H E S I V 3 EXAM QUESTIONS AND ANSWERS WITH
COMPLETE SOLUTIONS
1. A client who has been in active labor for 12 hours suddenly
tells the nurse that she has a strong urge to have a bowel
movement. What action should the nurse take?
A. Allow the client to use a bedpan.
B. Explain the fetal head is descending.
C. Perform a sterile vaginal exam.
D. Assist the client to the bathroom Correct Answer C. Perform
a sterile vaginal exam.
2. The nurse assesses a 78-year-old male client who has left
sided heart failure. Which symptoms would the nurse expect this
client to exhibit?
A. Dyspnea, cough and fatigue.
B. Hepatomegaly and distended neck veins.
C. Pain over the pericardium and friction rub.
D. Narrowing pulse pressure and distant heart sounds. Correct
Answer A. Dyspnea, cough and fatigue.
3. A female client comes to the clinic complaining of fatigue and
inability to sleep because she is the full-time caretaker for a 22-
year-old son who was paralyzed by a motor vehicle collision.
She adds that her husband left her because he says he can't take
her behavior anymore since all she does is care for their son.
What intervention should the nurse implement?
A. Teach the client to problem-solve for herself and establish
her own priorities.
B. Schedule a home visit in the afternoon to assess the son and
client's role as caregiver.
,C. Provide feedback to the client about her atonement for guilt
about her son's impairment.
D. Acknowledge the client's stress and suggest that she consider
respite care. Correct Answer D. Acknowledge the client's stress
and suggest that she consider respite care.
4. The nurse plans to administer a scheduled dose of metoprolol
(Toprol SR) at 0900 to a client with hypertension. At 0800, the
nurse notes that the client's telemetry pattern shows a second-
degree heart block with a ventricular rate of 50. What action
should the nurse take?
A. Administer the Toprol immediately and monitor the client
carefully until the heart rate increases.
B. Provide the dose of Toprol as scheduled and assign a UAP to
monitor the client's BP q30 minutes.
C. Hold the scheduled dose of Toprol and notify the healthcare
provider of the telemetry pattern.
D. Give the Toprol as scheduled if the client's systolic blood
pressure reading is greater than 180. Correct Answer C. Hold
the scheduled dose of Toprol and notify the healthcare provider
of the telemetry pattern.
5. A client who developed Syndrome of Inappropriate
Antidiuretic Hormone (SIADH) associated with small cell
carcinoma of the lung is preparing for discharge. When teaching
the client about self-management with demeclocycline
(Declomycin), the nurse should instruct the client to report
which condition to the healthcare provider?
A. Anxiety.
B. Insomnia.
C. Muscle cramping.
,D. Increased appetite Correct Answer C. Muscle cramping.
6. In determining the client position for insertion of an
indwelling urinary catheter, it is most important for the nurse to
recognize which client condition?
A. High urinary pH.
B. Fever.
C. Abdominal ascites.
D. Orthopnea. Correct Answer D. Orthopnea.
7. The nurse is reviewing a client's electrocardiogram and
determines that the PR interval (PRI) is prolonged. What does
this finding indicate?
A. Inability of the SA node to initiate an impulse at the normal
rate.
B. Initiation of the impulse from a location outside the SA node.
C. Increased conduction time from the SA node to the AV
junction.
D. Interference with the conduction through one or both
ventricles. Correct Answer C. Increased conduction time from
the SA node to the AV junction.
8. The nurse is teaching a male client with multiple sclerosis
how to empty his bladder using the Crede Method. When
performing a return demonstration, the client applies pressure to
the umbilical area of his abdomen. What instruction should the
nurse provide?
A. Stroke the inner thigh below the perineum to initiate urinary
flow.
B. Pour warm water over the external sphincter at the distal
glans.
, C. Apply downward manual pressure at the suprapubic region.
D. Contract, hold, and then relax the pubococcygeal muscle.
Correct Answer C. Apply downward manual pressure at the
suprapubic region.
9. A 35-year-old female client has just been admitted to the
postanesthesia recovery unit following a partial thyroidectomy.
Which statement reflects the nurse's accurate understanding of
the expected outcome for the client following this surgery?
A. Supplemental hormonal therapy will probably be
unnecessary.
B. The thyroid will regenerate to a normal size within a few
years.
C. The client will be restricted from eating seafood.
D. The remainder of the thyroid will be removed at a later date.
Correct Answer A. Supplemental hormonal therapy will
probably be unnecessary.
10. A client with gestational diabetes, at 39-weeks gestation, is
in the second stage of labor. After delivery of the fetal head, the
nurse recognizes that shoulder dystocia is occurring. What
intervention should the nurse implement first?
A. Lower the head of the bed and apply suprapubic pressure.
B. Encourage the client to move to a hands-and-knees position.
C. Prepare the client for an emergency cesarean birth.
D. Assist the client to sharply flex her thighs up against the
abdomen. Correct Answer D. Assist the client to sharply flex
her thighs up against the abdomen.
