GERO HESI PRACTICE EXAM AND
DETAILED ANSWERS WITH RATIONALE
NEWEST VERSION.
A frail, elderly client is admitted to the unit with a diagnosis of pneumonia.
Which finding is most important for the registered nurse (RN) to report to
the healthcare provider?
A. Fever and chills
B. Confusion and dehydration
C. Crackles in the lung fields
D. Nausea and vomiting - CorreCt Answers -B. Confusion and dehydration
Rationale: Confusion and dehydration (B) are findings of inadequate
oxygenation and perfusion in this frail elderly client. (A), (C) and (D) are all
common with pneumonia, but the most important finding is confusion and
evidence of dehydration, which require treatment for this frail elderly
client.
The registered nurse (RN) is assigned the care of an older client who
returns to the unit after surgery for closed angle glaucoma. What
intervention in the plan of care should the RN bring to the attention of the
healthcare team?
A. Assist with ambulating to commode
B. Monitor intake and output q8 hours
C. Administer morphine 4 mg IM q2 hour PRN pain
D. Place an eye patch on operative eye during sleep - CorreCt Answers -(C)
Administer morphine 4 mg IM q2 hour PRN pain
,Rationale: Morphine side effects include nausea, vomiting and
constipation, causing straining on stool, all of which can increase
intraocular pressure and cause intraocular bleeding during the
postoperative period. Administration of morphine 0.4 mg IM q2 hours
PRN pain (C) should be discussed with the healthcare team to determine
the risk of the side effects for the client. (A), (B) and (D) are interventions
that do not place the client at risk.
After a recent total hip replacement, an older female client, who transferred
to a rehabilitation facility placement, asks the registered nurse (RN) if she
broke her hip because she is old. How should the RN best respond?
A. Hip fractures can occur in any age group and require strength
conditioning
B. With aging, everything tends to break down more easily the older one
gets
C. Older people tend to look down instead of ahead, increasing the risk of
falls
D. Older women commonly lose bone calcium, which increases the risk of
fracture - CorreCt Answers -(D) Older women commonly lose bone calcium
which increases the risk of fracture.
Rationale: The best response is to provide the client with an explanation
based on aging and demineralization of the bone (D) in older females,
especially after menopause. (A, B and C) offer other responses but are not
client centered in response to her expressed self-concern.
An older male client is admitted for emergency treatment of acute closed-
angle glaucoma. The registered nurse (RN) begins administering the
prescribed miotic medications and glycerin (Glycol) therapy. Which
, intervention is most important for the RN to maintain during the client's
therapy?
A. Maintain lighting control in the room during therapy
B. Monitor intake and output q2 hours for 24 hours
C. Place an eye patch over the affected eye during sleep
D. Administer the eye drops at the scheduled intervals - CorreCt Answers -
(B) Monitor intake and output q2 hours for 24 hours
Rationale: Monitoring intake and output (B) is most important during the
administration of glycerin (Glycol) due to the rapid acting osmotic diuretic
effect of glycerin therapy. (A, C and D) are components of care, but the
most important action during glycerin administration is evaluation of
output.
The home health registered nurse (RN) visits an older woman with heart
failure (HF) who is on complete bed rest. Which intervention is most
important for the RN to suggest to the client to prevent complications
related to immobility?
A. Get as much sleep as possible
B. Perform leg exercises while in bed
C. increase protein intake to combat fatigue
D. Invite friends to visit to decrease risk for depression - CorreCt Answers -
(B) Perform leg exercises while in bed.
Rationale: The client is at risk for complications related to immobility. (B)
should be performed frequently to decrease the risk for thrombophlebitis.
(A, C and D) are measures to help the client while on bedrest, but the most
important complication that the client is at risk for deep vein thrombosis.
DETAILED ANSWERS WITH RATIONALE
NEWEST VERSION.
A frail, elderly client is admitted to the unit with a diagnosis of pneumonia.
Which finding is most important for the registered nurse (RN) to report to
the healthcare provider?
A. Fever and chills
B. Confusion and dehydration
C. Crackles in the lung fields
D. Nausea and vomiting - CorreCt Answers -B. Confusion and dehydration
Rationale: Confusion and dehydration (B) are findings of inadequate
oxygenation and perfusion in this frail elderly client. (A), (C) and (D) are all
common with pneumonia, but the most important finding is confusion and
evidence of dehydration, which require treatment for this frail elderly
client.
The registered nurse (RN) is assigned the care of an older client who
returns to the unit after surgery for closed angle glaucoma. What
intervention in the plan of care should the RN bring to the attention of the
healthcare team?
A. Assist with ambulating to commode
B. Monitor intake and output q8 hours
C. Administer morphine 4 mg IM q2 hour PRN pain
D. Place an eye patch on operative eye during sleep - CorreCt Answers -(C)
Administer morphine 4 mg IM q2 hour PRN pain
,Rationale: Morphine side effects include nausea, vomiting and
constipation, causing straining on stool, all of which can increase
intraocular pressure and cause intraocular bleeding during the
postoperative period. Administration of morphine 0.4 mg IM q2 hours
PRN pain (C) should be discussed with the healthcare team to determine
the risk of the side effects for the client. (A), (B) and (D) are interventions
that do not place the client at risk.
After a recent total hip replacement, an older female client, who transferred
to a rehabilitation facility placement, asks the registered nurse (RN) if she
broke her hip because she is old. How should the RN best respond?
A. Hip fractures can occur in any age group and require strength
conditioning
B. With aging, everything tends to break down more easily the older one
gets
C. Older people tend to look down instead of ahead, increasing the risk of
falls
D. Older women commonly lose bone calcium, which increases the risk of
fracture - CorreCt Answers -(D) Older women commonly lose bone calcium
which increases the risk of fracture.
Rationale: The best response is to provide the client with an explanation
based on aging and demineralization of the bone (D) in older females,
especially after menopause. (A, B and C) offer other responses but are not
client centered in response to her expressed self-concern.
An older male client is admitted for emergency treatment of acute closed-
angle glaucoma. The registered nurse (RN) begins administering the
prescribed miotic medications and glycerin (Glycol) therapy. Which
, intervention is most important for the RN to maintain during the client's
therapy?
A. Maintain lighting control in the room during therapy
B. Monitor intake and output q2 hours for 24 hours
C. Place an eye patch over the affected eye during sleep
D. Administer the eye drops at the scheduled intervals - CorreCt Answers -
(B) Monitor intake and output q2 hours for 24 hours
Rationale: Monitoring intake and output (B) is most important during the
administration of glycerin (Glycol) due to the rapid acting osmotic diuretic
effect of glycerin therapy. (A, C and D) are components of care, but the
most important action during glycerin administration is evaluation of
output.
The home health registered nurse (RN) visits an older woman with heart
failure (HF) who is on complete bed rest. Which intervention is most
important for the RN to suggest to the client to prevent complications
related to immobility?
A. Get as much sleep as possible
B. Perform leg exercises while in bed
C. increase protein intake to combat fatigue
D. Invite friends to visit to decrease risk for depression - CorreCt Answers -
(B) Perform leg exercises while in bed.
Rationale: The client is at risk for complications related to immobility. (B)
should be performed frequently to decrease the risk for thrombophlebitis.
(A, C and D) are measures to help the client while on bedrest, but the most
important complication that the client is at risk for deep vein thrombosis.
