Hesi NUR 112 Exam Questions & Answers with Rationales Updated
(Deeply & Well Explained Answers)
The |healthcare |provider |prescribes |methylergonovine |maleate |for |a |postpartum |client |with |uterine
|atony. |What |findings |should |indicate |to |the |nurse |to |withhold |the |next |dose |of |the |medication?
A. |Excessive |lochia.
B. |Saturation |of |more |than |one |pad |per |hour.
C. |Hypertension.
D. |Difficulty |locating |the |uterine |fundus. |- |Answer
C. |Hypertension.
Rationale
Methylergonovine, |an |ergot |alkaloid, |has |vasoconstrictive |effects |that |can |exaggerate |primary
|hypertension. |The |nurse |should |withhold |the |medication |if |the |client's |blood |pressure |is |elevated
(C) |and |notify |the |healthcare |provider. |(A, |B, |and |D) |are |signs |of |uterine |atony |and |are |indications
|for |the |use |of |the |medication.
The |nurse |has |completed |the |diet |teaching |of |a |male |client |who |is |being |discharged |following
|treatment |of |a |leg |wound. |A |high |protein |diet |is |encouraged |to |promote |wound |healing. |Which
|lunch |choice |by |the |client |indicates |that |the |teaching |was |effective?
A. |A |peanut |butter |sandwich |with |soda |and |cookies.
B. |A |tunafish |sandwich |with |chips |and |ice |cream.
C. |A |salad |with |three |kinds |of |lettuce |and |fruit.
D. |Vegetable |soup, |crackers, |and |milk. |- |Answer
B. |A |tunafish |sandwich |with |chips |and |ice |cream.
Rationale
(B) |contains |the |highest |amount |of |protein. |Four |ounces |of |tuna |contains |11 |g |of |protein, |and |ice
|cream |5 |g |of |protein |per |cup. |Chips |are |a |fat |with |virtually |no |protein |value. |(A) |contains |4 |grams |of
|protein |per |tablespoon. |(C) |contains |only |1 |gram |of |protein |per |1 |cup |serving. |(D) |may |have |beef
|flavoring |but |it |consist |mostly |of |vegetables |and |would |therefore |be |low |in |protein.
The |nurse |discontinues |a |continuous |IV |heparin |infusion |for |a |male |client |on |strict |bed |rest, |and |is
|now |preparing |to |administer |the |client's |first |dose |of |in |enoxaparin |(Lovenox). |Prior |to |giving |this
|subcutaneous |injection, |which |assessment |finding |requires |additional |intervention |by |the |nurse?
A. |Current |lab |report |indicates |an |aPTT |at |1.5 |times |the |client's |control.
B. |Several |bruised |areas |are |noted |on |the |client's |upper |extremities |bilaterally.
C. |The |client |states |that |his |right |calf |is |aching, |and |wants |pain |medication.
D. |The |spouse |is |assisting |the |client |who |is |shaving |with |an |electric |razor. |- |Answer
C. |The |client |states |that |his |right |calf |is |aching, |and |wants |pain |medication.
,Rationale
A |calf |ache |severe |enough |for |the |client |to |request |pain |medication |(C) |should |be |reported |to |the
|healthcare |provider |immediately |so |that |an |adjustment |in |the |anticoagulation |therapy |can |be |made.
|Calf |pain |may |be |a |sign |of |deep |vein |thrombosis |indicative |of |ineffective |anticoagulant |heparin
|therapy. |(A |and |B) |are |expected |findings. |Shaving |with |an |electric |razor |is |recommended |to |reduce
|the |possibility |of |bleeding |(D) |and |does |not |require |intervention.
While |the |nurse |is |providing |morning |care |for |a |client |with |chronic |obstructive |pulmonary |disease
|(COPD), |the |client |becomes |very |dyspneic |and |starts |to |panic. |What |action |should |the |nurse
|implement |first?
A. |Instruct |the |client |to |perform |diaphragmatic |breathing.
B. |Use |a |calm |voice |to |tell |the |client |to |breathe |slowly.
C. |Administer |two |puffs |of |a |metered-dose |inhaler.
D. |Assist |the |client |to |an |upright |position. |- |Answer
D. |Assist |the |client |to |an |upright |position.
Rationale
The |nurse |should |first |assist |the |client |to |an |upright |position |(D), |which |allows |the |lungs |to |expand
|fully. |After |this, |the |nurse |can |implement |(A, |B, |and |C) |as |needed.