COMPLETE SOLUTIONS
1. A client who has been in active labor for 12 hours suddenly
tells the nurse that she has a strong urge to have a bowel
movement. What action should the nurse take?
A. Allow the client to use a bedpan.
B. Explain the fetal head is descending.
C. Perform a sterile vaginal exam.
D. Assist the client to the bathroom Correct Answer C. Perform
a sterile vaginal exam.
2. The nurse assesses a 78-year-old male client who has left
sided heart failure. Which symptoms would the nurse expect this
client to exhibit?
A. Dyspnea, cough and fatigue.
B. Hepatomegaly and distended neck veins.
C. Pain over the pericardium and friction rub.
D. Narrowing pulse pressure and distant heart sounds. Correct
Answer A. Dyspnea, cough and fatigue.
3. A female client comes to the clinic complaining of fatigue and
inability to sleep because she is the full-time caretaker for a 22-
year-old son who was paralyzed by a motor vehicle collision.
She adds that her husband left her because he says he can't take
her behavior anymore since all she does is care for their son.
What intervention should the nurse implement?
A. Teach the client to problem-solve for herself and establish
her own priorities.
B. Schedule a home visit in the afternoon to assess the son and
client's role as caregiver.
,C. Provide feedback to the client about her atonement for guilt
about her son's impairment.
D. Acknowledge the client's stress and suggest that she consider
respite care. Correct Answer D. Acknowledge the client's stress
and suggest that she consider respite care.
4. The nurse plans to administer a scheduled dose of metoprolol
(Toprol SR) at 0900 to a client with hypertension. At 0800, the
nurse notes that the client's telemetry pattern shows a second-
degree heart block with a ventricular rate of 50. What action
should the nurse take?
A. Administer the Toprol immediately and monitor the client
carefully until the heart rate increases.
B. Provide the dose of Toprol as scheduled and assign a UAP to
monitor the client's BP q30 minutes.
C. Hold the scheduled dose of Toprol and notify the healthcare
provider of the telemetry pattern.
D. Give the Toprol as scheduled if the client's systolic blood
pressure reading is greater than 180. Correct Answer C. Hold
the scheduled dose of Toprol and notify the healthcare provider
of the telemetry pattern.
5. A client who developed Syndrome of Inappropriate
Antidiuretic Hormone (SIADH) associated with small cell
carcinoma of the lung is preparing for discharge. When teaching
the client about self-management with demeclocycline
(Declomycin), the nurse should instruct the client to report
which condition to the healthcare provider?
A. Anxiety.
B. Insomnia.
C. Muscle cramping.
,D. Increased appetite Correct Answer C. Muscle cramping.
6. In determining the client position for insertion of an
indwelling urinary catheter, it is most important for the nurse to
recognize which client condition?
A. High urinary pH.
B. Fever.
C. Abdominal ascites.
D. Orthopnea. Correct Answer D. Orthopnea.
7. The nurse is reviewing a client's electrocardiogram and
determines that the PR interval (PRI) is prolonged. What does
this finding indicate?
A. Inability of the SA node to initiate an impulse at the normal
rate.
B. Initiation of the impulse from a location outside the SA node.
C. Increased conduction time from the SA node to the AV
junction.
D. Interference with the conduction through one or both
ventricles. Correct Answer C. Increased conduction time from
the SA node to the AV junction.
8. The nurse is teaching a male client with multiple sclerosis
how to empty his bladder using the Crede Method. When
performing a return demonstration, the client applies pressure to
the umbilical area of his abdomen. What instruction should the
nurse provide?
A. Stroke the inner thigh below the perineum to initiate urinary
flow.
B. Pour warm water over the external sphincter at the distal
glans.
, C. Apply downward manual pressure at the suprapubic region.
D. Contract, hold, and then relax the pubococcygeal muscle.
Correct Answer C. Apply downward manual pressure at the
suprapubic region.
9. A 35-year-old female client has just been admitted to the
postanesthesia recovery unit following a partial thyroidectomy.
Which statement reflects the nurse's accurate understanding of
the expected outcome for the client following this surgery?
A. Supplemental hormonal therapy will probably be
unnecessary.
B. The thyroid will regenerate to a normal size within a few
years.
C. The client will be restricted from eating seafood.
D. The remainder of the thyroid will be removed at a later date.
Correct Answer A. Supplemental hormonal therapy will
probably be unnecessary.
10. A client with gestational diabetes, at 39-weeks gestation, is
in the second stage of labor. After delivery of the fetal head, the
nurse recognizes that shoulder dystocia is occurring. What
intervention should the nurse implement first?
A. Lower the head of the bed and apply suprapubic pressure.
B. Encourage the client to move to a hands-and-knees position.
C. Prepare the client for an emergency cesarean birth.
D. Assist the client to sharply flex her thighs up against the
abdomen. Correct Answer D. Assist the client to sharply flex
her thighs up against the abdomen.
