HESI level 2 (NSG 170) Test Questions and Answers Rated A
A client with acute appendicitis is experiencing
anxiety and loss of sleep about missing final A male client who smokes two packs of
examination week at college. Which outcome is cigarettes a day states he understands that
most important for the nurse to include in the smoking cigarettes is contributing to the difficulty
plan of care? that he and his wife are having in getting
pregnant and wants to know if other factors could
A. Sleeping six to eight hours. be contributing to their difficulty. What information
B. Achieve a sense of control. is best for the nurse to provide? (Select all that
C. Utilize problem solving skills. apply.)
D. Increased focus of attention. - A.Marijuana cigarettes do not affect sperm
ANSWER -B. Achieve a sense of control. count.
B.Alcohol consumption can cause erectile
The experience of psychological discomfort may dysfunction.
be as real as physical pain for the client and C.Low testosterone levels affect sperm
should be seen as a priority in care. Because the production.
client is experiencing anxiety, achieving a sense D.Cessation of smoking improves general health
of control is a key need (B) before (A, C and D) and fertility.
are addressed. E.Obesity has no effect on sperm production. -
ANSWER -B, C, D
Use of tobacco, alcohol, and marijuana may
A 57-year-old male client is scheduled to have a affect sperm counts. Sperm count is also
stress-thallium test the following morning and is negatively affected by low testosterone levels
NPO after midnight. At 0130, he is agitated and obesity.
because he cannot eat and is demanding food.
Which response is best for the nurse to provide
to this client?
A) I'm sorry sir, you have a prescription for Which response by a client with a nursing
nothing by mouth from midnight tonight. diagnosis of Spiritual distress indicates to the
B) I will let you have one cracker, but that is all nurse that a desired outcome measure has been
you can have for the rest of tonight. met?
C) What did the healthcare provider tell you A.Expresses concern about the meaning and
about the test you are having tomorrow? importance of life.
D) The test you are having tomorrow requires B.Remains angry at God for the continuation of
that you have nothing by mouth tonight. - the illness.
ANSWER -D. "The test you are having C.Accepts that punishment from God is not
tomorrow requires that you have nothing by related to illness.
mouth tonight." D.Refuses to participate in religious rituals that
have no meaning. - ANSWER -C.Accepts
Being direct and explaining to the client that the that punishment from God is not related to illness
test requires him to be NPO, is the most
therapeutic statement because the nurse is Acceptance that her illness is not God punishing
responding to the client's question and providing her, indicates a desired outcome for some
him the reason why. degree of resolution of spiritual distress
,HESI level 2 (NSG 170) Test Questions and Answers Rated A
A postoperative client has been receiving a
A mother brings her 4-month-old infant to the continuous IV infusion of meperidine (Demerol)
clinic for a well-child checkup. She asks if she 35 mg/hr for four days. The client has a PRN
should go back to work now or stay at home with prescription for Demerol 100 mg PO q3h. The
the baby. How should the nurse respond to the nurse notes that the client has become
mother? increasingly restless, irritable and confused,
A.Mothers can promote healthy bonding by stating that there are bugs all over the walls.
staying at home during the child's first years. What action should the nurse take first?
B.Determine if other family relatives can stay at A..Administer a PRN dose of the PO meperidine
home with the baby. (Demerol).
C.Ask the mother to talk about the options she B.Administer naloxone (Narcan) IV per PRN
has been considering. protocol.
D.Returning to work when an infant is young C.Decrease the IV infusion rate of the
helps the baby to adjust to other children. - meperidine (Demerol) per protocol.
ANSWER -C.Ask the mother to talk about D.Notify the healthcare provider of the client's
the options she has been considering. confusion and hallucinations. - ANSWER -
C.Decrease the IV infusion rate of the meperidine
It is common for mothers to feel ambivalent (Demerol) per protocol.
about returning to work and caring full time for
children at home. The nurse should assist the The client is exhibiting symptoms of Demerol
mother to explore her feelings on the subject toxicity which is consistent with the large doses of
while focusing on the optimal, appropriate, safe, Demerol received over four days. Decreasing the
and available options for her child infusion rate of the Demerol as per protocol is the
most effective action to immediately decrease the
amount of serum Demerol. The next nursing
action is for the nurse to notify the healthcare
A 4-year-old boy who is scheduled for a provider.
