BSN 266 HESI Practice
1. A male client with muscular dystrophy fell in his home and is admitted with a right hip
fracture. His right foot is cool, with palpable pedal pulses. Lungs are coarse with diminished
bibasilar breath sounds. Vital signs are temperature 101F, heart rate 128 beats/minute,
respirations 28 breaths/minute,and blood pressure 122/82. Which intervention is most important
for the nurseto implement first?
A. Obtain oxygen saturation level
B. Encourage incentive spirometry
C. Assess lower extremity circulation
D. Administer PRN oral antipyretic: D. Administer PRN oral antipyretic
2. The nurse is completing the preoperative assessment of a client who
is scheduled for a laparoscopic cholecystectomy under general anesthesia.Which finding
warrants notification of the healthcare provider prior to pro- ceeding with the scheduled
procedure?
A. Light yellow coloring of the client's skin and eyes B. The client's bloodpressure reading is
184/88 mm Hg.
C. The client vomits 20 ml of clear yellowish fluid D. The IV insertion site is red, swollen, and
leaking IV fluid: B. The client's blood pressure reading is 184/88 mmHg.
3. A client who has a history of hypothyroidism was initially admitted with lethargy and
confusion. Which additional finding warrants the most immediateaction by the nurse?
A. Facial puffiness and periorbital edema
B. Hematocrit of 30%
C. Cold and dry skin
D. Further decline in level of consciousness: D. Further decline in level ofconsciousness
4. Following surgical repair of the bladder, a female client is being discharged from the hospital
to home with an indwelling urinary catheter. Which instruc- tion is most important for the
nurse to provide to this client?
A. Avoid coiling the tubing and keep if free of kinks
B. Cleanse the perineal area with soap and water twice daily
C. Keep the drainage bag lower than the level of the bladder
D. Drink 1,000 ml of fluids daily to irrigate catheter: C. Keep the drainage baglower than the
level of the bladder
5. Which client has the highest risk for developing skin cancer?
,A. A 16-year old dark-skinned female who tans in tanning beds once a week
B. A 65 year-old fair-skinned male who is a construction worker
C. A 25 year-old dark-skinned male whose mother had skin cancer
D. A 70 year-old fair-skinned female who works as a secretary: B. A 65 year-oldfair-skinned
male who is a construction worker
6. When caring for a client with nephrotic syndrome, which assessment ismost important for
the nurse to obtain?
A. Daily weight
B. Vital signs
C. Level of consciousness
D. Bowel sounds: A. Daily weight
7. A female client who was involved in a motor vehicle collision is admitted with a fractured
left femur which is immobilized using a fracture traction splintin preparation for an open
reduction internal fixation (ORIF). The nurse deter-mines that her distal pulses are diminished
in the left foot. Which interventionsshould the nurse implement? (Select all that apply.) A. Offer
ice chips and oralclear liquids
B. Verify pedal pulses using a doppler pulse device C. Monitor left leg for pain,pallor,
paresthesia, paralysis, pressure
D. Evaluate the application of the splint to the left leg E. Administer oral antispasmodics and
narcotic analgesics: B. Verify pedal pulses using a dopplerpulse device
C. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure
D. Evaluate the application of the splint to the left leg
8. A male client with Herpes zoster (shingles) on his thorax tells the nurse thathe is having
difficulty sleeping. What is the probable etiology of this problem?
A. Pain
B. Nocturia
C. Dyspnea
D. Frequent cough: A. Pain
9. When planning care for a client newly diagnosed with open angle glauco-ma, the nurse
identifies a priority nursing diagnosis of, "visual sensory/per- ceptual alterations." This
diagnosis is based on which etiology?
A. Limited eye movement
B. Decreased peripheral vision
, C. Blurred distance vision
D. Photosensitivity: B. Decreased peripheral vision
10. A client who is newly diagnosed with emphysema is being prepared for discharge.Which
instruction is best for the nurse to provide the client to assistthem with dyspnea self-
management?
A. Allow additional time to complete physical activities to reduce oxygendemand
B. Practice inhaling through the nose and exhaling slowly through pursed lips
C. Use a humidifier to increase home air quality humidity between 30-50%
D. Strengthen abdominal muscles by alternating leg raises during exhalation-
: B. Practice inhaling through the nose and exhaling slowly through pursed lips
11. A client with cancer is receiving chemotherapy with a known vesicant. The client's IV has
been in place for 72 hours. The nurse determines that a new IV site cannot be obtained, and
leaves the present IV in place. What is the greatestclinical risk related to this situation?
A. Impaired skin integrity
B. Fluid volume excess
C. Acute pain and anxiety
D. Peripheral neurovascular dysfunction: A. Impaired skin integrity
12. A postoperative client reports incisional pain. The client has two prescrip- tions for PRN
analgesia that accompanied the client from the postanasthesia unit. Before selecting which
medication to administer, which action should thenurse implement?
A. Document the client's report of pain in the electronic medical record
B. Determine which prescription will have the quickest onset of action
C. Compare the client's pain scale rating with the prescribed dosing
D. Ask the client to choose which mediation is needed for pain: C. Compare theclient's pain
scale rating with the prescribed dosing
13. While assisting a female client to the toilet, the client begins to have aseizure and the
nurse eases her to the floor. The nurse calls for help and monitors the client until the seizing
stops. Which intervention should thenurse implement first?
