review the client's most recent laboratory reports.
Refer the client and family members for hospice care.
Notify the hospital ethics committee of the client situation.
Determine who is legally empowered to make decisions. - ANSWER -Determine who is
legally empowered to make decisions.
A male client with an infected wound tells the nurse that he follows a macrobiotic diet. Which
type of foods should the nurse recommend that the client 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 intermittent infusion of an antibiotic to a client whose intravenous
(IV) access is an antecubital saline lock. After the nurse opens the roller clamp on the IV tubing,
the alarm on the infusion pump indicates an obstruction. What action should the nurse take
first?
, Check for a blood return.
Reposition the client's arm.
Page | 2
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 be unable to infuse, resulting in an obstruction alarm, so
the nurse should first attempt to reposition the client's arm to alleviate any obstruction
What action should the nurse implement to prevent the formation of a sacral ulcer for a client
who is immobile?
Maintain in a lateral position using protective wrist and vest devices.
Position prone with a small pillow below the diaphragm.
Raise the head and knee gatch when lying in a supine position.
Transfer into a wheelchair close to the nurse's station for observation. - ANSWER -
Position prone with a small pillow below the diaphragm.
What intervention should the nurse include in the plan of care for a client who is being treated
with an Unna's paste boot for leg ulcers due 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 to assess wound healing. - ANSWER -Check capillary
refill of toes on lower extremity with Unna's paste boot.
Which nursing intervention is most beneficial in reducing the risk of urosepsis in a hospitalized
client with an indwelling urinary catheter?
, Ensure that the client's perineal area is cleansed twice a day.
Maintain accurate documentation of the fluid intake and output.
Encourage frequent ambulation if allowed or regular turning if on bedrest.
Page | 3
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 intervention to reduce the risk for urosepsis (spread of an infectious agent from the
urinary tract to systemic circulation) is removal of the urinary catheter as quickly as possible (D).
(A, B, and C) are helpful to reduce the risk of infection, but are of less priority than (D) in
reducing the risk of urosepsis.
A client provides the nurse with information about the reason for seeking care. The nurse
realizes that some information about past hospitalizations is missing. How should the nurse
obtain this information?
Solicit information on hospitalization from the insurance company.
Look up previous medical records from archived hospital documents.
Ask the client to discuss previous hospitalizations in the last 5 years.
Elicit specific facts about past hospitalizations with direct questions. - ANSWER -Elicit
specific facts about past hospitalizations with direct questions.
Direct questions should be used after the client's opening narrative to fill in any details that
have been left out or during the review of systems to elicit specific facts about past health
problems.
A signed consent form indicated a client should have an electromyogram, but a myelogram was
performed instead. Though the myelogram revealed the cause of the client's back pain, which
was subsequently treated, the client filed a lawsuit against the nurse and healthcare provider
for performing the incorrect procedure. The court is likely to rule in favor of the plaintiff
because these events represent what infraction?
A 75-year-old client who has a history of end stage renal failure and advanced lung cancer,
recently had a stroke. Two days ago the healthcare provider discontinued the client's dialysis
Page | 1
treatments, stating that death is inevitable, but the client is disoriented and will not sign a DNR
directive. What is the priority nursing intervention?
Review the client's most recent laboratory reports.
Refer the client and family members for hospice care.
Notify the hospital ethics committee of the client situation.
Determine who is legally empowered to make decisions. - ANSWER -Determine who is
legally empowered to make decisions.
A male client with an infected wound tells the nurse that he follows a macrobiotic diet. Which
type of foods should the nurse recommend that the client 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 intermittent infusion of an antibiotic to a client whose intravenous
(IV) access is an antecubital saline lock. After the nurse opens the roller clamp on the IV tubing,
the alarm on the infusion pump indicates an obstruction. What action should the nurse take
first?
, Check for a blood return.
Reposition the client's arm.
Page | 2
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 be unable to infuse, resulting in an obstruction alarm, so
the nurse should first attempt to reposition the client's arm to alleviate any obstruction
What action should the nurse implement to prevent the formation of a sacral ulcer for a client
who is immobile?
Maintain in a lateral position using protective wrist and vest devices.
Position prone with a small pillow below the diaphragm.
Raise the head and knee gatch when lying in a supine position.
Transfer into a wheelchair close to the nurse's station for observation. - ANSWER -
Position prone with a small pillow below the diaphragm.
What intervention should the nurse include in the plan of care for a client who is being treated
with an Unna's paste boot for leg ulcers due 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 to assess wound healing. - ANSWER -Check capillary
refill of toes on lower extremity with Unna's paste boot.
Which nursing intervention is most beneficial in reducing the risk of urosepsis in a hospitalized
client with an indwelling urinary catheter?
, Ensure that the client's perineal area is cleansed twice a day.
Maintain accurate documentation of the fluid intake and output.
Encourage frequent ambulation if allowed or regular turning if on bedrest.
Page | 3
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 intervention to reduce the risk for urosepsis (spread of an infectious agent from the
urinary tract to systemic circulation) is removal of the urinary catheter as quickly as possible (D).
(A, B, and C) are helpful to reduce the risk of infection, but are of less priority than (D) in
reducing the risk of urosepsis.
A client provides the nurse with information about the reason for seeking care. The nurse
realizes that some information about past hospitalizations is missing. How should the nurse
obtain this information?
Solicit information on hospitalization from the insurance company.
Look up previous medical records from archived hospital documents.
Ask the client to discuss previous hospitalizations in the last 5 years.
Elicit specific facts about past hospitalizations with direct questions. - ANSWER -Elicit
specific facts about past hospitalizations with direct questions.
Direct questions should be used after the client's opening narrative to fill in any details that
have been left out or during the review of systems to elicit specific facts about past health
problems.
A signed consent form indicated a client should have an electromyogram, but a myelogram was
performed instead. Though the myelogram revealed the cause of the client's back pain, which
was subsequently treated, the client filed a lawsuit against the nurse and healthcare provider
for performing the incorrect procedure. The court is likely to rule in favor of the plaintiff
because these events represent what infraction?