tonsillectomy and adenoidectomy asks the nurse,
"Will it hurt to have my tonsils and adenoids
taken out?" Which response is best for the nurse
to provide? A couple trying to cope with an infertility problem
A. "It may hurt a little because of the incision wants to know what can be done to preserve
made in your throat." emotional equilibrium. What is the best response
B. "It won't hurt because you're such a big boy."for the nurse to provide?
C. "It won't hurt because we put you to sleep." A. "Tell your friends and family so that they can
D. "It may hurt but we'll give you medicine to help
help you."
you feel better." - ANSWER -D. "It may hurt B. "Get involved with a support group. I will give
but we'll give you medicine to help you feel you some names."
better." C. "Talk only to other friends who are infertile
since only they can help."
Answering questions simply and directly provides D. "Start adoption proceedings immediately
comfort for the preschool-age child and builds since obtaining an infant is very difficult." -
confidence in the healthcare team. ANSWER -B: "Get involved with a support
group. I will give you some names."
A support group provides a safe haven for the
,HESI level 2 (NSG 170) Test Questions and Answers Rated A
couple to share their feelings and experience, their infant after death to facilitate closure. If
gain insight from others dealing with the same parents are hesitant about seeing or holding their
experience, and assure the couple that they are dead infant, the fetus should be available for a
not alone in their situation. few hours in the event they change their mind
after the initial shock. The other actions are not
indicated.
A 17-year-old unmarried, pregnant client with
drug addiction is a high school dropout,
homeless, and has a history of past abuse A client is told that her infant will be stillborn.
arrives at the clinic for her first prenatal visit. What is the most important action for the nurse to
Which findings should the nurse document as implement after the birth?
health risk factors for the client? (Select all that A.Ask the family if they would like to see and
apply.) hold the infant after birth.
A.Age. B.Inquire if the parents want a picture taken after
B.Drug addiction. the infant is born.
C.History of abuse. C.Discuss with the parents which funeral home
D.Pregnancy. should be notified.
E.Homelessness. D.Find out if the client has a special outfit for the
F.Unmarried. - ANSWER -A, B, C, D, E infant after the birth. - ANSWER -A.Ask the
family if they would like to see and hold the infant
Health risk factors for this client include age, drug after birth.
addiction, pregnancy, history of abuse and
homelessness. Each factor should be considered Interventions and support from the nursing staff
individually. The client, as an adolescent mother, during a prenatal loss are extremely important in
is at high risk for nutritional deficits, anemia, the grief process and healing of the parents.
gestational diabetes and hypertension, which Research had shown it is most helpful for a
also impact the fetus' risk for small for gestational mother and father to see and hold their deceased
age, fetal anomalies, and fetal demise. infant after delivery, so the parents should be
given this opportunity initially after birth. The
other actions should be done after determining
the parents' wishes and providing the opportunity
Which nursing intervention should the nurse for bonding and closure with their infant.
implement with parents who experience a fetal
demise and express the wish not to see the
baby?
A.Tell them there is nothing to fear. A client who had a miscarriage at 10-weeks
B. Insist that they hold infant so they can grieve. gestation tells the nurse that she already
C.Respect their wishes and release the body to purchased some baby things and picked out a
the morgue. name. After the surgical dilation and curettage
D.Keep the body available for a few hours in (D&C), the client wants to go home as soon as
case they change their minds. - ANSWER - possible. Based on the client's statements, which
D.Keep the body available for a few hours in action should the nurse implement?
case they change their minds. A.Ready the client for discharge.
B.Notify pastoral care to offer the client a
Grieving parents should be encouraged to hold blessing.
, HESI level 2 (NSG 170) Test Questions and Answers Rated A
C.Ask the client what name she had picked out
for the infant. Clients can experience grief/loss response at all
D.Inquire if the client would like to see what was stages of pregnancy loss.
obtained from her D&C. - ANSWER -C.Ask
the client what name she had picked out for the
infant
A client in the preoperative holding area receives
The client's cues about her preparation for the a prescription for midazolam (Versed) IV. 
baby indicate her need to express her feelings of The nurse determines that the surgical consent
loss, so encouraging further discussion about the form needs to be signed by the client. Which
infant's name provides an opportunity to offer action should the nurse implement?
support. The other actions are not indicated. A.Give the drug and allow the client to read and
sign the consent form.
