BSN 246 HESI Practice Exam (1 & 2)
Questions and Answers
1. The registered nurse (RN) is caring for a young adult who is having an
oral glucose tolerance tests (OGTT). Which laboratory result should the RN
assess as a normal value for the two hour postprandial result?
140 mg/dl.
160 mg/dl.
180 mg/dl.
200 mg/dl.: 140 mg/dl.
Rationale
The two hour postprandial level should be less 140 mg/dl for a young adult client .
2. The registered nurse (RN) is caring for a client who has a closed head
injury from a motor vehicle collision. Which finding should the RN assess
the client for the risk of diabetes insipidus (DI)?
High fever.
Low blood pressure.
Muscle rigidity.
Polydipsia.: Polydipsia.
Rationale
A characteristic finding of DI is excretion of large quantities of urine (5 to 20L/day),
and most clients compensate for fluid loss by drinking large amounts of water
(polydipsia). DI can occur when there has been damage or injury to the pituitary
gland or hypothalamus as a result of head trauma, tumor or an illness such as
meningitis. This damage interrupts the ADH production, storage and release
causing the excessive urination and thirst.
3. The registered nurse (RN) is caring for a client who developed oliguria
and was diagnosed with sepsis and dehydration 48 hours ago. Which
assessment finding indicates to the RN that the client is stabilizing?
Urine output of 40 mL/hour.
Apical pulse 100 and blood pressure 76/42.
Urine specific gravity 1.001.
Tented skin on dorsal surface of hands.: Urine output of 40 mL/hour.
,Rationale
A decrease in urinary output is a sign of dehydration. When the urine output
returns to a normal range, 40 mL/hour, the client's kidneys are perfusing
adequately and indicates the client's status is stablizing.
4. A client who is uses ipratropium reports having nausea, blurred vision,
headaches, and insomnia after using the inhaler. Which action should
the registered nurse (RN) implement first?
Withhold medication and report symptoms and vital signs to healthcare
provider.
Give PRN medication for nausea and vomiting and evaluate client in 30
minutes.
Reassure client that the ipratropium given will alleviate the symptoms.
Delay administration of ipratropium until next maintenance medication is
scheduled.: Withhold medication and report symptoms and vital signs to
healthcare provider.
Rationale
Headache, nausea, blurred vision and insomnia are symptoms of excessive use
of ipratropium, so withholding the medication until the healthcare provider is
notified should be initiated to maintain client safety.
5. The registered nurse (RN) is assessing a client who was discharged
home after management of chronic hypertension. Which equipment should
the RN instruct the client to use at home?
Exercise bicycle.
Sphygmomanometer.
Blood glucose monitor.
Weekly medication box.: Sphygmomanometer.
Rationale
Self-awareness is the best way for a client to manage chronic hypertension, so the
client should obtain a sphygmomanometer and learn how to monitor blood
pressure daily and maintain a record.
2/23
, 6. The registered nurse (RN) is teaching a client who is newly
diagnosed with emphysema how to perform pursed lip breathing. What is
the primary reason for teaching the client this method of breathing?
Decreases respiratory rate.
Increases O2 saturation throughout the body.
Conserves energy while ambulating.
Promotes CO2 elimination.: Promotes CO2 elimination.
Rationale
Pursed lip breathing helps eliminate CO2 by increasing positive pressure within
the alveoli increasing the surface area of the alveoli making it easier for the O2
and CO2 gas exchange to occur .
7. The registered nurse (RN) reviews the new prescription, phenelzine
(Nardil), a monoamine oxidase inhibitor (MAOI), for a client on the
psychiatric unit with depression. Which information is most important
for the RN to assess?
Consumption of any alcohol or tyramine-rich foods.
Complaints of nausea or vomiting.
Therapeutic serum drug levels.
Blood pressure and pulse prior to taking each dose.: Consumption of any
alcohol or tyramine-rich foods
Rationale
The consumption of any type of tyramine containing foods such as aged
cheeses, fermented fruits and vegetables, smoked or cured meats, dark wines
and other alcoholic products should be avoided when a client is prescribed a
MAOIs due to the a food-drug interaction causing a hypertensive crisis which
can lead to a hemorrhagic stroke.
8. A registered nurse (RN) is performing a mini-mental state examination
(MMSE) for a client who is being admitted to an assisted living community.
Which communication techniques should the RN implement to decrease
anxiety in the client? (Select all that apply.)Select all that apply
Use simple sentences during the examination.