A |female |client's |estranged |husband |arrives |at |the |hospital |and |demands |that |his |wife |have |no
|other |visitors. |The |client |becomes |angry |and |insists |that |the |estranged |husband |be |barred |from
|visiting |her. |Which |intervention |should |the |nurse |implement?
A. |Obtain |a |prescription |to |allow |client |to |dictate |who |can |visit.
B. |Request |a |multidisciplinary |care |conference |to |discuss |husband's |demands.
C. |Have |the |hospital's |medical-legal |department |meet |with |the |client.
D. |Encourage |the |client |to |speak |with |husband |regarding |his |disruptive |behavior. |- |Answer
B. |Request |a |multidisciplinary |care |conference |to |discuss |husband's |demands.
Rationale
A |multi-disciplinary |care |conference |involves |the |healthcare |team |to |evaluate |difficult |situations
|that |conflict |with |client |safety |and |autonomy. |During |this |conference, |the |client's |wishes
|regarding |her |health |care |decisions |can |be |clarified |to |all |team |members. |All |other |options |are |not
|indicated.
The |nurse |working |in |a |critical |care |unit |is |assigned |the |care |of |two |clients, |one |with |pneumonia
|who |is |being |mechanically |ventilated |and |the |other |who |had |a |thoracotomy | yesterday |and |is
|complaining |of |incisional |pain. |What |should |the |nurse |to |first?
A. |Assess |the |level |of |consciousness |and |vital |signs |for |both |clients.
B. |Complete |a |head |to |toe |assessment |of |the |client |with |pneumonia.
C. |Change |the |surgical |dressing |to |observe |the |appearance |of |the |incision.
D. |Review |the |plan |of |care |and |the |medications |that |are |due |for |both |clients. |- |Answer
A. Assess |the |level |of |consciousness |and |vital |signs |for |both |clients.
,Rationale
Assessing |the |level |of |consciousness |and |vital |signs |for |both |clients |(A) |provides |a |quick
|measurement |of |priority |need. |Before |a |complete |assessment |(B) |is |done |on |one |client, |the |nurse
|should |at |least |do |a |quick |assessment |of |the |other |client. |Changing |the |dressing |and |observing |the
|incision |(C) |may |be |indicated, |but |only |after |both |clients |are |quickly |assessed. |Reviewing |the |plan
|of |care |and |medications |due |for |administration |(D) |should |wait |until |the |nurse |has |evaluated |both
|clients |for |any |urgent |clinical |needs.
A |woman |at |24 |weeks |gestation |who |has |fever, |bodyaches, |and |has |been |coughing |for |the |last |5
|days |is |sent |to |the |hospital |with |admission |prescriptions |for |H1N1 |influenza. |Which |prescription
|has |the |highest |priority?
A. |Obtain |specimens |for |cultures.
B. |Vital |signs |q4 |hours.
C. |Assign |private |room.
D. |Ringers |lactate |IV |125 |mL/8 |hours. |- |Answer
C. |Assign |private |room.
Rationale
Novel |H1N1 |("swine |flu |virus"), |a |new |subtype |of |influenza |A |virus, |is |exhibited |by |fever, |cough,
|sore |throat, |runny |nose, |body |aches, |headache, |chills, |fatigue, |diarrhea, |and |vomiting. |According
|to |the |Center |for |Disease |Control, |it |is |best |to |place |a |client |requiring |Contact |or |Droplet
|Precautions |in |a |single |client |room, |so |to |protect |others, |the |client |who |is |exhibiting |signs |of |Novel
|H1N1 |influenza |should |be |assigned |to |a |private |room |(C). |(A, |B, |and |D) |do |not |have | the |right |the
|priority |of |(C).