B.Counter-sign the client's initials on the consent
form after giving the drug.
When caring for a client who abuses alcohol C.Withhold the drug until the client validates
regularly, the nurse should assess the client for understanding of the surgical procedure and
which condition? signs the consent form.
A.Gout. D.Call the healthcare provider to explain the
B.Anemia. surgical procedure before the client signs the
C.Scurvy. consent. - ANSWER -C.Withhold the drug
D.Rickets - ANSWER -B. Anemia until the client validates understanding of the
surgical procedure and signs the consent form.
One of the most prevalent health problems
encountered in population surveys is iron- Midazolam, a benzodiazepine sedative, is
deficiency anemia. Clients who abuse alcohol commonly used for conscious-sedation
are more prone to have mineral-deficient diets intraoperatively and interferes with the client's
that require additional iron to prevent anemia. cognition and level of consciousness, so the
consent form should be signed before the drug is
administered.
The nurse attempts to help an unmarried
teenager deal with her feelings following a
spontaneous abortion at 8 weeks' gestation. A client who had abdominal surgery two days
What type of emotional response should the ago has prescriptions for intravenous morphine
nurse anticipate? sulfate 4 mg every 2 hours and a clear liquid diet.
A.Grief related to her perceptions about the loss The client complains of feeling distended and has
of this child. sharp, cramping gas pains. What nursing
B.Relief of ambivalent feelings experienced with intervention should be implemented?
this pregnancy. A.Obtain a prescription for a laxative.
C.Shock because she may not have realized B.Withhold all oral fluid and food.
that she was pregnant. C.Assist the client to ambulate in the hall.
D.Guilt because she had not followed her D.Administer the prescribed morphine sulfate. -
healthcare provider's instructions. - ANSWER -C.Assist the client to ambulate in
ANSWER -A.Grief related to her the hall.
perceptions about the loss of this child.
A client with acute appendicitis is experiencing
anxiety and loss of sleep about missing final A male client who smokes two packs of
examination week at college. Which outcome is cigarettes a day states he understands that
most important for the nurse to include in the smoking cigarettes is contributing to the difficulty
plan of care? that he and his wife are having in getting
pregnant and wants to know if other factors could
A. Sleeping six to eight hours. be contributing to their difficulty. What information
B. Achieve a sense of control. is best for the nurse to provide? (Select all that
C. Utilize problem solving skills. apply.)
D. Increased focus of attention. - A.Marijuana cigarettes do not affect sperm
ANSWER -B. Achieve a sense of control. count.
B.Alcohol consumption can cause erectile
The experience of psychological discomfort may dysfunction.
be as real as physical pain for the client and C.Low testosterone levels affect sperm
should be seen as a priority in care. Because the production.
client is experiencing anxiety, achieving a sense D.Cessation of smoking improves general health
of control is a key need (B) before (A, C and D) and fertility.
are addressed. E.Obesity has no effect on sperm production. -
ANSWER -B, C, D
Use of tobacco, alcohol, and marijuana may
A 57-year-old male client is scheduled to have a affect sperm counts. Sperm count is also
stress-thallium test the following morning and is negatively affected by low testosterone levels
NPO after midnight. At 0130, he is agitated and obesity.
because he cannot eat and is demanding food.
Which response is best for the nurse to provide
to this client?
A) I'm sorry sir, you have a prescription for Which response by a client with a nursing
nothing by mouth from midnight tonight. diagnosis of Spiritual distress indicates to the
B) I will let you have one cracker, but that is all nurse that a desired outcome measure has been
you can have for the rest of tonight. met?
C) What did the healthcare provider tell you A.Expresses concern about the meaning and
about the test you are having tomorrow? importance of life.
D) The test you are having tomorrow requires B.Remains angry at God for the continuation of
that you have nothing by mouth tonight. - the illness.
