246 HESI STUDY GUIDE QUESTIONS AND ANSWERS 100% CORRECT!!, Exams of Nursing

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246 HESI STUDY GUIDE QUESTIONS AND

ANSWERS 100% CORRECT!!

D. Shave all chest hair that may distort sounds heard through the diaphragm. - ANSWER - ANSWER- Correct answer is C. The nurse should listen to all lungs fields during assessment and move from side to side during auscultation

A client with streptococcus pharyngitis reports high fever, difficulty swallowing and a muffled voice. Which complication should the nurse suspect? A. Foreign body obstruction. B. Laryngeal polyps. C. Peritonsillar abscess. D. Nasal polyps. - ANSWER. - ANSWER- Correct answer is C. Since infections are associated with abscesses and pus

The nurse is obtaining a health history for a client prior to a scheduled cholecystectomy. While interviewing the client, which assessment technique should the nurse use when asking about the client's use of illegal drugs and alcohol? A. Obtain a drug using screen to verify legitimacy of client's stated history. B. Allow the client to decline answering social questions. C. Ask specifically about alcohol, marijuana, cocaine, heroin, and amounts. D. Use the term illegal or illicit to describe street drugs - ANSWER - ANSWER- Correct answer is C. When interviewing the patient, questions should be clear and specific

The nurse applies pressure over an area of the lower abdomen where the client reports pain. The client denies pain upon palpation, but reports pain when the pressure is released. What action should the nurse implement? A. Offer to administer a laxative prescribed for PRN use. B. Obtain a prescription to catheterize the client's bladder. C. Instruct the client in distraction and relation techniques. D. Notify the healthcare provider of the rebound tenderness - ANSWER - ANSWER- Correct answer is D. As this could be a sign of appendicitis

The nurse is assessing an ulcer on a client's lower extremity, which is likely the result of either venous or arterial insufficiency. Which assessment technique should the nurse use to differentiate the pathophysiology causing the ulcer? A. Measure the degree of join range of motion in the extremity. B. Compare the skin turgor of the client's upper and lower leg. C. Observe the specific location and appearance of the ulceration. D. Note any change in the color of the ulcer when the leg is moved - ANSWER - ANSWER-Correct answer is C. Location and appearance of the ulcer would give us the type (venous vs arterial) Venous: develop on the inner lower leg, shallow wounds that are large and irregular edges that slope, red with granular tissue, discoloration with

yellow slough present, shiny skin warm or scaly Arterial: occur most often on the foot, on the heels and around lateral malleolus, round shaped, well-defined edges, yellow, brown or black in color, skin pale and non granulating, deep but may also appear shallow in early stages, skin is thin, smooth, taut, and dry. Loss of hair on the leg is also common

The nurse is conducting a physical assessment of a young adult. Which information provides the best indication of the individual's nutritional status? A. Status of current appetite. B. A 24-hour diet history. C. History of a recent weight loss. D. Condition of hair, nails, and skin - ANSWER - ANSWER- Correct answer is D. Hair, nail, and skin are the most important reflection of nutritional status

The nurse is assessing a healthy adult male during an annual physical examination. The nurse auscultates the client's abdomen and hears gurgling sound every ten seconds. What action should the nurse take in response to this finding? A. Document this normal bowel sound activity in the record. B. Encourage increased consumption of fiber in the diet. C. Observe the next bowel movement for signs of bleeding. D. Report the hyperactivity to the healthcare provider. - ANSWER - ANSWER- Correct answer is A. Normal Bowel sound consist of clicks and gurgles and 5-30 per minute. An occasional borborygmus (loud prolonged gurgle) may be heard

In observing a client's face, which assessment finding requires the most immediate intervention by the nurse? A. Eyelids are matted and crusted. B. Cornea are jaundiced. C. Oral mucosa is cyanotic. D. Face is flushed and diaphoretic. - ANSWER - ANSWER- Answer is C. Blue lips occur when the skin on the lips takes on a bluish tint or color. This generally is due to either a lack of oxygen in the blood or to extremely cold temperatures.

While obtaining a health history, a male client tells the nurse that he sometimes experiences shortness of breath. The nurse determines that the client's respirators are regular and deep, and his respiratory rate is 14 breaths/minutes. What is the best nursing action? A. Ask the client to perform light exercise and observe the respiratory effect. B. Document "dyspnea on exertion" in the client's medical record. C. Ask the client to describe the episodes of dyspnea in more detail.

