HESI NUR 314
,What is the primary purpose of interviewing a patient?
a. To get the patient's health history and current health status.
b. To allow the patient to become acquainted with the nurse.
c. To teach preventive health care methods to the patient.
d. To correlate the patient's complaints with objective signs. - CORRECT ANSWERS-a.
To get the *patient's health history and current health status.*
The nurse is assessing a patient who has an *unsteady gait and lacks coordination*.
The nurse finds that the *patient abuses alcohol*. What should be the first question the
nurse asks during the interview?
a. Has anyone asked you to quit drinking?
b. When did you have your last drink?
c. Have you injured anyone due to your drinking?
d. With whom did you drink last? - CORRECT ANSWERS-b. When did you have your
last drink?
The nurse has assessed the patients on the unit. Which patient requires immediate
attention?
a. A patient with a heart rate of 84 beats per minute and oxygen saturation of 99%
b. A patient who reports amber-colored urine after a ureteroscopy procedure
c. A patient with a blood pressure of 180/110 and urine output of 30 mL/hour
d. A patient with a respiratory rate of 16 bpm and a temperature of 98.6°F (37° C) -
CORRECT ANSWERS-c. A patient with *blood pressure of 180/110 and urine output of
30 mL/hour*
The student nurse is *caring for a patient with a urinary catheter*. The nurse instructs
the student to assess vital signs every hour. What other parameters should the nursing
student assess every hour?
a. Skin integrity
b. Blood glucose levels
c. Hemoglobin levels
d. Quantity and quality of urine - CORRECT ANSWERS-d. Quantity and quality of urine
A patient with *congestive heart failure* reports to the nurse a *ringing sensation in the
ears*. After reviewing the medication reports, the nurse suspects the patient is having
*side effects from one of the prescribed medications*. Which medication is likely to
cause these symptoms in the patient?
a. Mannitol (Osmitrol)
b. Digitalis (Digoxin)
c. Ethacrynic acid (Edecrin)
d. Captopril (Capoten) - CORRECT ANSWERS-c. Ethacrynic acid (Edecrin)
,The nurse is caring for a patient who was in an accident. The *nurse notices that the
patient has clear, watery drainage from the ear*. What is the priority *nursing
intervention in this situation*?
a. Irrigate the patient's ear canal with a warm solution
b. Report to the primary health care provider about the patient
c. Instill antibiotic solution into the patient's ear
d. Instill 2% acetic acid solution in the patient's ear - CORRECT ANSWERS-b. Report to
the primary health care provider about the patient
The nurse documents observations about the light reflex seen on the tympanic
membrane during an otoscopic examination. Which observation signifies that the ears
are normal?
a. The light reflection is at the 5 o'clock position on the right tympanic membrane, and
the 7 o'clock position on the left.
b. The light reflection is amber yellow in color.
c. The light reflection is at the 7 o'clock position in both the ears. - CORRECT
ANSWERS-a. The *light reflection is at the 5 o'clock position* on *the right tympanic
membrane*, and the *7 o'clock position on the left.*
The nurse takes special care while checking a patient's *tail of Spence*. What is the
reason for this intervention?
a. To detect supernumerary nipple
b. To detect breast cancer
c. To detect Paget's disease
d. To detect skin retraction - CORRECT ANSWERS-b. To detect breast cancer
An elderly patient with insomnia has been prescribed hypnotics and sedatives. What
does the nurse inform the patient about the side effects of these medications?
a. "You may develop hypoglycemia."
b. "You may have decreased appetite."
c. "You may increase the risk of delirium."
d. "You may experience nausea." - CORRECT ANSWERS-c. "You may increase the
risk of delirium."
While assessing an *older adult*, the nurse finds that the patient *does not speak or
understand English*. What should be the most important nursing intervention in this
situation?
a. Report to the primary healthcare provider.
b. Request that family members translate.
c. Schedule another day for the assessment.
