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HESI LEVEL 1 PRACTICE EXAM Question and Answers 202 5 The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take? A. Infuse normal saline at a keep vein open rate. B. Discontinue the IV and flush the port with heparin. C. Infuse 10% dextrose and water at 54 ml/hour. D. Obtain a stat blood glucose level and notify the healthcare provider. - ✔C A crying toddler has a blood pressure measurement of 120/70 mm Hg. What action should the nurse implement? A. Notify the healthcare provider of the measurement. B. Quiet the child and retake the blood pressure. C. Ask the parent if the child has a history of hypertension. D. Document the finding and recheck in 4 hours. - ✔B The mother of a neonate asks the nurse why it is so important to keep the infant warm. What information should the nurse provide? A. The kidneys and renal function are not fully developed. B. Warmth promotes sleep so the infant will grow quickly. C. A large body surface area favors heat loss to the environment. D. The thick layer of subcutaneous fat is inadequate for insulation. - ✔C
What action by the nurse demonstrates culturally sensitive care? A. Asks permission before touching a client. B. Avoids questions about male-female relationships. C. Explains the differences between Western medical care and cultural folk remedies. D. Applies knowledge of a cultural group unless a client embraces Western customs. - ✔A A client has a nursing diagnosis of, "Spiritual distress related to a loss of hope, secondary to impending death." What intervention is best for the nurse to implement when caring for this client? A. Help the client to accept the final stage of life. B. Assist and support the client in establishing short-term goals. C. Encourage the client to make future plans, even if they are unrealistic. D. Instruct the client's family to focus on positive aspects of the client's life.
- ✔B A client who is 5 foot 5 inches tall and weighs 200 pounds is scheduled for surgery the next day. Which question is most important for the nurse to include during the preoperative assessment? A. "What is your daily calorie consumption?" B. "What vitamin and mineral supplements do you take?" C. "Do you feel that you are overweight?" D. "Will a clear liquid diet be okay after surgery?" - ✔B
C. Document the care plan goals that were successfully met. D. Prioritize interventions to be added to the client's plan of care. - ✔A A female client asks the nurse to find someone who can translate her treatment concerns into her native language. Which action should the nurse take? A. Explain that anyone who speaks her language can answer her questions. B. Provide a translator only in an emergency situation. C. Ask a family member or friend of the client to translate. D. Request and document the name of the certified translator. - ✔D An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP? A. Position the client on the right side of the bed in reverse Trendelenburg. B. Fill the enema container with 1000 mL of warm water and 5 mL of castile soap. C. Reposition in a Sims' position with the client's weight on the anterior ilium. D. Raise the side rails on both sides of the bed and elevate the bed to waist level. - ✔C A child with a penetrating eye injury comes to the school clinic. What action should the nurse implement? A. Remove the object impaled in the eye and then apply a regular eye patch.
B. Place an ice bag over the eye until the healthcare provider is seen. C. Irrigate the affected eye copiously with a cool sterile saline solution. D. Apply a Fox shield to the affected eye and any type of patch to the other eye. - ✔D When making the bed of a client who needs a bed cradle, which action should the nurse include? A. Teach the client to call for help before getting out of bed. B. Keep both the upper and lower side rails in a raised position. C. Keep the bed in the lowest position while changing the sheets. D. Drape the top sheet and covers loosely over the bed cradle. - ✔D A male client with venous incompetence stands up and his blood pressure subsequently drops. Which finding should the nurse identify as a compensatory response? A. Bradycardia. B. Increase in pulse rate. C. Peripheral vasodilation. D. Increase in cardiac output. - ✔B When assessing a preschooler, which finding warrants further assessment by the nurse? A. Able to ride a tricycle. B. Talks about an imaginary friend. C. Dresses independently.
