NSG 123: HESI: FINAL EXAM QUESTIONS WITH COMPLETE
SOLUTIONS
1) An older adult man recently diagnosed with chronic obstructive pulmonary
disease (COPD) is admitted with shortness of breath. The nurse observes the
client sitting upright and leaning over the bedside table, using accessory muscles
to assist in breathing. What action should the nurse take?
A) Assist the lien tot a high Fowler's position in bed
B) Observe the client for the presence of a barrel chest
C) Prepare to transfer the client to a critical care unit
D) Instruct the client to pursed lip breathing techniques -- Correct
Answer ✔✔ D. Instruct the client in pursed lip breathing techniques
2) A client with multiple sclerosis has urinary retention related to sensorimotor
deficits. Which action should the nurse include in the client's plan of care? --
Correct Answer ✔✔ Teach the client techniques for performing intermittent
catheterization
3) When providing care for a client following bronchoscopy, which assessment
finding should he nurse immediately report to the healthcare provider?
, A) Slight blood-tinged sputum
B) Dyspnea and dysphagia
C) Sore throat and hoarseness
D) No gag reflex after thirty minutes -- Correct Answer ✔✔ D. No
gag reflex after thirty minutes
4) A male client tells the clinic nurse that he is experiencing burning on urination,
and assessment reveals that he had sexual intercourse four days ago with a
woman he casually met. Which action should the nurse implement?
A) Observe the perineal area for a chancroid-like lesion
B) Obtain a specimen of urethral drainage for culture
C) Assess for perineal itching, erythema and excoriation
D) Identify all sexual partners in the last four days -- Correct Answer
✔✔ B. Obtain a specimen of urethral drainage for culture
5) A client with Addison's disease started taking hydrocortisone in a divided daily
dose last week. It is most important for the nurse to monitor which serum
laboratory value?
A) Osmolarity
B) Glucose
C) Albumin
D) Platelets -- Correct Answer ✔✔ B. Glucose
6) A client with acquired immunodeficiency syndrome (AIDS) has impaired gas
exchange from a respiratory infection. Which assessment finding warrants
immediate intervention by the nurse?
A) Elevated temperature
B) Generalized weakness
C) Diminished lung sounds
D) Pain when swallowing -- Correct Answer ✔✔ D. Pain when
swallowing
,7) An older male client tells the nurse that he is losing sleep because he has to get
up several times at night to go to the bathroom, that he has trouble starting his
urinary stream, and that he does not feel like his bladder is ever completely
empty. Which intervention should the nurse implement?
A) Collect a urine specimen for culture analysis
B) Review the client's fluid intake prior to bedtime
C) Palpate the bladder above the symphysis pubis
D) Obtain a fingerstick blood glucose level -- Correct Answer ✔✔ C.
Palpate the bladder above the symphysis pubis
8) Fluids are restricted to 1,500 ml daily for a male client with acute kidney injury
(AKI). He is frustrated and complaining of constant thirst, and the nurse discovers
that the family is providing the client with additional fluids. Which intervention
should the nurse implement?
A) Remove all sources of liquids from the client's room
B) Allow family to give client a measured amount of ice chips
C) Restrict family visiting until the client's condition is stable
D) Provide the client with oral swabs to moisten his mouth -- Correct
Answer ✔✔ D. Provide the client with oral swabs to moisten his
mouth
9) During a paracentesis, two liters of fluid are removed from the abdomen of a
client with ascites. A drainage bag is placed, and 50 ml of clear, straw-colored
fluid drains within the first hour. What action should the nurse implement?
A) Palpate for abdominal distention
B) Send fluid to the lab for analysis
C) Continue to monitor the fluid output
D) Clamp the drainage tube for 5 minutes -- Correct Answer ✔✔ C.
Continue to monitor the fluid output
, 10) While assessing a client with degenerative joint disease, the nurse observes
Heberden's nodes, large prominences on the client's fingers that are reddened.
The client reports that the nodes are painful. Which action should the nurse
take?
A) Review the client's dietary intake of high-protein foods
B) Notify the healthcare provider of the finding immediately
C) Discuss approaches to the chronic pain control with the client
D) Assess the client's radial pulses and capillary refill time -- Correct
Answer ✔✔ C. Discuss approaches to the chronic pain control with
the client
11) A client who took a camping vacation two weeks ago in a county with a tropical
climate comes to the clinic describing vague symptoms and diarrhea for the past
week. Which finding is most important for the nurse report to the healthcare
provider?
A) Weakness and fatigue
B) Intestinal cramping
C) Weight loss
D) Jaundiced sclera -- Correct Answer ✔✔ D. Jaundiced sclera
12) Ten hours following thrombolysis for an ST elevation myocardial infarction
(STEMI), a client is receiving a lidocaine infusion for isolated runs of ventricular
tachycardia (VT). Which finding should the nurse document in the electronic
medical record as a therapeutic response to the lidocaine infusion?
A) Stabilization of blood pressure ranges
B) Cessation of chest pain
C) Reduce heart rate
D) Decreased frequency of episodes of VT -- Correct Answer ✔✔ D.