The nurse is assessing a female client who states that her hemorrhoids are inflamed and hurt constantly. Which intervention is best for the nurse to complete a focused assessment? A. Ask the client how long she has experienced discomfort related to hemorrhoids. B. Place the client in a standing position, leaning over the exam bed for inspection. C. Determine if the client uses any over-the-counter preparation for hemorrhoids. D. Position client in left lateral position to inspect perianal area for fissures or sacs. - ANSWER - ANSWER- Correct answer is D. A focused assessment collects relevant information pertaining to the current condition of the patient after a change or new symptom develops

The nurse is performing an initial assessment of a client who has an expressionless facial affect, slurred speech, and red conjunctivae. What question should the nurse ask first? "Have you A. Been depressed lately?" B. Had everything to eat in the last 24 hours?" C. Ever had problems with you blood sugar?" D. Been sleeping well?" - ANSWER - ANSWER- Correct answer is D. To rule out symptoms for lack of sleep, asking the client if he slept well would help determining why he has the presented symptoms

After checking a client's pupillary response to light, the practical nurse (PN) tells the nurse that the client's pupils are constricted with minimal response to light. Before verifying the PN's findings, which action should the nurse take? A. Brighten the light in the client's room. B. Assess the client's visual fields. C. Review the client's medication list. D. Administer PRN saline eye solution - ANSWER - ANSWER- Correct answer is B. PERRLA: Accommodation is the following step which refers to your eyes' ability to see things that are both close up and far away

The nurse completes inspection of the abdomen on an adult client. Which finding is considered normal for this client? A. Masses. B. Peristaltic waves. C. Heterogeneous color. D. Homogeneous color. - ANSWER - ANSWER- Correct answer is D. Symmetry is a great value of normal body imagine while performing inspection.

Which skill should the nurse have an older client demonstrate to evaluate performance of daily living activities? A. Opening a bar soap package. B. Sorting a collection of socks. C. Reading a short paragraph. D. Telephoning a family member - ANSWER - ANSWER- Correct answer is B. ADL is used as an indicator of a person's functional status.

A client sustained a subconjunctival hemorrhage. The presence of which set of symptoms indicate that the client needs to be seen for further evaluation by an ophthalmologist? A. Acute pain, change in visual acuity, and foreign body sensation. B. Frequent burning, irritation and tearing of the eyes. C. Bilateral itchy, red eyes with watery discharge D. Diminished ability to focus on close work and excessive illumination required - ANSWER - ANSWER- Correct answer is D. Diminished ability to focus on close work could be a sign of cranial nerve damage and could lead to reduced visual acuity, due to a reduced ability of the lens in the eye to focus light on the retina, results in images that appear blurry.

To assess a female client for hirsutism, which action should the nurse take? A. Lightly palpate over the client's entire scalp. B. Apply and release light pressure to the skin. C. Assess the appearance of the client's face. D. Observe the hair shafts on the client's scalp - ANSWER - ANSWER- Correct answer is C. Hirsutism is a condition in women that results in excessive growth of dark or coarse hair in a male-like pattern like face, chest and back

An older adult client is admitted to the medical unit because of loss of appetite and generalized malaise. To analyze the client medical condition, which laboratory value is most important for the nurse to review? A. Hematocrit. B. Serum Calcium. C. Hemoglobin. D. Serum pre-albumin - ANSWER - ANSWER- Correct answer is C. Hemoglobin is the main lab value to check for anemia. Anemia is a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues

C. Notify the healthcare provider. D. Use a doppler ultrasonic stethoscope - ANSWER - ANSWER- Correct answer is D. Doppler ultrasonic stethoscope is used when the nurse couldn't palpate a pedal pulse of a client

A homeless male client with a history of alcohol abuse had a cerebrovascular accident (CVA) 10 years ago that resulted in left hemiparesis. Today he is complaining of pain in his left leg, is afebrile, has 4+ pitting edema in the lower left leg, and minimal swelling of the right leg. Which action should the nurse implement first? A. Inspect legs for infection of trauma. B. Obtain a blood alcohol level. C. Complete a mental status exam. D. Inquire about dietary salt intake. - ANSWER - ANSWER- Correct answer is A. Since it is a single leg, the nurse has to rule out any trauma of infection especially the left side for the patient is awakened

The nurse is assessing a client for goiter and is unable to observe the thyroid gland. Which action should the nurse take? A. Defer the thyroid exam and observe the client for signs of myxedema. B. Document that thyroid gland size is normal with no visible goiter. C. Ask the client to swallow while palpating along the sides of the trachea. D. Palpate deeply and firmly over the location of the thyroid gland. - ANSWER - ANSWER-Correct answer is C. To palpate a client thyroid gland: Use one hand to slightly retract the sternocleidomastoid muscle while using the other to palpate the thyroid. Have the patient swallow a sip of water as you palpate, feeling for the upward movement of the thyroid gland

