HESI 3RD SEMESTER EXAM 1
QUESTIONS WITH CORRECT
ANSWERS GRADED A+
The nurse working in a postoperative surgical clinic is assessing a woman
who had a left radical mastectomy for breast cancer. Which factor puts this
client at greatest risk for developing lymphedema?
A. She sustained an insect bite to her left arm yesterday.
B. She has lost twenty pounds since the surgery.
C. Her healthcare provider now prescribes a calcium channel blocker for
hypertension.
D. Her hobby is playing classical music on the piano.
A. She sustained an insect bite to her left arm yesterday.
In preparing to administer intravenous albumin to a client following surgery,
what is the priority nursing intervention? (Select all that apply.)
A. Set the infusion pump to infuse the albumin within four hours.
B. Compare the client's blood type with the label on the albumin.
C. Assign a UAP to monitor blood pressure q15 minutes.
D. Administer through a large gauge catheter.
E. Monitor hemoglobin and hematocrit levels.
F. Assess for increased bleeding after administration.
A. Set the infusion pump to infuse the albumin within four hours.
D. Administer through a large gauge catheter.
E. Monitor hemoglobin and hematocrit levels.
F. Assess for increased bleeding after administration.
The nurse working on a telemetry unit finds a client unconscious and in
pulseless ventricular tachycardia (VT). The client has an implanted automatic
,defibrillator. What action should the nurse implement?
A. Prepare the client for transcutaneous pacemaker.
B. Shock the client with 200 joules per hospital policy.
C. Use a magnet to deactivate the implanted pacemaker.
D. Observe the monitor until the onset of ventricular fibrillation.
B. Shock the client with 200 joules per hospital policy.
A 57-year-old male client is scheduled to have a stress-thallium test the
following morning and is NPO after midnight. At 0130, he is agitated 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 nothing by mouth from midnight
tonight."
B. "I will let you have one cracker, but that is all you can have for the rest of
tonight."
C. "What did the healthcare provider tell you about the test you are having
tomorrow."
D. "The test you are having tomorrow requires that you have nothing by mouth
tonight."
D. "The test you are having tomorrow requires that you have nothing by mouth
tonight."
In assessing cancer risk, the nurse identifies which woman as being at
greatest risk of developing breast cancer?
A. A 35-year-old multipara who never breastfed.
B. A 50-year-old whose mother had unilateral breast cancer.
C. A 55-year-old whose mother-in-law had bilateral breast cancer.
D. A 20-year-old whose menarche occurred at age 9.
B. A 50-year-old whose mother had unilateral breast cancer.
During lung assessment, the nurse places a stethoscope on a client's chest
and instructs him/her to say "99" each time the chest is touched with the
stethoscope. What should be the correct interpretation if the nurse hears the
spoken words "99" very clearly through the stethoscope?
,A. This is a normal auscultatory finding.
B. May indicate pneumothorax.
C. May indicate pneumonia.
D. May indicate severe emphysema.
C. May indicate pneumonia.
A client with a completed ischemic stroke has a blood pressure of 180/90 mm
Hg. Which action should the nurse implement?
A. Position the head of the bed (HOB) flat.
B. Withhold intravenous fluids.
C. Administer a bolus of IV fluids.
D. Give an antihypertensive medications.
D. Give an antihypertensive medications.
Which symptoms should the nurse expect a client to exhibit who is known to
have a pheochromocytoma?
A. Numbness, tingling, and cramps in the extremities.
B. Headache, diaphoresis, and palpitations.
C. Cyanosis, fever, and classic signs of shock.
D. Nausea, vomiting, and muscular weakness.
B. Headache, diaphoresis, and palpitations.
The nurse is assessing a client with chronic kidney disease (CKD). Which
finding is most important for the nurse to respond to first?
A. Potassium of 6.0 mEq
B. Daily urine output of 400mL
C. Peripheral neuropathy
D. Uremic fetor
A. Potassium of 6.0 mEq
The nurse is receiving report from surgery about a client with a penrose drain
who is to be admitted to the postoperative unit. Before choosing a room for
this client, which information is most important for the nurse to obtain?
, A. If suctioning will be needed for drainage of the wound.
B. If the family would prefer a private or semi-private room.
C. Null.
D. If the client's wound is infected.
D. If the client's wound is infected.
The client is admitted to the hospital with a medical diagnosis of
pneumococcal pneumonia. The nurse knows that the prognosis for gram-
negative pneumonias (such as E.coli, Klebsiella, Pseudomonas, and Proteus)
is very poor because
A. The occur in the lower lobe of the aveoli which are more sensitive to
infection.
B. Gram-negative organisms are more resistant to antibiotic therapy.
C. They occur in healthy young adults who have recently been debilitated by
an upper respiratory infection.
D. Gram- negative pneumonias usually affect infants and small children.
B. Gram-negative organisms are more resistant to antibiotic therapy.
Which assessment finding by the nurse during a client's clinical breast
examination requires follow-up?
A. Newly retracted nipple.
B. A thickened area where the skin folds under the breast.
C. Whitish nipple discharge.
D. Tender lumpiness noted bilaterally throughout the breasts.
A. Newly retracted nipple.
A client with multiple sclerosis has experienced an exacerbation of symptoms,
including paresthesias, diplopia, and nystagmus. Which instruction should the
nurse provide?