C. Remove the container cap and lay it with the inside facing down on the sterile field. D. Hold the container high and pour the solution into a receptacle at the back of the sterile field. - ✔B What is the best action for the nurse to take when initiating contact with a toddler for the first time? A. Ask the toddler to point to where it hurts. B. Tell the child your name and that you are the nurse. C. Call the child by name while picking up the toddler. D. Kneel in front of the toddler and speak softly to the child. - ✔D A single mother of two teenagers, ages 16 and 18, was just told that she has advanced cancer. She is devastated by the news, and expresses her concern about who will care for her children. Which statement by the nurse is likely to be most helpful at this time? A. "Your children are old enough to help you make decisions about their futures." B. "The social worker can tell you about placement alternatives for your children." C. "Tell me what you would like to see happen with your children in the future." D. "You have just received bad news, and you need some time to adjust to it." - ✔C
During the admission interview, which technique is most efficient for the nurse to use when obtaining information about signs and symptoms of a client's primary health problem? A. Restatement of responses. B. Open-ended questions. C. Closed-ended questions. D. Problem-seeking responses. - ✔C The nurse is providing passive range of motion (ROM) exercises to the hip and knee for a client who is unconscious. After supporting the client's knee with one hand, what action should the nurse take next? A. Raise the bed to a comfortable working level. B. Bend the client's knee. C. Move the knee toward the chest as far as it will go. D. Cradle the client's heel. - ✔D The nurse should instruct a client to avoid which product while taking carisoprodol (Soma) for muscle spasms? A. Aspirin products. B. Antacids. C. Alcoholic beverages. D. Dairy products. - ✔C
D. Grains and legume combinations used by the client. - ✔B An older client who is a resident in a long term care facility has been bedridden for a week. Which finding should the nurse identify as a client risk factor for pressure ulcers? A. Generalized dry skin. B. Localized dry skin on lower extremities. C. Red flush over entire skin surface. D. Rashes in the axillary, groin, and skin fold regions. - ✔D A 6-year-old squirms and giggles when the nurse begins to palpate the abdomen. What action should the nurse implement? A. Postpone the abdominal palpation until the next examination. B. Place the child's hand under the examiner's hand while palpating. C. Touch the abdomen firmly as the child takes short, quick breaths. D. Press the abdomen with the child bearing down and holding the breath. - ✔B An older client with a d ecreased percentage of lean body mass is likely to receive a prescription that is adjusted based on which pharmacokinetic process? A. Absorption. B. Metabolism. C. Elimination. D. Distribution - ✔D
What is the correct procedure for performing an opthalmoscopic examination on a client's right retina? A. Instruct the client to look at examiner's nose and not move his/her eyes during the exam. B. Set ophthalmoscope on the plus 2 to 3 lens and hold it in front of the examiner's right eye. C. From a distance of 12 to 15 inches and slightly to the side, shine the light into the client's pupil. D. For optimum visualization, keep the ophthalmoscope at least 3 inches from the client's eye. - ✔C A middle-aged woman who enjoys being a teacher and mentor feels that she should pass down her legacy of knowledge and skills to the younger generation. According to Erikson, she is involved in what developmental stage? A. Generativity. B. Ego integrity. C. Identification. D. Valuing wisdom. - ✔A A 17-year-old male student reports to the school clinic one morning for a scheduled health exam. He tells the nurse that he just finished football practice and is on his way to class. The nurse assesses his vital signs: temperature 100 F, pulse 80, respirations 20, and blood pressure 122/82. What is the best action for the nurse to take?
A. Respiratory rate. B. Wound location. C. Pedal pulses. D. Pain rating. - ✔A The nurse receives a unit of blood from the blood bank for a postoperative client who is currently in the X-ray department. What action should the nurse implement? A. Return the blood to the blood bank for refrigeration within 30 minutes. B. Hang the blood transfusion as soon as the client returns to the unit. C. Store the blood bag in the nursing unit's refrigerator until the client returns. D. Take the unit of blood to the X-ray department to initiate the transfusion. - ✔A To assess the effectiveness of an analgesic administered to a 4-year-old, what intervention is best for the nurse to implement? A. Use a happy-face/sad-face pain scale. B. Ask the mother if she thinks the analgesic is working. C. Assess for changes in the child's vital signs. D. Teach the child to point to a numeric pain scale - ✔A The nurse is using a genogram while conducting a client's health assessment and past medical history. What information should the genogram provide? A. Inherited familial health disorders. B. Chronic health problems.
C. Reason for seeking health care. D. Undetected disorders. - ✔A The nurse is discussing dietary preferences with a client who adheres to a vegan diet. Which dietary supplement should the nurse encourage the client to include in the dietary plan? A. Fiber. B. Folate. C. Ascorbic acid. D. Vitamin B12. - ✔D An older client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings through a gastrostomy tube (GT). What is the best position for the client for administration of the bolus tube feedings? A. Prone. B. Fowler's. C. Sims'. D. Supine. - ✔B Which topic should the nurse include in planning a secondary prevention project for the local retirement community? A. Safety measures in the home. B. Adult immunization program. C. Rehabilitation after surgery.