Decreased frequency of episodes of VT
SOLUTIONS
1) An older adult man recently diagnosed with chronic obstructive pulmonary
disease (COPD) is admitted with shortness of breath. The nurse observes the
client sitting upright and leaning over the bedside table, using accessory muscles
to assist in breathing. What action should the nurse take?
A) Assist the lien tot a high Fowler's position in bed
B) Observe the client for the presence of a barrel chest
C) Prepare to transfer the client to a critical care unit
D) Instruct the client to pursed lip breathing techniques -- Correct
Answer ✔✔ D. Instruct the client in pursed lip breathing techniques
2) A client with multiple sclerosis has urinary retention related to sensorimotor
deficits. Which action should the nurse include in the client's plan of care? --
Correct Answer ✔✔ Teach the client techniques for performing intermittent
catheterization
3) When providing care for a client following bronchoscopy, which assessment
finding should he nurse immediately report to the healthcare provider?
, A) Slight blood-tinged sputum
B) Dyspnea and dysphagia
C) Sore throat and hoarseness
D) No gag reflex after thirty minutes -- Correct Answer ✔✔ D. No
gag reflex after thirty minutes
4) A male client tells the clinic nurse that he is experiencing burning on urination,
and assessment reveals that he had sexual intercourse four days ago with a
woman he casually met. Which action should the nurse implement?
A) Observe the perineal area for a chancroid-like lesion
B) Obtain a specimen of urethral drainage for culture
C) Assess for perineal itching, erythema and excoriation
D) Identify all sexual partners in the last four days -- Correct Answer
✔✔ B. Obtain a specimen of urethral drainage for culture
5) A client with Addison's disease started taking hydrocortisone in a divided daily
dose last week. It is most important for the nurse to monitor which serum
laboratory value?
A) Osmolarity
B) Glucose
C) Albumin
D) Platelets -- Correct Answer ✔✔ B. Glucose
6) A client with acquired immunodeficiency syndrome (AIDS) has impaired gas
exchange from a respiratory infection. Which assessment finding warrants
immediate intervention by the nurse?
A) Elevated temperature
B) Generalized weakness
C) Diminished lung sounds
D) Pain when swallowing -- Correct Answer ✔✔ D. Pain when
swallowing
,7) An older male client tells the nurse that he is losing sleep because he has to get
up several times at night to go to the bathroom, that he has trouble starting his
urinary stream, and that he does not feel like his bladder is ever completely
empty. Which intervention should the nurse implement?
A) Collect a urine specimen for culture analysis
B) Review the client's fluid intake prior to bedtime
C) Palpate the bladder above the symphysis pubis
D) Obtain a fingerstick blood glucose level -- Correct Answer ✔✔ C.
Palpate the bladder above the symphysis pubis
8) Fluids are restricted to 1,500 ml daily for a male client with acute kidney injury
(AKI). He is frustrated and complaining of constant thirst, and the nurse discovers
that the family is providing the client with additional fluids. Which intervention
should the nurse implement?
A) Remove all sources of liquids from the client's room
B) Allow family to give client a measured amount of ice chips
C) Restrict family visiting until the client's condition is stable
D) Provide the client with oral swabs to moisten his mouth -- Correct
Answer ✔✔ D. Provide the client with oral swabs to moisten his
mouth
9) During a paracentesis, two liters of fluid are removed from the abdomen of a
client with ascites. A drainage bag is placed, and 50 ml of clear, straw-colored
fluid drains within the first hour. What action should the nurse implement?
A) Palpate for abdominal distention
B) Send fluid to the lab for analysis
C) Continue to monitor the fluid output
D) Clamp the drainage tube for 5 minutes -- Correct Answer ✔✔ C.
Continue to monitor the fluid output
, 10) While assessing a client with degenerative joint disease, the nurse observes
Heberden's nodes, large prominences on the client's fingers that are reddened.
The client reports that the nodes are painful. Which action should the nurse
take?
A) Review the client's dietary intake of high-protein foods
B) Notify the healthcare provider of the finding immediately
C) Discuss approaches to the chronic pain control with the client
D) Assess the client's radial pulses and capillary refill time -- Correct
Answer ✔✔ C. Discuss approaches to the chronic pain control with
the client
11) A client who took a camping vacation two weeks ago in a county with a tropical
climate comes to the clinic describing vague symptoms and diarrhea for the past
week. Which finding is most important for the nurse report to the healthcare
provider?
A) Weakness and fatigue
B) Intestinal cramping
C) Weight loss
D) Jaundiced sclera -- Correct Answer ✔✔ D. Jaundiced sclera
12) Ten hours following thrombolysis for an ST elevation myocardial infarction
(STEMI), a client is receiving a lidocaine infusion for isolated runs of ventricular
tachycardia (VT). Which finding should the nurse document in the electronic
medical record as a therapeutic response to the lidocaine infusion?
A) Stabilization of blood pressure ranges
B) Cessation of chest pain
C) Reduce heart rate
D) Decreased frequency of episodes of VT -- Correct Answer ✔✔ D.
Decreased frequency of episodes of VT
