NURSE 241 HESI PRACTICE TEST QUESTIONS AND ANSWERS 100% CORRECT!!, Exams of Nursing

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NURSE 241 HESI PRACTICE TEST QUESTIONS

AND ANSWERS 100% CORRECT!!

The nurse is examining a male client who reports itching on his right arm. The nurse observes a rash made up of multiple flat areas of redness ranging from pinpoint to 0. cm in diameter. How should the nurse record this finding?

a. Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm. b. Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter. c. Several areas of red, papular lesions from pinpoint to 0.5 cm in size. d. Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter. - ANSWER b Macules are localized flat skin discolorations less than 1 cm in diameter. However, when recording such a finding the nurse should describe the appearance rather than simply naming the condition.

After completing an assessment and determining that a client has a problem, which action should the nurse perform next?

a. Determine the etiology of the problem. b. Prioritize nursing care interventions. c. Plan appropriate interventions. d. Collaborate with the client to set goals. - ANSWER a Before planning care, the nurse should determine the etiology, or cause, of the problem, because this will help determine goals, plan of care, and priorities of interventions.

The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein? a. A college-age track runner with a sprained ankle. b. A lactating woman nursing her 3-day-old infant. c. A school-aged child with Type 2 diabetes. d. An elderly man being treated for a peptic ulcer. - ANSWER b A lactating woman has the greatest need for additional protein intake due to the increased metabolic protein demands of lactation.

A young mother of three children complains of increased anxiety during her annual physical exam. Which information should the nurse obtain first? a. Sexual activity patterns. b. Nutritional history. c. Leisure activities.

The nurse is administering medications through a nasogastric tube (NGT) which is connected to suction. After ensuring correct tube placement, which action should the nurse take next? a. Clamp the tube for 20 minutes. b. Flush the tube with water. c. Administer the medications as prescribed. d. Crush the tablets and dissolve them in sterile water - ANSWER b The NGT should be flushed before, after, and in between each medication administered.

A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. Which action is best for the nurse to take?

a. Record the coughing incident. No further action is required at this time. b. Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider. c. After clearing the tube with 30 ml of air, check the pH of the fluid withdrawn from the tube. d. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling. - ANSWER c Coughing, vomiting, and suctioning can precipitate displacement of the tip of the small bore feeding tube upward into the esophagus, placing the client at increased risk for aspiration. Checking the sample of fluid withdrawn from the tube (after clearing the tube with 30 mL of air) for acidic (stomach) or alkaline (intestine) values is a more sensitive method for these tubes, and the nurse should assess tube placement in this way prior to taking any other action. The auscultating method has been found to be unreliable for small-bore feeding tubes.

The nurse assigns an unlicensed assistive personnel (UAP) to obtain vital signs from a very anxious client. Which instructions should the nurse give the UAP? a. Remain calm with the client and record abnormal results in the chart. b. Notify the medication nurse immediately if the pulse or blood pressure is low. c. Report the results of the vital signs to the nurse. d. Reassure the client that the vital signs are normal. - ANSWER c Interpretation of vital signs is the responsibility of the nurse, so the unlicensed assistive personnel (UAP) should report vital sign measurements to the nurse. Any instructions requiring the UAP to interpret the vital signs causes the UAP to function beyond the scope of the UAP's authority.

At the beginning of the shift, the nurse assesses a client who is admitted from the postanesthesia care unit (PACU). When should the nurse document the client's findings? a. At the beginning, middle, and end of the shift. b. After client priorities are identified for the development of the nursing care plan. c. At the end of the shift, so full attention can be given to the client's needs. d. Immediately after the assessments are completed. - ANSWER d Documentation of client findings should occur immediately after any component of the nursing process, so assessments should be entered in the client's medical record as readily as findings are obtained.

A client's spouse is learning passive range of motion for the client's contracted shoulder. The nurse observes that the spouse is holding the client's arm above and below the elbow. Which nursing action should the nurse implement? a. Acknowledge that the spouse is supporting the arm correctly. b. Encourage the spouse to keep the joint covered to maintain warmth. c. Reinforce the need to grip directly under the joint for better support. d. Instruct the spouse to grip directly over the joint for better motion. - ANSWER a The client's spouse is correctly holding the arm above and below the elbow to perform passive range-of-motion to the contracted shoulder. The nurse should acknowledge this fact. The joint that is being exercised should be uncovered while the rest of the body should remain covered for warmth and privacy.

Which snack food is best for the nurse to provide a client with myasthenia gravis who is at risk for altered nutritional status? a. Chocolate pudding. b. Graham crackers. c. Sugar-free gelatin. d. Apple slices. - ANSWER a The client with myasthenia gravis is at high risk for altered nutrition because of fatigue and muscle weakness resulting in dysphagia. Snacks that are semisolid, such as pudding are easy to swallow and require minimal chewing effort and provide calories and protein.

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 the entire skin surface. d. Rashes in the axillary, groin, and skin fold regions. - ANSWER d

The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. Which action should the nurse implement next?

a. Encourage the client to cough to help loosen secretions. b. Advise the client to increase the intake of oral fluids. c. Rotate the suction catheter to obtain any remaining secretions. d. Reoxygenate the client before attempting to suction again. - ANSWER d Nasotracheal suctioning should not be continued for longer than ten to fifteen seconds, since the client's oxygenation is compromised during this time. Additional suctioning may continue after the client has received oxygen.

A client who has a sinus infection is recieving a prescription for amoxicillin/clavulanate potassium 500 mg PO every 8 hours. The available form is 250 mg amoxicillin/125 mg clavulanate tablets. How many tablets should the nurse administer for each dose? (Enter numeric value only.) - ANSWER 2 Using desired/available formula: 500 mg / 250 mg × 1 tablet = 2 tablets

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. - ANSWER c Lay descriptors of health problems can be vague and nonspecific. To efficiently obtain specific information, the nurse should use closed-ended questions that focus on common signs and symptoms of a client's health problem.