C. Conduct mandatory HIV testing of those who work with AIDS clients. D. Freeze HIV blood specimens at - 70 F to kill the virus. - ✔B The nurse hears short, high-pitched sounds just before the end of inspiration in the right and left lower lobes when auscultating a client's lungs. How should this finding be recorded? A. Inspiratory wheezes in both lungs. B. Crackles in the right and left lower lobes. C. Abnormal lung sounds in the bases of both lungs. D. Pleural friction rub in the right and left lower lobes. - ✔B A male nurse is assigned to care for a female Muslim client. When the nurse offers to bathe the client, the client requests that a female nurse perform this task. How should the male nurse respond? A. "May I ask your daughter to help you with your personal hygiene?" B. "I will ask one of the female nurses to bathe you." C. "A staff member on the next shift will help you." D. "I will keep you draped and hand you the supplies as you need them." - ✔B How should the nurse measure the length of a 14-month-old child? A. Standing height. B. Prone recumbent position. C. Supine recumbent position. D. Side-lying position. - ✔C
When providing discharge teaching for a client with osteoporosis, the nurse should reinforce which home care activity? A. A diet low in phosphates. B. Skin inspection for bruising. C. Exercise regimen, including swimming. D. Elimination of hazards to home safety. - ✔D A client's IV infusion of 0.9% Sodium Chloride (normal saline) infiltrated earlier today, and approximately 500 ml of normal saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding "stronger pain medications." What action is most important for the nurse to take? A. Ask about any past history of drug abuse or addiction. B. Measure the pulse volume and capillary refill distal to the infiltration. C. Compress the infiltrated tissue to measure the degree of edema. D. Evaluate the extent of ecchymosis over the forearm area. - ✔B A resident in a skilled nursing facility for short-term rehabilitation after a hip replacement tells the nurse, "I don't want any more blood taken for those useless tests." Which narrative documentation should the nurse enter in the client's medical record? A. Healthcare provider notified of failure to collect specimens for prescribed blood studies. B. Blood specimens not collected because client no longer wants blood tests performed.
A. Compress the flank and upper buttocks. B. Measure the client's abdominal girth. C. Gently palpate the lower abdomen. D. Apply light pressure over the shins. - ✔A A client with chronic gouty arthritis takes allopurinol (Zyloprim) and experiences an acute attack of gouty arthritis. The healthcare provider prescribes concurrent low-dose colchicine. What information should the nurse provide the client that best explains the action of the colchicine? A. Acts like aspirin to relieve pain. B. Facilitates the excretion of uric acid. C. Reduces inflammation at the affected site. D. Prevents formation of uric acid crystals. - ✔C A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs? A. Autopsy of the body is prohibited. B. Blood transfusions are forbidden. C. Alcohol use in any form is not allowed. D. A vegetarian diet must be followed. - ✔B A client asks the nurse to explain the meaning of a narrow therapeutic index of a medication. What information should the nurse use to answer the question?
A. The onset of action for the medication occurs very quickly. B. A small margin exists between safe and toxic plasma levels. C. Bioavailability is significantly reduced by the first-pass effect. D. Minimum dosage is needed for the medication to be effective. - ✔B A male client with severe orthopedic injuries following a motor vehicle collision is irritable, angry, and belittles the nurses. While a nurse is changing the dressing over a laceration, the client screams, "Don't touch me! You're so stupid that you'll make it worse!" Which intervention is best for the nurse to implement? A. Leave the room without saying a word. B. Provide information about infection prevention. C. Allow the client to change the dressing himself. D. Explain the healthcare provider's prescription. - ✔B During CPR, when attempting to ventilate a client's lungs, the nurse notes that the chest is not moving. What action should the nurse take first? A. Use a laryngoscope to check for a foreign body lodged in the esophagus. B. Reposition the head to validate that the head is in the proper position to open the airway. C. Turn the client to the side and administer three back blows. D. Perform a finger sweep of the mouth to remove any vomitus. - ✔B What action should the nurse implement to prevent the formation of a sacral ulcer for a client who is immobile?
