HESI Final Exam review with
correct answers.
A female client with an NG tube attached to low suction states that she is nauseated. The nurse
assesses that there has been no drainage through the NG tube in the last 2 hours. Which action
should the nurse take?
A) Irrigate the NG tube with sterile normal saline.
B) Reposition the client on her side.
C) Advance the NG tube 5cm.
D) Administer an IV antiemetic as prescribed. Ans B.
The immediate priority is to determine if the tube is functioning correctly, which would then
relieve the client's nausea. The least invasive intervention, repositioning the client, should be
attempted first followed by the others.
Which change in lab values indicates to the nurse that a client with rheumatoid arthritis may be
experiencing an adverse effect of methotrexate (Mexate) therapy?
A) Increase in rheumatoid factor.
B) Decrease in hemoglobin level.
C) Increase in blood glucose level.
D) Decrease in erythrocyte sedimentation rate (ESR; sed rate) Ans B.
Methotrexate is an immunosuppressant. A common side effect is bone marrow depression,
which would be reflected by a decrease in the hemoglobin level. A indicates disease
progression but is not a side effect of the medication. C is not related to this medication. D
indicates that inflammation associated with the disease has diminished.
The nurse is counseling a healthy 30 year old female client regarding osteoporosis prevention.
Which activity would be most beneficial in achieving the client's goal of osteoporosis?
,A) Cross country skiing.
B) Scuba diving.
C) Horseback riding.
D) Kayaking. Ans A.
Weight bearing exercise is an important measure to reduce the risk of osteoporosis. Cross
country skiing includes the most weight bearing exercise out of the choices.
A male client has just undergone a laryngectomy and has a cuffed tracheostomy tube in place.
When initiating bolus tube feedings postoperatively, when should the nurse inflate the cuff?
A) Immediately after feeding.
B) Just prior to tube feeding.
C) Continuous inflation is required.
D) Inflation is not required. Ans B.
The cuff should be inflate before the feeding to block the trachea and prevent food from
entering if oral feedings are started while a cuff tracheostomy tube is in place. It should remain
inflated throughout feeding to prevent aspiration of food into the respiratory system. C places
the patient at risk for tracheal wall necrosis.
What is the most important nursing priority for a client who has been admitted for a possible
kidney stone?
A) Reducing dairy products in the diet.
B) Straining all urine.
C) Measuring intake and output.
D) Increasing fluid intake. Straining all urine is the most important nursing action to take in this
case. Encouraging fluid intake is important for any client who may have a kidney stone, but is
,even more important to strain urine. Straining the urine will enable the nurse to determine
when the kidney stone has been passed and may prevent the need for surgery.
Which data would the nurse expect to find when reviewing laboratory values of an 80 year old
man who is in good health overall?
A) CBC reveals increased WBC and decreased RBC.
B) Chemistries reveal an increased serum billirubin level with slightly increased liver enzyme
levels.
C) Urinalysis reveals slight protein in the urine and bacteriuria, with pyurina.
D) Serum electrolytes reveal a decreased sodium level and increased potassium level. Ans C.
In older adults, the protein found in urine slightly rises, probably as a result of kidney changes
or subclinical UTIs, and clients frequently experience asymptomatic bacteriuria and pyuria as a
result of incomplete bladder emptying. Lab findings in A, B, and D are not considered to be
normal findings in an older adult.
During assessment of a client in the ICU, the nurse notes that the client's breath sounds are
clear on auscultation, but jugular vein distention and muffled heart sounds are present. Which
intervention should the nurse implement?
A) Prepare the client for a pericardial tap.
B) Administer IV Lasix.
C) Assist the client to cough and breathe deeply.
D) Instruct the client to restrict the oral fluid intake. Ans A.
The client is exhibiting symptoms of cardiac tamponade, a collection of fluid in the pericardial
sac that results in a reduction in cardiac output, which is a potentially fatal complication of
pericarditis. Treatment for a tamponade is a pericardial tap. Fluids are frequently increased in
the initial treatment of tamponade to compensate for the decrease in cardiac output, but this is
not the same priority as A.
, Which consideration is most important when the nurse is assigning a room for a client being
admitted with progressive systemic sclerosis (scleroderma)?
A) Provide a room that can be kept warm.
B) Make sure that the room can be kept dark.
C) Keep the client close to the nursing unit.
D) Select a room that is visible from the nurses' desk. Ans A.
Abnormal blood flow in response to cold (Raynaud's phenomenon) is precipitated in clients
with scleroderma.
A 58 year old client who has no health problems asks the nurse about receiving the
pneumococcal vaccine (Pneumovax). Which statement given by the nurse would offer the client
accurate information about this vaccine?
A) The vaccine is given annually before the flu season to those older than 50 years.
B) The immunization is administered once to older adults or those at risk for illness.
C) The vaccine is for all ages and is given primarily to those persons traveling overseas to areas
of infection.
D) The vaccine will prevent the occurrence of pneumococcal pneumonia for up to 5 years. Ans
B.
It is usually recommended that persons older than 65 years and those with a history of chronic
illness should receive the vaccine once in their lifetime. The vaccine is usually given once in a
lifetime, but with immunosuppressed clients or clients with a history of pneumonia,
revaccination is sometimes required.
A client with alcohol related liver disease is admitted to the unit. Which prescription should the
nurse call the HCP about for re verification for this client?
correct answers.