A |client |who |received |partial |thickness |(second |degree) |burns |over |the |anterior |surfaces |of |both
|arms, |legs, |and |chest |in |a |burning |vehicle |collision |receives |a |prescription |for |daily |dressing
|changes |and |therapeutic |baths. |The |nurse |determines |that |a |hoist |is |required |to |move |the |immobile
|client |from |a |stretcher |into |the |therapeutic |bath. |Which |intervention |should |the |nurse |implement
|first?
A. |Obtain |the |hoist |from |the |supply |room.
B. |Explain |the |procedure |to |the |client.
C. |Medicate |the |client |with |an |analgesic.
D. |Remove |all |bandages |prior |to |moving |the |client. |- |Answer
B. Explain |the |procedure |to |the |client.
Rationale
Before |implementing |any |new |procedure, |an |explanation |of |the |procedure |should |be |provided
(B). |Bringing |large |pieces |of |equipment |into |the |client's |room |(A), |such |as |a |mechanical |lift, |may
|alarm |the |client |if |the |procedure |has |not |been |explained. |The |client |should |be |medicated |(C), |but
|first |explaining |what |is |involved |in |the |procedure |helps |prepare |the |client |for |subsequent |actions.
|Dressing |bandages |provide |protection |for |the |wounds |and |help |eliminate |exposure |to |air, |which
|can |cause |pain, |so |removal |should |be |done |immediately |prior |to |submersion |in |the |bath |(D).
, A |client |develops |urticaria |on |the |trunk |and |neck |shortly |after |a |secondary |infusion |of |piperacillin
|is |initiated. |In |what |order |should |the |nurse |implement |these |interventions? |(Arrange |the |actions |in
|order |of |priority, |with |the |highest |priority |first |and |least |priority |last |or |at |the |bottom.)
A. Stop |the |infusion.
B. Assess |vital |signs.
C. Contact |the |healthcare |provider.
D. Initiate |adverse |event |report.
E. Document |reaction |to |the |drug. |- |Answer
1. Stop |the |infusion.
2. Assess |vital |signs.
3. Contact |the |healthcare |provider.
4. Document |reaction |to |the |drug.
5. Initiate |adverse |event |report.
Rationale
The |client |is |exhibiting |a |drug |reaction |and |quick |action |is |required. |When |a |drug |reaction |is
|suspected, |first |the |infusion |should |be |stopped. |Then |vital |signs |and |airway |compromise |should |be
|assessed |and |the |findings |reported |to |the |healthcare |provider. |Documentation |of |the |occurrence,
|including |a |description |of |the |rash |and |details |of |the |reaction |should |be |completed |after |the
|healthcare |provider |is |notified. |Finally, |and |adverse |drug |reaction |or |adverse |event |report |should
|be |completed.
The |nurse |is |conducting |intake |interviews |of |children |at |a |city |clinic. |Which |child |is |most
|susceptible |to |contracting |lead |poisoning?
A. An |adolescent |who |works |part |time |in |a |paint |factory.
B. A |10-year-old |who |is |an |insulin-dependent |diabetic |(Type |1).
C. An |8-year-old |who |lives |in |a |housing |project.
D. A |2-year-old |who |plays |on |aging |outdoor |playground |equipment. |- |Answer
D. |A |2-year-old |who |plays |on |aging |outdoor |playground |equipment.
Rationale
Children |who |ingest |dust |and |soil |and |paint |from |playground |equipment |usually |practice |pica— |the
|habitual, |purposeful, |and |compulsive |ingestion |of |non-food |products, |characteristic |of |toddlers
|(D). |Lead |enters |the |system |by |ingestion |or |inhalation, |usually |from |paint, |gasoline, |dust |and |soil,
|food, |and |water. |Though |(A) |may |present |a |hazard, |governmental |regulations |decrease |the |risk |of
|contracting |lead |poisoning |by |requiring |use |of |respirators |in |lead |paint |areas. |(B) |is |not |related |to
|lead |poisoning. |(C) |does |not |practice |pica |the |way |a |toddler |does.
While |changing |a |client's |postoperative |dressing, |the |nurse |observes |a |red |and |swollen |wound
|with |a |moderate |amount |of |yellow |and |green |drainage |and |a |foul |odor. |Given |there |is |a |positive
|methicillin-resistant |Staphylococcus |aureus |(MRSA), |which |is |the |most |important |action |for |the
|nurse |to |take?