Move to another question if the client seems confused.
3/23
Questions and Answers
1. The registered nurse (RN) is caring for a young adult who is having an
oral glucose tolerance tests (OGTT). Which laboratory result should the RN
assess as a normal value for the two hour postprandial result?
140 mg/dl.
160 mg/dl.
180 mg/dl.
200 mg/dl.: 140 mg/dl.
Rationale
The two hour postprandial level should be less 140 mg/dl for a young adult client .
2. The registered nurse (RN) is caring for a client who has a closed head
injury from a motor vehicle collision. Which finding should the RN assess
the client for the risk of diabetes insipidus (DI)?
High fever.
Low blood pressure.
Muscle rigidity.
Polydipsia.: Polydipsia.
Rationale
A characteristic finding of DI is excretion of large quantities of urine (5 to 20L/day),
and most clients compensate for fluid loss by drinking large amounts of water
(polydipsia). DI can occur when there has been damage or injury to the pituitary
gland or hypothalamus as a result of head trauma, tumor or an illness such as
meningitis. This damage interrupts the ADH production, storage and release
causing the excessive urination and thirst.
3. The registered nurse (RN) is caring for a client who developed oliguria
and was diagnosed with sepsis and dehydration 48 hours ago. Which
assessment finding indicates to the RN that the client is stabilizing?
Urine output of 40 mL/hour.
Apical pulse 100 and blood pressure 76/42.
Urine specific gravity 1.001.
Tented skin on dorsal surface of hands.: Urine output of 40 mL/hour.
,Rationale
A decrease in urinary output is a sign of dehydration. When the urine output
returns to a normal range, 40 mL/hour, the client's kidneys are perfusing
adequately and indicates the client's status is stablizing.
4. A client who is uses ipratropium reports having nausea, blurred vision,
headaches, and insomnia after using the inhaler. Which action should
the registered nurse (RN) implement first?
Withhold medication and report symptoms and vital signs to healthcare
provider.
Give PRN medication for nausea and vomiting and evaluate client in 30
minutes.
Reassure client that the ipratropium given will alleviate the symptoms.
Delay administration of ipratropium until next maintenance medication is
scheduled.: Withhold medication and report symptoms and vital signs to
healthcare provider.
Rationale
Headache, nausea, blurred vision and insomnia are symptoms of excessive use
of ipratropium, so withholding the medication until the healthcare provider is
notified should be initiated to maintain client safety.
5. The registered nurse (RN) is assessing a client who was discharged
home after management of chronic hypertension. Which equipment should
the RN instruct the client to use at home?
Exercise bicycle.
Sphygmomanometer.
Blood glucose monitor.
Weekly medication box.: Sphygmomanometer.
Rationale
Self-awareness is the best way for a client to manage chronic hypertension, so the
client should obtain a sphygmomanometer and learn how to monitor blood
pressure daily and maintain a record.
2/23
, 6. The registered nurse (RN) is teaching a client who is newly
diagnosed with emphysema how to perform pursed lip breathing. What is
the primary reason for teaching the client this method of breathing?
Decreases respiratory rate.
Increases O2 saturation throughout the body.
Conserves energy while ambulating.
Promotes CO2 elimination.: Promotes CO2 elimination.
Rationale
Pursed lip breathing helps eliminate CO2 by increasing positive pressure within
the alveoli increasing the surface area of the alveoli making it easier for the O2
and CO2 gas exchange to occur .
7. The registered nurse (RN) reviews the new prescription, phenelzine
(Nardil), a monoamine oxidase inhibitor (MAOI), for a client on the
psychiatric unit with depression. Which information is most important
for the RN to assess?
Consumption of any alcohol or tyramine-rich foods.
Complaints of nausea or vomiting.
Therapeutic serum drug levels.
Blood pressure and pulse prior to taking each dose.: Consumption of any
alcohol or tyramine-rich foods
Rationale
The consumption of any type of tyramine containing foods such as aged
cheeses, fermented fruits and vegetables, smoked or cured meats, dark wines
and other alcoholic products should be avoided when a client is prescribed a
MAOIs due to the a food-drug interaction causing a hypertensive crisis which
can lead to a hemorrhagic stroke.
8. A registered nurse (RN) is performing a mini-mental state examination
(MMSE) for a client who is being admitted to an assisted living community.
Which communication techniques should the RN implement to decrease
anxiety in the client? (Select all that apply.)Select all that apply
Use simple sentences during the examination.
Move to another question if the client seems confused.
3/23