A female client with an NG tube attached to low suction states that she is nauseated. The nurse
assesses that there has been no drainage through the NG tube in the last 2 hours. Which action
should the nurse take?
A) Irrigate the NG tube with sterile normal saline.
B) Reposition the client on her side.
C) Advance the NG tube 5cm.
D) Administer an IV antiemetic as prescribed. Ans B.
The immediate priority is to determine if the tube is functioning correctly, which would then
relieve the client's nausea. The least invasive intervention, repositioning the client, should be
attempted first followed by the others.
Which change in lab values indicates to the nurse that a client with rheumatoid arthritis may be
experiencing an adverse effect of methotrexate (Mexate) therapy?
A) Increase in rheumatoid factor.
B) Decrease in hemoglobin level.
C) Increase in blood glucose level.
D) Decrease in erythrocyte sedimentation rate (ESR; sed rate) Ans B.
Methotrexate is an immunosuppressant. A common side effect is bone marrow depression,
which would be reflected by a decrease in the hemoglobin level. A indicates disease
progression but is not a side effect of the medication. C is not related to this medication. D
indicates that inflammation associated with the disease has diminished.
The nurse is counseling a healthy 30 year old female client regarding osteoporosis prevention.
Which activity would be most beneficial in achieving the client's goal of osteoporosis?
,A) Cross country skiing.
B) Scuba diving.
C) Horseback riding.
D) Kayaking. Ans A.
Weight bearing exercise is an important measure to reduce the risk of osteoporosis. Cross
country skiing includes the most weight bearing exercise out of the choices.
A male client has just undergone a laryngectomy and has a cuffed tracheostomy tube in place.
When initiating bolus tube feedings postoperatively, when should the nurse inflate the cuff?
A) Immediately after feeding.
B) Just prior to tube feeding.
C) Continuous inflation is required.
D) Inflation is not required. Ans B.
The cuff should be inflate before the feeding to block the trachea and prevent food from
entering if oral feedings are started while a cuff tracheostomy tube is in place. It should remain
inflated throughout feeding to prevent aspiration of food into the respiratory system. C places
the patient at risk for tracheal wall necrosis.
What is the most important nursing priority for a client who has been admitted for a possible
kidney stone?
A) Reducing dairy products in the diet.
B) Straining all urine.
C) Measuring intake and output.
D) Increasing fluid intake. Straining all urine is the most important nursing action to take in this
case. Encouraging fluid intake is important for any client who may have a kidney stone, but is
,even more important to strain urine. Straining the urine will enable the nurse to determine
when the kidney stone has been passed and may prevent the need for surgery.
Which data would the nurse expect to find when reviewing laboratory values of an 80 year old
man who is in good health overall?
A) CBC reveals increased WBC and decreased RBC.
B) Chemistries reveal an increased serum billirubin level with slightly increased liver enzyme
levels.
C) Urinalysis reveals slight protein in the urine and bacteriuria, with pyurina.
D) Serum electrolytes reveal a decreased sodium level and increased potassium level. Ans C.
In older adults, the protein found in urine slightly rises, probably as a result of kidney changes
or subclinical UTIs, and clients frequently experience asymptomatic bacteriuria and pyuria as a
result of incomplete bladder emptying. Lab findings in A, B, and D are not considered to be
normal findings in an older adult.
During assessment of a client in the ICU, the nurse notes that the client's breath sounds are
clear on auscultation, but jugular vein distention and muffled heart sounds are present. Which
intervention should the nurse implement?
A) Prepare the client for a pericardial tap.
B) Administer IV Lasix.
C) Assist the client to cough and breathe deeply.
D) Instruct the client to restrict the oral fluid intake. Ans A.
The client is exhibiting symptoms of cardiac tamponade, a collection of fluid in the pericardial
sac that results in a reduction in cardiac output, which is a potentially fatal complication of
pericarditis. Treatment for a tamponade is a pericardial tap. Fluids are frequently increased in
the initial treatment of tamponade to compensate for the decrease in cardiac output, but this is
not the same priority as A.
, Which consideration is most important when the nurse is assigning a room for a client being
admitted with progressive systemic sclerosis (scleroderma)?
A) Provide a room that can be kept warm.
B) Make sure that the room can be kept dark.
C) Keep the client close to the nursing unit.
D) Select a room that is visible from the nurses' desk. Ans A.
Abnormal blood flow in response to cold (Raynaud's phenomenon) is precipitated in clients
with scleroderma.
A 58 year old client who has no health problems asks the nurse about receiving the
pneumococcal vaccine (Pneumovax). Which statement given by the nurse would offer the client
accurate information about this vaccine?
A) The vaccine is given annually before the flu season to those older than 50 years.
B) The immunization is administered once to older adults or those at risk for illness.
C) The vaccine is for all ages and is given primarily to those persons traveling overseas to areas
of infection.
D) The vaccine will prevent the occurrence of pneumococcal pneumonia for up to 5 years. Ans
B.
It is usually recommended that persons older than 65 years and those with a history of chronic
illness should receive the vaccine once in their lifetime. The vaccine is usually given once in a
lifetime, but with immunosuppressed clients or clients with a history of pneumonia,
revaccination is sometimes required.
A client with alcohol related liver disease is admitted to the unit. Which prescription should the
nurse call the HCP about for re verification for this client?