While completing an admission assessment for a client with gastrointestinal bleeding, the nurse inspects the perineal area and anus. Which findings indicates a normal appearance of the anus? A. Increased pigmentation and coarse skin. B. Flap of tissue at sphincter. C. Hypotonic tone of the anal sphincter. D. Dimpled area above anus. - ANSWER - ANSWER- Correct answer is A

Which focused assessment technique should the nurse use for a client admitted with possible dehydration? A. Press skin over a bony prominence. B. Grasp skin fold of the posterior forearm. C. Check hands for parchment-like appearance.

D. Measure the circumference of the calf - ANSWER - ANSWER- Correct answer is B. Skin turgor is assessed by first grasping a fold of skin on the back of the patient's hand.

The nurse begins a client's musculoskeletal assessment. While using the technique of inspection, the nurse assesses for which possible findings? (Select all that apply) A. Osteopenia. B. Kyphosis. C. Atrophy. D. Contracture. E. Crepitus. - ANSWER - ANSWER- Correct answers are B, C, and D

A client comes to the clinic due to shoulder discomfort and intermittent pain while swimming today. To assist normal range of motion (ROM) of the client's shoulder, which assessment techniques should the nurse ask the client to perform? A. Alternate both index fingers to tough the tip of nose accurately. B. Extend arms up to 180 degrees besides the ears. C. Extend arms straight out and hold without drifting. D. Hold arms up at 90 degree while arms are pushed downward - ANSWER - ANSWER-Correct answer is D

A client reports to the healthcare provider's office for a routine post-surgical evaluation six weeks after a hysterectomy. Which history-taking approach should the nurse use to gather the needed information? A. Conduct a comprehensive review of systems. B. Perform a head-to-toe physical assessment. C. Prepare to collect a vaginal specimen for Pap smear. D. Collect information about the client's activities since surgery - ANSWER - ANSWER-Correct answer is D

In assessing a male client's level of consciousness, the nurse determines that the client does not open his eyes spontaneously. What should the nurse do next? A. Notify the healthcare provider. B. Observe for eye opening to a painful stimulus. C. Check the pupillary response to light. D. Ask the client to open his eyes. - ANSWER - ANSWER- Correct answer is C

In assessing a client's sensory nerve function, the nurse prepares to assess the client's response to temperature. What action should the nurse include during this assessment? A. Darken the client's room environment. B. Cover the client with a warmed blanket.

While assessing the legs of a female client, the nurse observes leathery-looking skin. The client reports aching tired legs that swell if she stands for long periods of time. To screen for venous insufficiency, the nurse should ask the client if she has experienced which subject finding? A. Decreased pain when legs are elevated. B. Deep, continuous pain in the calf muscles. C. Cool, pale skin below the knees. D. Painful symptoms alleviated by warmth - ANSWER - ANSWER- Correct answer is A. Elevation of the legs decreases swelling and helps with blood flow

During an abdominal assessment, a client with a temperature of 103 F (39.4 C) experiences pain and abruptly stops inhaling during deep palpation. Which prescription is most important for the nurse to implement? A. Electrocardiogram. B. Complete bed rest. C. Monitor urinary output. D. Nothing by mouth. - ANSWER - ANSWER- Correct answer is D.

After placing a client in a supine position, the nurse uses the diaphragm of the stethoscope to auscultate bowel sounds and hears a loud, high pitched almost continuous gurgling in two quadrants. What action should the nurse implement? A. Use the bell of the stethoscope to auscultate again. B. Elevate the head of the client's bed immediately. C. Document the presence of borborygmi. D. Auscultate the remaining two quadrants - ANSWER - ANSWER- Correct answer is D. Full assessment of all parts of the lungs, side by side, should be performed before taking any other action or document the findings

To objectively confirm the presence of fever, before taking the client's temperature, which action should the nurse take? A. Ask the client to describe any other related symptoms. B. Use both hands to hold and palpate the client's hands. C. Lightly pinch a fold of skin over the client's sternum. D. Place the dorsum of the hand on the client's forehead - ANSWER - ANSWER- Correct answer is B

A male client who is admitted for an acute brain attack reports the onset of a burning sensation in his hands and legs. Which action should the nurse implement to identify additional findings that are consistent with the client's paresthesia? A. Evaluate client's muscle strength and hand grips.