ANSWER -D. "The test you are having C.Accepts that punishment from God is not
tomorrow requires that you have nothing by related to illness.
mouth tonight." D.Refuses to participate in religious rituals that
have no meaning. - ANSWER -C.Accepts
Being direct and explaining to the client that the that punishment from God is not related to illness
test requires him to be NPO, is the most
therapeutic statement because the nurse is Acceptance that her illness is not God punishing
responding to the client's question and providing her, indicates a desired outcome for some
him the reason why. degree of resolution of spiritual distress
,HESI level 2 (NSG 170) Test Questions and Answers Rated A
A postoperative client has been receiving a
A mother brings her 4-month-old infant to the continuous IV infusion of meperidine (Demerol)
clinic for a well-child checkup. She asks if she 35 mg/hr for four days. The client has a PRN
should go back to work now or stay at home with prescription for Demerol 100 mg PO q3h. The
the baby. How should the nurse respond to the nurse notes that the client has become
mother? increasingly restless, irritable and confused,
A.Mothers can promote healthy bonding by stating that there are bugs all over the walls.
staying at home during the child's first years. What action should the nurse take first?
B.Determine if other family relatives can stay at A..Administer a PRN dose of the PO meperidine
home with the baby. (Demerol).
C.Ask the mother to talk about the options she B.Administer naloxone (Narcan) IV per PRN
has been considering. protocol.
D.Returning to work when an infant is young C.Decrease the IV infusion rate of the
helps the baby to adjust to other children. - meperidine (Demerol) per protocol.
ANSWER -C.Ask the mother to talk about D.Notify the healthcare provider of the client's
the options she has been considering. confusion and hallucinations. - ANSWER -
C.Decrease the IV infusion rate of the meperidine
It is common for mothers to feel ambivalent (Demerol) per protocol.
about returning to work and caring full time for
children at home. The nurse should assist the The client is exhibiting symptoms of Demerol
mother to explore her feelings on the subject toxicity which is consistent with the large doses of
while focusing on the optimal, appropriate, safe, Demerol received over four days. Decreasing the
and available options for her child infusion rate of the Demerol as per protocol is the
most effective action to immediately decrease the
amount of serum Demerol. The next nursing
action is for the nurse to notify the healthcare
A 4-year-old boy who is scheduled for a provider.
tonsillectomy and adenoidectomy asks the nurse,
"Will it hurt to have my tonsils and adenoids
taken out?" Which response is best for the nurse
to provide? A couple trying to cope with an infertility problem
A. "It may hurt a little because of the incision wants to know what can be done to preserve
made in your throat." emotional equilibrium. What is the best response
B. "It won't hurt because you're such a big boy."for the nurse to provide?
C. "It won't hurt because we put you to sleep." A. "Tell your friends and family so that they can
D. "It may hurt but we'll give you medicine to help
help you."
you feel better." - ANSWER -D. "It may hurt B. "Get involved with a support group. I will give
but we'll give you medicine to help you feel you some names."
better." C. "Talk only to other friends who are infertile
since only they can help."
Answering questions simply and directly provides D. "Start adoption proceedings immediately
comfort for the preschool-age child and builds since obtaining an infant is very difficult." -
confidence in the healthcare team. ANSWER -B: "Get involved with a support
group. I will give you some names."
A support group provides a safe haven for the
,HESI level 2 (NSG 170) Test Questions and Answers Rated A
couple to share their feelings and experience, their infant after death to facilitate closure. If
gain insight from others dealing with the same parents are hesitant about seeing or holding their
experience, and assure the couple that they are dead infant, the fetus should be available for a
not alone in their situation. few hours in the event they change their mind
after the initial shock. The other actions are not
indicated.
A 17-year-old unmarried, pregnant client with
drug addiction is a high school dropout,
homeless, and has a history of past abuse A client is told that her infant will be stillborn.
arrives at the clinic for her first prenatal visit. What is the most important action for the nurse to
Which findings should the nurse document as implement after the birth?
health risk factors for the client? (Select all that A.Ask the family if they would like to see and
apply.) hold the infant after birth.
A.Age. B.Inquire if the parents want a picture taken after
B.Drug addiction. the infant is born.
C.History of abuse. C.Discuss with the parents which funeral home
D.Pregnancy. should be notified.