, d. Use interpreters for better communication. - CORRECT ANSWERS-d. Use
interpreters for better communication
Which disease conditions are associated with hard, nontender Heberden and Bouchard
nodules?
a. Osteoporosis
b. Osteoarthritis
c. Carpal tunnel syndrome
d. Scoliosis - CORRECT ANSWERS-b. Osteoarthritis
Which intervention helps the nurse to listen to the lung sounds in a young child?
a. Encouraging the child to exercise prior to auscultation
b. Giving the child a pinwheel and asking the child to blow
c. Allowing the child to listen to a parent's lung sounds
d. Allowing the child to examine the tongue blade - CORRECT ANSWERS-b. Giving the
child a pinwheel and asking the child to blow
The nurse is *teaching a patient with diabetes about foot care*. Which instructions
should the nurse include about maintaining blood flow to the feet?
a. Curl and spread out the toes frequently.
b. Dry feet carefully after a shower or bath.
c. Apply a thin coat of lotion on the skin.
d. Keep the toenails trimmed and straight. - CORRECT ANSWERS-a. Curl and spread
out the toes frequently.
Which condition is associated with venous pooling (chronic venous insufficiency- veins
are not working effectively, making it difficult for the blood from the legs to return to the
heart)?
a. Diabetes
b. Obesity
c. Smoking
d. Arteriosclerosis - CORRECT ANSWERS-b. Obesity
After reviewing the prescription of a patient, *the nurse warns the patient about the
possibility of insomnia*. Which *medication* would have this effect?
a. Hypnotics
b. Barbiturates
c. Diuretics
d. Antihypertensives - CORRECT ANSWERS-c. Diuretics
The registered nurse (RN) notifies the spouse of a client who was admitted to hospice
with shallow respirations, of a change in the client's condition. Over the past hour, the
client's respiratory pattern has changed to a *Cheyne Stokes pattern*. After receiving
this information, the client's spouse begins vacuuming around the bed. Which stage of
grief is the spouse displaying during the visit?
,What is the primary purpose of interviewing a patient?
a. To get the patient's health history and current health status.
b. To allow the patient to become acquainted with the nurse.
c. To teach preventive health care methods to the patient.
d. To correlate the patient's complaints with objective signs. - CORRECT ANSWERS-a.
To get the *patient's health history and current health status.*
The nurse is assessing a patient who has an *unsteady gait and lacks coordination*.
The nurse finds that the *patient abuses alcohol*. What should be the first question the
nurse asks during the interview?
a. Has anyone asked you to quit drinking?
b. When did you have your last drink?
c. Have you injured anyone due to your drinking?
d. With whom did you drink last? - CORRECT ANSWERS-b. When did you have your
last drink?
The nurse has assessed the patients on the unit. Which patient requires immediate
attention?
a. A patient with a heart rate of 84 beats per minute and oxygen saturation of 99%
b. A patient who reports amber-colored urine after a ureteroscopy procedure
c. A patient with a blood pressure of 180/110 and urine output of 30 mL/hour
d. A patient with a respiratory rate of 16 bpm and a temperature of 98.6°F (37° C) -
CORRECT ANSWERS-c. A patient with *blood pressure of 180/110 and urine output of
30 mL/hour*
The student nurse is *caring for a patient with a urinary catheter*. The nurse instructs
the student to assess vital signs every hour. What other parameters should the nursing
student assess every hour?
a. Skin integrity
b. Blood glucose levels
c. Hemoglobin levels
d. Quantity and quality of urine - CORRECT ANSWERS-d. Quantity and quality of urine
A patient with *congestive heart failure* reports to the nurse a *ringing sensation in the
ears*. After reviewing the medication reports, the nurse suspects the patient is having
*side effects from one of the prescribed medications*. Which medication is likely to
cause these symptoms in the patient?