(Deeply & Well Explained Answers)
The |healthcare |provider |prescribes |methylergonovine |maleate |for |a |postpartum |client |with |uterine
|atony. |What |findings |should |indicate |to |the |nurse |to |withhold |the |next |dose |of |the |medication?
A. |Excessive |lochia.
B. |Saturation |of |more |than |one |pad |per |hour.
C. |Hypertension.
D. |Difficulty |locating |the |uterine |fundus. |- |Answer
C. |Hypertension.
Rationale
Methylergonovine, |an |ergot |alkaloid, |has |vasoconstrictive |effects |that |can |exaggerate |primary
|hypertension. |The |nurse |should |withhold |the |medication |if |the |client's |blood |pressure |is |elevated
(C) |and |notify |the |healthcare |provider. |(A, |B, |and |D) |are |signs |of |uterine |atony |and |are |indications
|for |the |use |of |the |medication.
The |nurse |has |completed |the |diet |teaching |of |a |male |client |who |is |being |discharged |following
|treatment |of |a |leg |wound. |A |high |protein |diet |is |encouraged |to |promote |wound |healing. |Which
|lunch |choice |by |the |client |indicates |that |the |teaching |was |effective?
A. |A |peanut |butter |sandwich |with |soda |and |cookies.
B. |A |tunafish |sandwich |with |chips |and |ice |cream.
C. |A |salad |with |three |kinds |of |lettuce |and |fruit.
D. |Vegetable |soup, |crackers, |and |milk. |- |Answer
B. |A |tunafish |sandwich |with |chips |and |ice |cream.
Rationale
(B) |contains |the |highest |amount |of |protein. |Four |ounces |of |tuna |contains |11 |g |of |protein, |and |ice
|cream |5 |g |of |protein |per |cup. |Chips |are |a |fat |with |virtually |no |protein |value. |(A) |contains |4 |grams |of
|protein |per |tablespoon. |(C) |contains |only |1 |gram |of |protein |per |1 |cup |serving. |(D) |may |have |beef
|flavoring |but |it |consist |mostly |of |vegetables |and |would |therefore |be |low |in |protein.
The |nurse |discontinues |a |continuous |IV |heparin |infusion |for |a |male |client |on |strict |bed |rest, |and |is
|now |preparing |to |administer |the |client's |first |dose |of |in |enoxaparin |(Lovenox). |Prior |to |giving |this
|subcutaneous |injection, |which |assessment |finding |requires |additional |intervention |by |the |nurse?
A. |Current |lab |report |indicates |an |aPTT |at |1.5 |times |the |client's |control.
B. |Several |bruised |areas |are |noted |on |the |client's |upper |extremities |bilaterally.
C. |The |client |states |that |his |right |calf |is |aching, |and |wants |pain |medication.
D. |The |spouse |is |assisting |the |client |who |is |shaving |with |an |electric |razor. |- |Answer
C. |The |client |states |that |his |right |calf |is |aching, |and |wants |pain |medication.
,Rationale
A |calf |ache |severe |enough |for |the |client |to |request |pain |medication |(C) |should |be |reported |to |the
|healthcare |provider |immediately |so |that |an |adjustment |in |the |anticoagulation |therapy |can |be |made.
|Calf |pain |may |be |a |sign |of |deep |vein |thrombosis |indicative |of |ineffective |anticoagulant |heparin
|therapy. |(A |and |B) |are |expected |findings. |Shaving |with |an |electric |razor |is |recommended |to |reduce
|the |possibility |of |bleeding |(D) |and |does |not |require |intervention.
While |the |nurse |is |providing |morning |care |for |a |client |with |chronic |obstructive |pulmonary |disease
|(COPD), |the |client |becomes |very |dyspneic |and |starts |to |panic. |What |action |should |the |nurse
|implement |first?
A. |Instruct |the |client |to |perform |diaphragmatic |breathing.
B. |Use |a |calm |voice |to |tell |the |client |to |breathe |slowly.
C. |Administer |two |puffs |of |a |metered-dose |inhaler.
D. |Assist |the |client |to |an |upright |position. |- |Answer
D. |Assist |the |client |to |an |upright |position.
Rationale
The |nurse |should |first |assist |the |client |to |an |upright |position |(D), |which |allows |the |lungs |to |expand
|fully. |After |this, |the |nurse |can |implement |(A, |B, |and |C) |as |needed.