E.Homelessness. D.Find out if the client has a special outfit for the
F.Unmarried. - ANSWER -A, B, C, D, E infant after the birth. - ANSWER -A.Ask the
family if they would like to see and hold the infant
Health risk factors for this client include age, drug after birth.
addiction, pregnancy, history of abuse and
homelessness. Each factor should be considered Interventions and support from the nursing staff
individually. The client, as an adolescent mother, during a prenatal loss are extremely important in
is at high risk for nutritional deficits, anemia, the grief process and healing of the parents.
gestational diabetes and hypertension, which Research had shown it is most helpful for a
also impact the fetus' risk for small for gestational mother and father to see and hold their deceased
age, fetal anomalies, and fetal demise. infant after delivery, so the parents should be
given this opportunity initially after birth. The
other actions should be done after determining
the parents' wishes and providing the opportunity
Which nursing intervention should the nurse for bonding and closure with their infant.
implement with parents who experience a fetal
demise and express the wish not to see the
baby?
A.Tell them there is nothing to fear. A client who had a miscarriage at 10-weeks
B. Insist that they hold infant so they can grieve. gestation tells the nurse that she already
C.Respect their wishes and release the body to purchased some baby things and picked out a
the morgue. name. After the surgical dilation and curettage
D.Keep the body available for a few hours in (D&C), the client wants to go home as soon as
case they change their minds. - ANSWER - possible. Based on the client's statements, which
D.Keep the body available for a few hours in action should the nurse implement?
case they change their minds. A.Ready the client for discharge.
B.Notify pastoral care to offer the client a
Grieving parents should be encouraged to hold blessing.
, HESI level 2 (NSG 170) Test Questions and Answers Rated A
C.Ask the client what name she had picked out
for the infant. Clients can experience grief/loss response at all
D.Inquire if the client would like to see what was stages of pregnancy loss.
obtained from her D&C. - ANSWER -C.Ask
the client what name she had picked out for the
infant
A client in the preoperative holding area receives
The client's cues about her preparation for the a prescription for midazolam (Versed) IV. 
baby indicate her need to express her feelings of The nurse determines that the surgical consent
loss, so encouraging further discussion about the form needs to be signed by the client. Which
infant's name provides an opportunity to offer action should the nurse implement?
support. The other actions are not indicated. A.Give the drug and allow the client to read and
sign the consent form.
B.Counter-sign the client's initials on the consent
form after giving the drug.
When caring for a client who abuses alcohol C.Withhold the drug until the client validates
regularly, the nurse should assess the client for understanding of the surgical procedure and
which condition? signs the consent form.
A.Gout. D.Call the healthcare provider to explain the
B.Anemia. surgical procedure before the client signs the
C.Scurvy. consent. - ANSWER -C.Withhold the drug
D.Rickets - ANSWER -B. Anemia until the client validates understanding of the
surgical procedure and signs the consent form.
One of the most prevalent health problems
encountered in population surveys is iron- Midazolam, a benzodiazepine sedative, is
deficiency anemia. Clients who abuse alcohol commonly used for conscious-sedation
are more prone to have mineral-deficient diets intraoperatively and interferes with the client's
that require additional iron to prevent anemia. cognition and level of consciousness, so the
consent form should be signed before the drug is
administered.
The nurse attempts to help an unmarried
teenager deal with her feelings following a
spontaneous abortion at 8 weeks' gestation. A client who had abdominal surgery two days
What type of emotional response should the ago has prescriptions for intravenous morphine
nurse anticipate? sulfate 4 mg every 2 hours and a clear liquid diet.
A.Grief related to her perceptions about the loss The client complains of feeling distended and has
of this child. sharp, cramping gas pains. What nursing
B.Relief of ambivalent feelings experienced with intervention should be implemented?
this pregnancy. A.Obtain a prescription for a laxative.
C.Shock because she may not have realized B.Withhold all oral fluid and food.
that she was pregnant. C.Assist the client to ambulate in the hall.
D.Guilt because she had not followed her D.Administer the prescribed morphine sulfate. -
healthcare provider's instructions. - ANSWER -C.Assist the client to ambulate in
ANSWER -A.Grief related to her the hall.
perceptions about the loss of this child.