a. Mannitol (Osmitrol)
b. Digitalis (Digoxin)
c. Ethacrynic acid (Edecrin)
d. Captopril (Capoten) - CORRECT ANSWERS-c. Ethacrynic acid (Edecrin)
,The nurse is caring for a patient who was in an accident. The *nurse notices that the
patient has clear, watery drainage from the ear*. What is the priority *nursing
intervention in this situation*?
a. Irrigate the patient's ear canal with a warm solution
b. Report to the primary health care provider about the patient
c. Instill antibiotic solution into the patient's ear
d. Instill 2% acetic acid solution in the patient's ear - CORRECT ANSWERS-b. Report to
the primary health care provider about the patient
The nurse documents observations about the light reflex seen on the tympanic
membrane during an otoscopic examination. Which observation signifies that the ears
are normal?
a. The light reflection is at the 5 o'clock position on the right tympanic membrane, and
the 7 o'clock position on the left.
b. The light reflection is amber yellow in color.
c. The light reflection is at the 7 o'clock position in both the ears. - CORRECT
ANSWERS-a. The *light reflection is at the 5 o'clock position* on *the right tympanic
membrane*, and the *7 o'clock position on the left.*
The nurse takes special care while checking a patient's *tail of Spence*. What is the
reason for this intervention?
a. To detect supernumerary nipple
b. To detect breast cancer
c. To detect Paget's disease
d. To detect skin retraction - CORRECT ANSWERS-b. To detect breast cancer
An elderly patient with insomnia has been prescribed hypnotics and sedatives. What
does the nurse inform the patient about the side effects of these medications?
a. "You may develop hypoglycemia."
b. "You may have decreased appetite."
c. "You may increase the risk of delirium."
d. "You may experience nausea." - CORRECT ANSWERS-c. "You may increase the
risk of delirium."
While assessing an *older adult*, the nurse finds that the patient *does not speak or
understand English*. What should be the most important nursing intervention in this
situation?
a. Report to the primary healthcare provider.
b. Request that family members translate.
c. Schedule another day for the assessment.
, d. Use interpreters for better communication. - CORRECT ANSWERS-d. Use
interpreters for better communication
Which disease conditions are associated with hard, nontender Heberden and Bouchard
nodules?
a. Osteoporosis
b. Osteoarthritis
c. Carpal tunnel syndrome
d. Scoliosis - CORRECT ANSWERS-b. Osteoarthritis
Which intervention helps the nurse to listen to the lung sounds in a young child?
a. Encouraging the child to exercise prior to auscultation
b. Giving the child a pinwheel and asking the child to blow
c. Allowing the child to listen to a parent's lung sounds
d. Allowing the child to examine the tongue blade - CORRECT ANSWERS-b. Giving the
child a pinwheel and asking the child to blow
The nurse is *teaching a patient with diabetes about foot care*. Which instructions
should the nurse include about maintaining blood flow to the feet?
a. Curl and spread out the toes frequently.
b. Dry feet carefully after a shower or bath.
c. Apply a thin coat of lotion on the skin.
d. Keep the toenails trimmed and straight. - CORRECT ANSWERS-a. Curl and spread
out the toes frequently.
Which condition is associated with venous pooling (chronic venous insufficiency- veins
are not working effectively, making it difficult for the blood from the legs to return to the
heart)?
a. Diabetes
b. Obesity
c. Smoking
d. Arteriosclerosis - CORRECT ANSWERS-b. Obesity
After reviewing the prescription of a patient, *the nurse warns the patient about the
possibility of insomnia*. Which *medication* would have this effect?
a. Hypnotics
b. Barbiturates
c. Diuretics
d. Antihypertensives - CORRECT ANSWERS-c. Diuretics
The registered nurse (RN) notifies the spouse of a client who was admitted to hospice
with shallow respirations, of a change in the client's condition. Over the past hour, the
client's respiratory pattern has changed to a *Cheyne Stokes pattern*. After receiving
this information, the client's spouse begins vacuuming around the bed. Which stage of
grief is the spouse displaying during the visit?