A |female |client's |estranged |husband |arrives |at |the |hospital |and |demands |that |his |wife |have |no
|other |visitors. |The |client |becomes |angry |and |insists |that |the |estranged |husband |be |barred |from
|visiting |her. |Which |intervention |should |the |nurse |implement?
A. |Obtain |a |prescription |to |allow |client |to |dictate |who |can |visit.
B. |Request |a |multidisciplinary |care |conference |to |discuss |husband's |demands.
C. |Have |the |hospital's |medical-legal |department |meet |with |the |client.
D. |Encourage |the |client |to |speak |with |husband |regarding |his |disruptive |behavior. |- |Answer
B. |Request |a |multidisciplinary |care |conference |to |discuss |husband's |demands.
Rationale
A |multi-disciplinary |care |conference |involves |the |healthcare |team |to |evaluate |difficult |situations
|that |conflict |with |client |safety |and |autonomy. |During |this |conference, |the |client's |wishes
|regarding |her |health |care |decisions |can |be |clarified |to |all |team |members. |All |other |options |are |not
|indicated.
The |nurse |working |in |a |critical |care |unit |is |assigned |the |care |of |two |clients, |one |with |pneumonia
|who |is |being |mechanically |ventilated |and |the |other |who |had |a |thoracotomy | yesterday |and |is
|complaining |of |incisional |pain. |What |should |the |nurse |to |first?
A. |Assess |the |level |of |consciousness |and |vital |signs |for |both |clients.
B. |Complete |a |head |to |toe |assessment |of |the |client |with |pneumonia.
C. |Change |the |surgical |dressing |to |observe |the |appearance |of |the |incision.
D. |Review |the |plan |of |care |and |the |medications |that |are |due |for |both |clients. |- |Answer
A. Assess |the |level |of |consciousness |and |vital |signs |for |both |clients.
,Rationale
Assessing |the |level |of |consciousness |and |vital |signs |for |both |clients |(A) |provides |a |quick
|measurement |of |priority |need. |Before |a |complete |assessment |(B) |is |done |on |one |client, |the |nurse
|should |at |least |do |a |quick |assessment |of |the |other |client. |Changing |the |dressing |and |observing |the
|incision |(C) |may |be |indicated, |but |only |after |both |clients |are |quickly |assessed. |Reviewing |the |plan
|of |care |and |medications |due |for |administration |(D) |should |wait |until |the |nurse |has |evaluated |both
|clients |for |any |urgent |clinical |needs.
A |woman |at |24 |weeks |gestation |who |has |fever, |bodyaches, |and |has |been |coughing |for |the |last |5
|days |is |sent |to |the |hospital |with |admission |prescriptions |for |H1N1 |influenza. |Which |prescription
|has |the |highest |priority?
A. |Obtain |specimens |for |cultures.
B. |Vital |signs |q4 |hours.
C. |Assign |private |room.
D. |Ringers |lactate |IV |125 |mL/8 |hours. |- |Answer
C. |Assign |private |room.
Rationale
Novel |H1N1 |("swine |flu |virus"), |a |new |subtype |of |influenza |A |virus, |is |exhibited |by |fever, |cough,
|sore |throat, |runny |nose, |body |aches, |headache, |chills, |fatigue, |diarrhea, |and |vomiting. |According
|to |the |Center |for |Disease |Control, |it |is |best |to |place |a |client |requiring |Contact |or |Droplet
|Precautions |in |a |single |client |room, |so |to |protect |others, |the |client |who |is |exhibiting |signs |of |Novel
|H1N1 |influenza |should |be |assigned |to |a |private |room |(C). |(A, |B, |and |D) |do |not |have | the |right |the
|priority |of |(C).
A |client |who |received |partial |thickness |(second |degree) |burns |over |the |anterior |surfaces |of |both
|arms, |legs, |and |chest |in |a |burning |vehicle |collision |receives |a |prescription |for |daily |dressing
|changes |and |therapeutic |baths. |The |nurse |determines |that |a |hoist |is |required |to |move |the |immobile
|client |from |a |stretcher |into |the |therapeutic |bath. |Which |intervention |should |the |nurse |implement
|first?