B. Observe skin for erythema, edema, and warmth. C. Review the client's serum electrolytes. D. Check distal phalanges capillary refil - ANSWER - ANSWER- Correct answer is A.

A client is being evaluated for environmental allergies. While examining the client's nasal passage, which finding suggests to the nurse that the client is experiencing allergic rhinitis? A. Purulent secretions from eyes and nares. B. Eye tearing and thick yellow nasal drainage. C. Snoring and bilateral, pale gray nodules. D. Intranasal edema and swelling of turbinates - ANSWER - ANSWER- Correct answer is D.

To confirm the presence of a barrel chest documented in the client's medical record, which action should the nurse take? A. Observe the appearance of the thorax. B. Auscultate the client's breath sounds. C. Percuss diaphragmatic excursion. D. Palpate tactile fremitus on the posterior chest. - ANSWER - ANSWER- Correct answer is A. The chest takes on a barrel-like appearance called a "barrel chest."

When auscultating a client's lung sounds, the nurse hears rhonchi in the upper lung fields anteriorly. Which action should the nurse take first? A. Measure capillary refill. B. Ask the client to cough. C. Monitor oxygen saturation. D. Document the finding. - ANSWER - ANSWER- Correct answer is B. Many abnormal breath sounds are best heard after asking the patient to cough

During a health assessment, the client reports being treated for osteoarthritis. The nurse examines a client's hands and finds Heberden's nodes. Which finding should the nurse document in the client's medical record? A. Proximal intertarsal join swelling of big toe. B. Non-painful enlarged interphalangeal joints. C. Distal interphalangeal joint nodules that deviate. D. Frozen, non-movable phalangeal joints - ANSWER - ANSWER- Correct answer is C. Heberden nodes (hard or bony swellings in the distal interphalangeal joints) along with a deviated distal finger are a classic finding in osteoarthritis

The nurse prepares to begin a systematic assessment of a client's heart sounds. Upon positioning the stethoscope as seen in the picture what should the nurse do first? A. Identify S1 and S2 heart sounds. B. Change to the bell of the stethoscope. C. Move the stethoscope to the apical site. D. Listen for abnormal sounds - ANSWER - ANSWER- Correct answer is A. 1st assessment of hearts sounds is to identify S1 and S2 heart sounds. S1 is normally a single sound because mitral and tricuspid valve closure occurs almost simultaneously. Clinically, S1 corresponds to the pulse. The second heart sound (S2) represents closure of the semilunar (aortic and pulmonary) valves.

During assessment of a client's neck, the nurse prepares to assess for jugular vein distention (JVD) as seen in the picture. What should the nurse do next? A. Listen to swishing sound during systole. B. Use the bell of the stethoscope to auscultate. C. Remove the stethoscope to observe the site. D. Palpate the site of erythema and tenderness. - ANSWER - ANSWER- Correct answer is C

What is gamma globulin and when is it used? - ANSWER - ANSWER- Gamma globulin, which is an immune globulin, contains most of the antibodies circulating in the blood. When injected into an individual, it prevents a specific antigen from entering a host cell. So the antigen is neutralized by the antibodies gamma globulin supplies. Used when a pt is exposed to Hep A

A nurse is obtaining a health history from the newly admitted client who has chronic pain in the knee. What should the nurse include in the pain assessment? Select all that apply.

1. Pain history, including location, intensity, and quality of pain
2. Client's purposeful body movement in arranging the papers on the bedside table
3. Pain pattern, including precipitating and alleviating factors
4. Vital signs, such as increased blood pressure and heart rate
5. The client's family statement about increases in pain with ambulation - ANSWER - ANSWER- 1 & 3

While assessing a client's skin, a nurse notices that the skin is dry. What is the probable etiology of the condition? Select all that apply - ANSWER - ANSWER- The use of hard soap and frequent bathing may result in dry skin. A skin allergy may result in skin rashes, but not dry skin. Using tanning pills and petroleum products may result in skin cancer.

The community nurse is assessing an elderly client who lives alone at home. the client refrains from physical activity for fear of falling when walking. Which interventions by the nurse are most beneficial to promote a healthy lifestyle? - ANSWER -ANSWER- Encourage the client to wear nonskid shoes. Suggest that the client use an assistive device. Help the client rearrange furniture in the house

Which features distinguish nursing diagnoses from medical diagnoses? Select all that apply 1 Nursing diagnoses involve the client when possible. 2 Nursing diagnoses are based on results of diagnostic tests and procedures. 3 Nursing diagnoses are the identification of a disease condition in the client. 4 Nursing diagnoses involve the sorting of health problems within the nursing domain. 5 Nursing diagnoses involve clinical judgment about the client's response to health problems - ANSWER - ANSWER- 1. Nursing diagnoses involve (client participation) the client when possible. 4. Nursing diagnoses involve the sorting of health problems within the nursing domain. 5.Nursing diagnoses involve clinical judgment about the client's response to health problems.

