Hesi review
A client has a nasogastric tube connected to low intermittent suction. When administering
medications through the nasogastric tube, which action should the nurse do first?
The nurse should first turn off the suction (D) and then confirm placement of the tube in
the stomach (B) before instilling the medications (C). To prevent immediate removal of the
instilled medications and allow absorption, the tube should be clamped for a period of time
(A) before reconnecting the suction.
In assisting an older adult client prepare to take a tub bath, which nursing action is most
important?
To prevent burns or excessive chilling, the nurse must check the bath water
temperature (A). (B, C, and D) promote comfort and privacy and are important
interventions but are of less priority than promoting safety.
The nurse is teaching an obese client, newly diagnosed with arteriosclerosis, about reducing the
risk of a heart attack or stroke. Which health promotion brochure is most important for the nurse
to provide to this client?
A health promotion brochure about decreasing cholesterol (C) is most important to
provide this client, because the most significant risk factor contributing to
development of arteriosclerosis is excess dietary fat, particularly saturated fat and
cholesterol. (A) does not address the underlying causes of arteriosclerosis. (B and D) are
also important factors for reversing arteriosclerosis but are not as important as lowering
cholesterol (C).
The nurse is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose
client winces and pulls away from a painful stimulus. Which action should the nurse take next?
The client has demonstrated a purposeful response to pain, which should be
documented as such (A). Response to painful stimulus is assessed after response to verbal
stimulus, not before (B). There is no indication for placing the client on seizure precautions
(C). Reporting (D) is nonpurposeful movement.
An older client who had abdominal surgery 3 days earlier was given a barbiturate for sleep and is
now requesting to go to the bathroom. Which action should the nurse implement?
Barbiturates cause central nervous system (CNS) depression and individuals taking
these medications are at greater risk for falls. The nurse should assist the client to the
bathroom (A). A bedpan (B) is not necessary as long as safety is ensured. Whether the
client needs to void or have a bowel movement, (C) is irrelevant in terms of meeting this
client's safety needs. There is no indication that this client cannot voice her or his needs, so
assessment of the bladder is not needed (D).
A male client is laughing at a television program with his wife when the evening nurse enters the
room. He says his foot is hurting and he would like a pain pill. How should the nurse respond?
Ask him to rate his pain on a scale of 1 to 10. Obtaining a subjective estimate of the
pain experience by asking the client to rate his pain (A) helps the nurse determine
which pain medication should be administered and also provides a baseline for
evaluating the effectiveness of the medication. Medicating for pain should not be delayed
, so that it can be used as a sleep medication (B). (C) is judgmental. (D) should be used as an
adjunct to pain medication, not instead of medication.
The nurse is instructing a client in the proper use of a metered-dose inhaler. Which instruction
should the nurse provide the client to ensure the optimal benefits from the drug?
"Compress the inhaler while slowly breathing in through your mouth." The medication
should be inhaled through the mouth simultaneously with compression of the inhaler
(B). This will facilitate the desired destination of the aerosol medication deep in the lungs
for an optimal bronchodilation effect. (A, C, and D) do not allow for deep lung penetration.
While conducting an intake assessment of an adult male at a community mental health clinic, the
nurse notes that his affect is flat, he responds to questions with short answers, and he reports
problems with sleeping. He reports that his life partner recently died from pneumonia. Which
action is most important for the nurse to implement?
Encourage the client to see the clinic's grief counselor. The client is exhibiting normal
grieving behaviors, so referral to a grief counselor (A) is the most important
intervention for the nurse to implement. (B) is indicated, but is not a high-priority
intervention. (C) is irrelevant at this time but might be important when determining the
client's risk for contracting the illness. An antidepressant may be indicated (D), depending
on further assessment, but grief counseling is a better action at this time because grief is an
expected reaction to the loss of a loved one.
The nurse is administering the 0900 medications to a client who was admitted during the night.
Which client statement indicates that the nurse should further assess the medication order?
"This is a new pill I have never taken before." The client's recognition of a "new" pill
requires further assessment (D) to verify that the medication is correct, if it is a new
prescription or a different manufacturer, or if the client needs further instruction. The
time difference may not be as significant in terms of its effect, but this should be explained
(A). Although comments about cost (B) should be considered when developing a discharge
plan, (D) is a higher priority. The client's feelings (C) should be acknowledged, but
observation of the five rights of medication administration is most essential.
Ten minutes after signing an operative permit for a fractured hip, an older client states, "The
aliens will be coming to get me soon!" and falls asleep. Which action should the nurse
implement next?
Assess the client's neurologic status. This statement may indicate that the client is
confused. Informed consent must be provided by a mentally competent individual, so
the nurse should further assess the client's neurologic status (B) to be sure that the
client understands and can legally provide consent for surgery. (A) does not provide
sufficient follow-up. If the nurse determines that the client is confused, the surgeon must be
notified (C) and permission obtained from the next of kin (D).
Which serum laboratory value should the nurse monitor carefully for a client who has a
nasogastric (NG) tube to suction for the past week?