A. |Obtain |the |hoist |from |the |supply |room.
B. |Explain |the |procedure |to |the |client.
C. |Medicate |the |client |with |an |analgesic.
D. |Remove |all |bandages |prior |to |moving |the |client. |- |Answer
B. Explain |the |procedure |to |the |client.
Rationale
Before |implementing |any |new |procedure, |an |explanation |of |the |procedure |should |be |provided
(B). |Bringing |large |pieces |of |equipment |into |the |client's |room |(A), |such |as |a |mechanical |lift, |may
|alarm |the |client |if |the |procedure |has |not |been |explained. |The |client |should |be |medicated |(C), |but
|first |explaining |what |is |involved |in |the |procedure |helps |prepare |the |client |for |subsequent |actions.
|Dressing |bandages |provide |protection |for |the |wounds |and |help |eliminate |exposure |to |air, |which
|can |cause |pain, |so |removal |should |be |done |immediately |prior |to |submersion |in |the |bath |(D).
, A |client |develops |urticaria |on |the |trunk |and |neck |shortly |after |a |secondary |infusion |of |piperacillin
|is |initiated. |In |what |order |should |the |nurse |implement |these |interventions? |(Arrange |the |actions |in
|order |of |priority, |with |the |highest |priority |first |and |least |priority |last |or |at |the |bottom.)
A. Stop |the |infusion.
B. Assess |vital |signs.
C. Contact |the |healthcare |provider.
D. Initiate |adverse |event |report.
E. Document |reaction |to |the |drug. |- |Answer
1. Stop |the |infusion.
2. Assess |vital |signs.
3. Contact |the |healthcare |provider.
4. Document |reaction |to |the |drug.
5. Initiate |adverse |event |report.
Rationale
The |client |is |exhibiting |a |drug |reaction |and |quick |action |is |required. |When |a |drug |reaction |is
|suspected, |first |the |infusion |should |be |stopped. |Then |vital |signs |and |airway |compromise |should |be
|assessed |and |the |findings |reported |to |the |healthcare |provider. |Documentation |of |the |occurrence,
|including |a |description |of |the |rash |and |details |of |the |reaction |should |be |completed |after |the
|healthcare |provider |is |notified. |Finally, |and |adverse |drug |reaction |or |adverse |event |report |should
|be |completed.
The |nurse |is |conducting |intake |interviews |of |children |at |a |city |clinic. |Which |child |is |most
|susceptible |to |contracting |lead |poisoning?
A. An |adolescent |who |works |part |time |in |a |paint |factory.
B. A |10-year-old |who |is |an |insulin-dependent |diabetic |(Type |1).
C. An |8-year-old |who |lives |in |a |housing |project.
D. A |2-year-old |who |plays |on |aging |outdoor |playground |equipment. |- |Answer
D. |A |2-year-old |who |plays |on |aging |outdoor |playground |equipment.
Rationale
Children |who |ingest |dust |and |soil |and |paint |from |playground |equipment |usually |practice |pica— |the
|habitual, |purposeful, |and |compulsive |ingestion |of |non-food |products, |characteristic |of |toddlers
|(D). |Lead |enters |the |system |by |ingestion |or |inhalation, |usually |from |paint, |gasoline, |dust |and |soil,
|food, |and |water. |Though |(A) |may |present |a |hazard, |governmental |regulations |decrease |the |risk |of
|contracting |lead |poisoning |by |requiring |use |of |respirators |in |lead |paint |areas. |(B) |is |not |related |to
|lead |poisoning. |(C) |does |not |practice |pica |the |way |a |toddler |does.
While |changing |a |client's |postoperative |dressing, |the |nurse |observes |a |red |and |swollen |wound
|with |a |moderate |amount |of |yellow |and |green |drainage |and |a |foul |odor. |Given |there |is |a |positive
|methicillin-resistant |Staphylococcus |aureus |(MRSA), |which |is |the |most |important |action |for |the
|nurse |to |take?
