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NURSING MISC HESI
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EXAM 2025
A health care provider prescribes 500 mg of an antibiotic intravenous piggyback
(IVPB) every 12 hours. The vial of antibiotic contains 1 g and indicates that the
addition of 2.5 mL of sterile water will yield 3 mL of reconstituted solution. How
many milliliters of the antibiotic should be added to the 50 mL IVPB bag? Record
your answer using one decimal place. mL
1.5
The nurse is caring for a non-ambulatory client with a reddened sacrum that is
unrelieved byrepositioning. What nursing diagnosis should be included on the
client's plan of care?
Risk for pressure ulcer
Risk for impaired skin integrity
Impaired skin integrity, related to infrequent turning and
repositioning Impaired skin integrity, related to the effects of
pressure and shearing force
A client has a pressure ulcer that is full thickness with necrosis into the
1
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subcutaneous tissue down to the underlying fascia. The nurse should
document the assessment finding as which stage of pressure ulcer?
Stage I
Stage II
Stage III
Unstageab
le
A pressure ulcer with necrotic tissue is unstageable. The necrotic tissue must be
removed before the wound can be staged. A stage I pressure ulcer is defined as an
area of persistent redness with no break in skin integrity. A stage II pressure ulcer is a
partial-thickness wound with skin loss involving the epidermis, dermis, or both; the
ulcer is superficial and may present as an abrasion, blister, or shallow crater. A stage
III pressure ulcer involves full thickness tissue loss with visible subcutaneous fat.
Bone, tendon, and muscle are not exposed.
A client is being admitted for a total hip replacement. When is it necessary for
the nurse to ensure that a medication reconciliation is completed? Select all that
apply.
After reporting severe
pain On admission to
the hospital
Upon entering the operating room
Before transfer to a rehabilitation
facility
At time of scheduling for the surgical procedure
Medication reconciliation involves the creation of a list of all medications the client is
2
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taking and comparing it to the health care provider's prescriptions on admission or
when there is a transfer to a different setting or service, or discharge. A change in
status does not require medication reconciliation. A medication reconciliation should
be completed long before entering the operating room. Total hip replacement is
elective surgery, and scheduling takes place before admission; medication
reconciliation takes place when the client is admitted.
A client is taking lithium sodium (Lithium). The nurse should notify the health
care provider for which of the following laboratory values?
White blood cell (WBC) count of
15,000 mm3 Negative protein in the
urine
Blood urea nitrogen (BUN) of 20
mg/dL Prothrombin of 12.0
seconds
White cell counts can increase with this drug. The expected range of the WBC count
is 5000 to 10,000 mm3 for a healthy adult. Urinalysis, BUN, and prothrombin are not
necessary and these are normal values.
Often when a family member is dying, the client and the family are at different
stages of grieving. During which stage of a client's grieving is the family likely
to require more emotional nursing care than the client?
Ange
r
Deni
3
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al
4
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NURSING MISC HESI
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EXAM 2025
A health care provider prescribes 500 mg of an antibiotic intravenous piggyback
(IVPB) every 12 hours. The vial of antibiotic contains 1 g and indicates that the
addition of 2.5 mL of sterile water will yield 3 mL of reconstituted solution. How
many milliliters of the antibiotic should be added to the 50 mL IVPB bag? Record
your answer using one decimal place. mL
1.5
The nurse is caring for a non-ambulatory client with a reddened sacrum that is
unrelieved byrepositioning. What nursing diagnosis should be included on the
client's plan of care?
Risk for pressure ulcer
Risk for impaired skin integrity
Impaired skin integrity, related to infrequent turning and
repositioning Impaired skin integrity, related to the effects of
pressure and shearing force
A client has a pressure ulcer that is full thickness with necrosis into the
1
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subcutaneous tissue down to the underlying fascia. The nurse should
document the assessment finding as which stage of pressure ulcer?
Stage I
Stage II
Stage III
Unstageab
le
A pressure ulcer with necrotic tissue is unstageable. The necrotic tissue must be
removed before the wound can be staged. A stage I pressure ulcer is defined as an
area of persistent redness with no break in skin integrity. A stage II pressure ulcer is a
partial-thickness wound with skin loss involving the epidermis, dermis, or both; the
ulcer is superficial and may present as an abrasion, blister, or shallow crater. A stage
III pressure ulcer involves full thickness tissue loss with visible subcutaneous fat.
Bone, tendon, and muscle are not exposed.
A client is being admitted for a total hip replacement. When is it necessary for
the nurse to ensure that a medication reconciliation is completed? Select all that
apply.
After reporting severe
pain On admission to
the hospital
Upon entering the operating room
Before transfer to a rehabilitation
facility
At time of scheduling for the surgical procedure
Medication reconciliation involves the creation of a list of all medications the client is
2
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taking and comparing it to the health care provider's prescriptions on admission or
when there is a transfer to a different setting or service, or discharge. A change in
status does not require medication reconciliation. A medication reconciliation should
be completed long before entering the operating room. Total hip replacement is
elective surgery, and scheduling takes place before admission; medication
reconciliation takes place when the client is admitted.
A client is taking lithium sodium (Lithium). The nurse should notify the health
care provider for which of the following laboratory values?
White blood cell (WBC) count of
15,000 mm3 Negative protein in the
urine
Blood urea nitrogen (BUN) of 20
mg/dL Prothrombin of 12.0
seconds
White cell counts can increase with this drug. The expected range of the WBC count
is 5000 to 10,000 mm3 for a healthy adult. Urinalysis, BUN, and prothrombin are not
necessary and these are normal values.
Often when a family member is dying, the client and the family are at different
stages of grieving. During which stage of a client's grieving is the family likely
to require more emotional nursing care than the client?
Ange
r
Deni
3
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al
4
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