A 50-year-old client with a 30-year history of smoking reports a chronic cough and shortness of breath related to chronic obstructive pulmonary disease (COPD). The clinical data on admission are as follows: a heart rate of 100, a blood pressure of 138/82, a respiratory rate of 32, a tympanic temperature 36.8 °C, and an oxygen saturation of 80%. Which vital signs obtained by the nurse during the therapy indicates a positive outcome? Select all that apply. A. Radial pulse: 70 B. Temperature: 37 °C C. Respiratory rate: 14 D. Blood pressure: 110/ E. Oxygen saturation: 96% - ANSWER - ANSWER- C, D, E

Which client is at an increased risk for right-sided heart failure? Client A: R Jugular Venous Pressure: 2.5 cm L Jugular Venous Pressure: 3.0 cm Client B: RJVP = 2.0 LJVP = 1. Client C: RJVP = 1.5 LJVP = 1.0 - ANSWER - ANSWER- Client A

What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? Select all that apply. A. Tetany B. Seizures

color, due to an increased amount of deoxygenated hemoglobin, which may be due to heart or lung disease.

The nurse is assessing a client who reports breathlessness. Which activity best ensures that the nurse obtains accurate and complete data to prevent a nursing diagnostic error? A. Assess the client's lungs. B. Assess the client for pain. C. Obtain details of smoking habits. D. Ask about the onset of breathlessness. - ANSWER - ANSWER- A. The nurse should assess the client's lungs to gather objective data that will support subjective data provided by the client.

What causes false low diastolic readings? - ANSWER - ANSWER- poor fitting cuff deflating cuff too quickly, applying the stethoscope too firmly against the antecubital fossa

What causes false low systolic readings? - ANSWER - ANSWER- inflating the cuff inadequately, too big of a blood pressure cuff

What causes false high systolic readings? - ANSWER - ANSWER- too small of a bp cuff

What type of interview is most appropriate when a nurse admits a client to a clinic? A. Directive B. Exploratory C. Problem solving D. Information giving - ANSWER - ANSWER- A. The first step in the problem-solving process is data collection so that client needs can be identified. During the initial interview a direct approach obtains specific information, such as allergies, current medications, and health history

After recovery from a modified neck dissection for oropharyngeal cancer, the client receives external radiation to the operative site. For which most critical reaction to the radiation should the nurse assess the client? A. Dry mouth B. Skin reactions C. Mucosal edema D. Bone marrow suppression - ANSWER - ANSWER- C

A nurse is caring for an older adult with a hearing loss secondary to aging. What can the nurse expect to identify when assessing this client? Select all that apply. A. Dry cerumen B. Tears in the tympanic membrane C. Difficulty hearing high pitched voices D. Decrease of hair in the auditory canal E. Overgrowth of the epithelial auditory lining - ANSWER -ANSWER- A, C

A senior high school student, whose immunization status is current, asks the school nurse which immunizations will be included in the precollege physical. Which vaccine should the nurse tell the student to expect to receive? A. Hepatitis C (HepC) B. Influenza type B (HIB) C. Measles, mumps, rubella (MMR) D. Diphtheria, tetanus, pertussis (DTaP) - ANSWER -ANSWER- C

A client with severe bleeding due to a motor vehicle accident was admitted to the emergency department. The nurse assessed that the client was unconscious and the healthcare provider diagnosed the client with a hand fracture. The client is receiving oxygen therapy as well as intravenous fluids through the antecubital fossa. Which sites should be used to obtain the client's pulse rate? Select all that apply. A. Apical B. Carotid C. Brachial D. Femoral E. Popliteal - ANSWER -ANSWER- B, D

A nurse is teaching a client about different prevention and detection practices to ensure breast health. Which statement made by the client indicates the need for further teaching? A. "I will increase my meat consumption." B. "I will perform a self-breast examination every week." C. "I will schedule routine mammograms." D. "I will reduce my caffeine and theophylline intake." - ANSWER -ANSWER- A

The triage nurse in the emergency department receives four clients simultaneously. Which of the clients should the nurse determine can be treated last? A. Multipara in active labor B. Middle-aged woman with substernal chest pain C. Older adult male with a partially amputated finger