A client has a nasogastric tube connected to low intermittent suction. When administering
medications through the nasogastric tube, which action should the nurse do first?
The nurse should first turn off the suction (D) and then confirm placement of the tube in
the stomach (B) before instilling the medications (C). To prevent immediate removal of the
instilled medications and allow absorption, the tube should be clamped for a period of time
(A) before reconnecting the suction.
In assisting an older adult client prepare to take a tub bath, which nursing action is most
important?
To prevent burns or excessive chilling, the nurse must check the bath water
temperature (A). (B, C, and D) promote comfort and privacy and are important
interventions but are of less priority than promoting safety.
The nurse is teaching an obese client, newly diagnosed with arteriosclerosis, about reducing the
risk of a heart attack or stroke. Which health promotion brochure is most important for the nurse
to provide to this client?
A health promotion brochure about decreasing cholesterol (C) is most important to
provide this client, because the most significant risk factor contributing to
development of arteriosclerosis is excess dietary fat, particularly saturated fat and
cholesterol. (A) does not address the underlying causes of arteriosclerosis. (B and D) are
also important factors for reversing arteriosclerosis but are not as important as lowering
cholesterol (C).
The nurse is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose
client winces and pulls away from a painful stimulus. Which action should the nurse take next?
The client has demonstrated a purposeful response to pain, which should be
documented as such (A). Response to painful stimulus is assessed after response to verbal
stimulus, not before (B). There is no indication for placing the client on seizure precautions
(C). Reporting (D) is nonpurposeful movement.
An older client who had abdominal surgery 3 days earlier was given a barbiturate for sleep and is
now requesting to go to the bathroom. Which action should the nurse implement?
Barbiturates cause central nervous system (CNS) depression and individuals taking
these medications are at greater risk for falls. The nurse should assist the client to the
bathroom (A). A bedpan (B) is not necessary as long as safety is ensured. Whether the
client needs to void or have a bowel movement, (C) is irrelevant in terms of meeting this
client's safety needs. There is no indication that this client cannot voice her or his needs, so
assessment of the bladder is not needed (D).
A male client is laughing at a television program with his wife when the evening nurse enters the
room. He says his foot is hurting and he would like a pain pill. How should the nurse respond?
Ask him to rate his pain on a scale of 1 to 10. Obtaining a subjective estimate of the
pain experience by asking the client to rate his pain (A) helps the nurse determine
which pain medication should be administered and also provides a baseline for
evaluating the effectiveness of the medication. Medicating for pain should not be delayed
, so that it can be used as a sleep medication (B). (C) is judgmental. (D) should be used as an
adjunct to pain medication, not instead of medication.
The nurse is instructing a client in the proper use of a metered-dose inhaler. Which instruction
should the nurse provide the client to ensure the optimal benefits from the drug?
"Compress the inhaler while slowly breathing in through your mouth." The medication
should be inhaled through the mouth simultaneously with compression of the inhaler
(B). This will facilitate the desired destination of the aerosol medication deep in the lungs
for an optimal bronchodilation effect. (A, C, and D) do not allow for deep lung penetration.
While conducting an intake assessment of an adult male at a community mental health clinic, the
nurse notes that his affect is flat, he responds to questions with short answers, and he reports
problems with sleeping. He reports that his life partner recently died from pneumonia. Which
action is most important for the nurse to implement?
Encourage the client to see the clinic's grief counselor. The client is exhibiting normal
grieving behaviors, so referral to a grief counselor (A) is the most important
intervention for the nurse to implement. (B) is indicated, but is not a high-priority
intervention. (C) is irrelevant at this time but might be important when determining the
client's risk for contracting the illness. An antidepressant may be indicated (D), depending
on further assessment, but grief counseling is a better action at this time because grief is an
expected reaction to the loss of a loved one.
The nurse is administering the 0900 medications to a client who was admitted during the night.
Which client statement indicates that the nurse should further assess the medication order?
"This is a new pill I have never taken before." The client's recognition of a "new" pill
requires further assessment (D) to verify that the medication is correct, if it is a new
prescription or a different manufacturer, or if the client needs further instruction. The
time difference may not be as significant in terms of its effect, but this should be explained
(A). Although comments about cost (B) should be considered when developing a discharge
plan, (D) is a higher priority. The client's feelings (C) should be acknowledged, but
observation of the five rights of medication administration is most essential.
Ten minutes after signing an operative permit for a fractured hip, an older client states, "The
aliens will be coming to get me soon!" and falls asleep. Which action should the nurse
implement next?
Assess the client's neurologic status. This statement may indicate that the client is
confused. Informed consent must be provided by a mentally competent individual, so
the nurse should further assess the client's neurologic status (B) to be sure that the
client understands and can legally provide consent for surgery. (A) does not provide
sufficient follow-up. If the nurse determines that the client is confused, the surgeon must be
notified (C) and permission obtained from the next of kin (D).
Which serum laboratory value should the nurse monitor carefully for a client who has a
nasogastric (NG) tube to suction for the past week?