A. Document details of the seizure activity
B. Observe for lacerations to the tongue
C. Observe for prolonged periods of apnea
D. Evaluate for evidence of incontinence: C. Observe for prolonged periods ofapnea
1. A male client with muscular dystrophy fell in his home and is admitted with a right hip
fracture. His right foot is cool, with palpable pedal pulses. Lungs are coarse with diminished
bibasilar breath sounds. Vital signs are temperature 101F, heart rate 128 beats/minute,
respirations 28 breaths/minute,and blood pressure 122/82. Which intervention is most important
for the nurseto implement first?
A. Obtain oxygen saturation level
B. Encourage incentive spirometry
C. Assess lower extremity circulation
D. Administer PRN oral antipyretic: D. Administer PRN oral antipyretic
2. The nurse is completing the preoperative assessment of a client who
is scheduled for a laparoscopic cholecystectomy under general anesthesia.Which finding
warrants notification of the healthcare provider prior to pro- ceeding with the scheduled
procedure?
A. Light yellow coloring of the client's skin and eyes B. The client's bloodpressure reading is
184/88 mm Hg.
C. The client vomits 20 ml of clear yellowish fluid D. The IV insertion site is red, swollen, and
leaking IV fluid: B. The client's blood pressure reading is 184/88 mmHg.
3. A client who has a history of hypothyroidism was initially admitted with lethargy and
confusion. Which additional finding warrants the most immediateaction by the nurse?
A. Facial puffiness and periorbital edema
B. Hematocrit of 30%
C. Cold and dry skin
D. Further decline in level of consciousness: D. Further decline in level ofconsciousness
4. Following surgical repair of the bladder, a female client is being discharged from the hospital
to home with an indwelling urinary catheter. Which instruc- tion is most important for the
nurse to provide to this client?
A. Avoid coiling the tubing and keep if free of kinks
B. Cleanse the perineal area with soap and water twice daily
C. Keep the drainage bag lower than the level of the bladder
D. Drink 1,000 ml of fluids daily to irrigate catheter: C. Keep the drainage baglower than the
level of the bladder
5. Which client has the highest risk for developing skin cancer?
,A. A 16-year old dark-skinned female who tans in tanning beds once a week
B. A 65 year-old fair-skinned male who is a construction worker
C. A 25 year-old dark-skinned male whose mother had skin cancer
D. A 70 year-old fair-skinned female who works as a secretary: B. A 65 year-oldfair-skinned
male who is a construction worker
6. When caring for a client with nephrotic syndrome, which assessment ismost important for
the nurse to obtain?
A. Daily weight
B. Vital signs
C. Level of consciousness
D. Bowel sounds: A. Daily weight
7. A female client who was involved in a motor vehicle collision is admitted with a fractured
left femur which is immobilized using a fracture traction splintin preparation for an open
reduction internal fixation (ORIF). The nurse deter-mines that her distal pulses are diminished
in the left foot. Which interventionsshould the nurse implement? (Select all that apply.) A. Offer
ice chips and oralclear liquids
B. Verify pedal pulses using a doppler pulse device C. Monitor left leg for pain,pallor,
paresthesia, paralysis, pressure
D. Evaluate the application of the splint to the left leg E. Administer oral antispasmodics and
narcotic analgesics: B. Verify pedal pulses using a dopplerpulse device
C. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure
D. Evaluate the application of the splint to the left leg
8. A male client with Herpes zoster (shingles) on his thorax tells the nurse thathe is having
difficulty sleeping. What is the probable etiology of this problem?
A. Pain
B. Nocturia
C. Dyspnea
D. Frequent cough: A. Pain
9. When planning care for a client newly diagnosed with open angle glauco-ma, the nurse
identifies a priority nursing diagnosis of, "visual sensory/per- ceptual alterations." This
diagnosis is based on which etiology?
A. Limited eye movement
B. Decreased peripheral vision
, C. Blurred distance vision
D. Photosensitivity: B. Decreased peripheral vision
10. A client who is newly diagnosed with emphysema is being prepared for discharge.Which
instruction is best for the nurse to provide the client to assistthem with dyspnea self-
management?
A. Allow additional time to complete physical activities to reduce oxygendemand
B. Practice inhaling through the nose and exhaling slowly through pursed lips
C. Use a humidifier to increase home air quality humidity between 30-50%
D. Strengthen abdominal muscles by alternating leg raises during exhalation-
: B. Practice inhaling through the nose and exhaling slowly through pursed lips
11. A client with cancer is receiving chemotherapy with a known vesicant. The client's IV has
been in place for 72 hours. The nurse determines that a new IV site cannot be obtained, and
leaves the present IV in place. What is the greatestclinical risk related to this situation?
A. Impaired skin integrity
B. Fluid volume excess
C. Acute pain and anxiety
D. Peripheral neurovascular dysfunction: A. Impaired skin integrity
12. A postoperative client reports incisional pain. The client has two prescrip- tions for PRN
analgesia that accompanied the client from the postanasthesia unit. Before selecting which
medication to administer, which action should thenurse implement?
A. Document the client's report of pain in the electronic medical record
B. Determine which prescription will have the quickest onset of action
C. Compare the client's pain scale rating with the prescribed dosing
D. Ask the client to choose which mediation is needed for pain: C. Compare theclient's pain
scale rating with the prescribed dosing
13. While assisting a female client to the toilet, the client begins to have aseizure and the
nurse eases her to the floor. The nurse calls for help and monitors the client until the seizing
stops. Which intervention should thenurse implement first?
A. Document details of the seizure activity
B. Observe for lacerations to the tongue
C. Observe for prolonged periods of apnea
D. Evaluate for evidence of incontinence: C. Observe for prolonged periods ofapnea