A. Stay out of direct sunlight.
B. Restrict intake of high protein foods.
C. Schedule extra rest periods.
D. Go to the emergency room immediately.
C. Schedule extra rest periods.
QUESTIONS WITH CORRECT
ANSWERS GRADED A+
The nurse working in a postoperative surgical clinic is assessing a woman
who had a left radical mastectomy for breast cancer. Which factor puts this
client at greatest risk for developing lymphedema?
A. She sustained an insect bite to her left arm yesterday.
B. She has lost twenty pounds since the surgery.
C. Her healthcare provider now prescribes a calcium channel blocker for
hypertension.
D. Her hobby is playing classical music on the piano.
A. She sustained an insect bite to her left arm yesterday.
In preparing to administer intravenous albumin to a client following surgery,
what is the priority nursing intervention? (Select all that apply.)
A. Set the infusion pump to infuse the albumin within four hours.
B. Compare the client's blood type with the label on the albumin.
C. Assign a UAP to monitor blood pressure q15 minutes.
D. Administer through a large gauge catheter.
E. Monitor hemoglobin and hematocrit levels.
F. Assess for increased bleeding after administration.
A. Set the infusion pump to infuse the albumin within four hours.
D. Administer through a large gauge catheter.
E. Monitor hemoglobin and hematocrit levels.
F. Assess for increased bleeding after administration.
The nurse working on a telemetry unit finds a client unconscious and in
pulseless ventricular tachycardia (VT). The client has an implanted automatic
,defibrillator. What action should the nurse implement?
A. Prepare the client for transcutaneous pacemaker.
B. Shock the client with 200 joules per hospital policy.
C. Use a magnet to deactivate the implanted pacemaker.
D. Observe the monitor until the onset of ventricular fibrillation.
B. Shock the client with 200 joules per hospital policy.
A 57-year-old male client is scheduled to have a stress-thallium test the
following morning and is NPO after midnight. At 0130, he is agitated 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 nothing by mouth from midnight
tonight."
B. "I will let you have one cracker, but that is all you can have for the rest of
tonight."
C. "What did the healthcare provider tell you about the test you are having
tomorrow."
D. "The test you are having tomorrow requires that you have nothing by mouth
tonight."
D. "The test you are having tomorrow requires that you have nothing by mouth
tonight."
In assessing cancer risk, the nurse identifies which woman as being at
greatest risk of developing breast cancer?
A. A 35-year-old multipara who never breastfed.
B. A 50-year-old whose mother had unilateral breast cancer.
C. A 55-year-old whose mother-in-law had bilateral breast cancer.
D. A 20-year-old whose menarche occurred at age 9.
B. A 50-year-old whose mother had unilateral breast cancer.
During lung assessment, the nurse places a stethoscope on a client's chest
and instructs him/her to say "99" each time the chest is touched with the
stethoscope. What should be the correct interpretation if the nurse hears the
spoken words "99" very clearly through the stethoscope?
,A. This is a normal auscultatory finding.
B. May indicate pneumothorax.
C. May indicate pneumonia.
D. May indicate severe emphysema.
C. May indicate pneumonia.
A client with a completed ischemic stroke has a blood pressure of 180/90 mm
Hg. Which action should the nurse implement?
A. Position the head of the bed (HOB) flat.
B. Withhold intravenous fluids.
C. Administer a bolus of IV fluids.
D. Give an antihypertensive medications.
D. Give an antihypertensive medications.
Which symptoms should the nurse expect a client to exhibit who is known to
have a pheochromocytoma?
A. Numbness, tingling, and cramps in the extremities.
B. Headache, diaphoresis, and palpitations.
C. Cyanosis, fever, and classic signs of shock.
D. Nausea, vomiting, and muscular weakness.
B. Headache, diaphoresis, and palpitations.
The nurse is assessing a client with chronic kidney disease (CKD). Which
finding is most important for the nurse to respond to first?
A. Potassium of 6.0 mEq
B. Daily urine output of 400mL
C. Peripheral neuropathy
D. Uremic fetor
A. Potassium of 6.0 mEq
The nurse is receiving report from surgery about a client with a penrose drain
who is to be admitted to the postoperative unit. Before choosing a room for
this client, which information is most important for the nurse to obtain?
, A. If suctioning will be needed for drainage of the wound.
B. If the family would prefer a private or semi-private room.
C. Null.
D. If the client's wound is infected.
D. If the client's wound is infected.
The client is admitted to the hospital with a medical diagnosis of
pneumococcal pneumonia. The nurse knows that the prognosis for gram-
negative pneumonias (such as E.coli, Klebsiella, Pseudomonas, and Proteus)
is very poor because
A. The occur in the lower lobe of the aveoli which are more sensitive to
infection.
B. Gram-negative organisms are more resistant to antibiotic therapy.
C. They occur in healthy young adults who have recently been debilitated by
an upper respiratory infection.
D. Gram- negative pneumonias usually affect infants and small children.
B. Gram-negative organisms are more resistant to antibiotic therapy.
Which assessment finding by the nurse during a client's clinical breast
examination requires follow-up?
A. Newly retracted nipple.
B. A thickened area where the skin folds under the breast.
C. Whitish nipple discharge.
D. Tender lumpiness noted bilaterally throughout the breasts.
A. Newly retracted nipple.
A client with multiple sclerosis has experienced an exacerbation of symptoms,
including paresthesias, diplopia, and nystagmus. Which instruction should the
nurse provide?
A. Stay out of direct sunlight.
B. Restrict intake of high protein foods.
C. Schedule extra rest periods.
D. Go to the emergency room immediately.
C. Schedule extra rest periods.