A male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead. Which should be the nurse's first response?

a. "It is important that you continue your medication while learning to meditate." b. "Spiritual meditation requires a time commitment of 15 to 20 minutes daily." c. "Obtain your healthcare provider's permission before starting meditation." d. "Complementary therapy and western medicine can be effective for you." - ANSWER a The prolonged practice of meditation may lead to a reduced need for antihypertensive medications. However, the medications must be continued while the physiologic

response to meditation is monitored. The healthcare provider should be informed, but permission is not required to meditate. Although it is true that this complementary therapy might be effective, it is essential that the client continues with antihypertensive medications until the effect of meditation can be measured.

The nurse witnesses the signature of a client who has signed an informed consent. Which statement best explains this nursing responsibility? a. The client voluntarily signed the form. b. The client fully understands the procedure. c. The client agrees with the procedure to be done. d.The client authorizes continued treatment. - ANSWER a The nurse signs the consent form to witness that the client voluntarily signs the consent, that the client's signature is authentic, and that the client is otherwise competent to give consent.

A client with pericardial effusion has phrenic nerve compression resulting in recurrent hiccups. The healthcare provider prescribes metoclopramide liquid 10 mg PO q6 hours. Metoclopramide is available as 5 mg/5mL. A measuring device marked in teaspoons is being used. How many teaspoons should the nurse administer? - ANSWER 2 First, using the formula Desired dose / Dose on hand × Quantity of volume on hand (D/H × Q), 10 mg / 5 mg × 5 mL. Next, using the known conversion of 5 mL = 1 tsp : 5 mL : 1 tsp :: 10 mL : x 5 / 10 : 1 / x 5x = 10x = 2

A client who is in hospice care reports increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement? a. Give an around-the-clock schedule for the administration of analgesics. b. Administer analgesic medication as needed when the pain is severe. c. Provide medication to keep the client sedated and unaware of stimuli. d. Offer a medication-free period so that the client can do daily activities. - ANSWER a The most effective management of pain is achieved using an around-the-clock schedule that provides analgesic medications on a regular basis and in a timely manner. Analgesic medication should be administered before the client's pain peaks. Providing comfort is a priority for the client who is dying.

During shift change report, the nurse receives reports that a client has abnormal heart sounds. Which placement of the stethoscope should the nurse use to hear the client's heart sounds? a. Place the stethoscope bell at random points on the posterior chest. b. Use the stethoscope bell over the valvular areas of the anterior chest.

c. Suggest that the client also select orange juice, to promote absorption. d. Encourage the client to attend classes on dietary management of CKD. - ANSWER a Foods such as eggs and milk are high in biologic proteins which are allowed because they are complete proteins and supply the essential amino acids that are necessary for growth and cell repair.

A client with multiple sclerosis is prescribed dantrolene 0.1 gram PO bid for spasticity. Dantrolene is available in 100 mg capsules. How many capsules should the nurse administer? (Enter numeric value only.) - ANSWER 1 Using the conversion of 1 gram = 1,000 mg : 0.1 gram = 100 mg / 100 mg = 1 capsule

A client with type 2 diabetes is receiving metformin 1 gram PO twice daily. The medication is available in 500 mg tablets. How many tablets should the nurse administer? (Enter numeric value only.) - ANSWER 2 Using the known equivalent, 1 gram = 1,000 mg, the nurse should first convert the dose to the same unit of measurement, which is 1 gram = 1,000 mg. Using the formula D/H × Q, 1,000 mg / 500 mg × 1 = 2 tablets.

An unlicensed assistive personnel (UAP) places a client in a right 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 1,000 mL of warm water and 5 mL of castile soap. c. Reposition in a modified left lateral recumbent 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. - ANSWER c The modified left lateral recumbent position allows the enema solution to follow the anatomical course of the intestines and allows the best overall results, so the UAP should reposition the client in the modified left lateral recumbent position, which distributes the client's weight to the anterior ilium.

An older resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. Which action should the nurse implement first? a. Reaffirm the client's desire for no resuscitative efforts. b. Transfer the client to a hospice inpatient facility. c. Prepare the family for the client's impending death. d. Notify the healthcare provider of the family's request. - ANSWER d

When a family requests hospice care, the nurse should first communicate with the healthcare provider. Hospice care is provided for clients with a limited life expectancy, which must be identified by the healthcare provider. Once the healthcare provider supports the transfer to hospice care, the nurse can collaborate with the hospice staff and healthcare provider to determine what additional care should be implemented.

On admission, a client presents a signed living will that includes a Do Not Resuscitate (DNR) prescription. When the client stops breathing, the nurse performs cardiopulmonary resuscitation (CPR) and successfully revives the client. Which crime could the nurse potentially be charged with? a. Assault. b. Battery. c. Malpractice. d. False imprisonment. - ANSWER b Civil laws protect individual rights and include intentional torts, such as assault (an intentional threat to engage in harmful contact with another) or battery (unwanted touching). Performing any procedure against the client's wishes can potentially pose a legal issue, such as battery, even if the procedure is of questionable benefit to the client.

The nurse notices that the mother of a 9-year-old Asian child always looks at the floor when she talks to the nurse. Which action should the nurse take? a. Talk directly to the child instead of the mother. b. Continue asking the mother questions about the child. c. Ask another nurse to interview the mother now. d. Tell the mother politely to look at you when answering. - ANSWER b Eye contact is a culturally-influenced form of nonverbal communication. In some non-Western cultures, such as the Asian culture, a client or family member may avoid eye contact as a form of respect, so the nurse should continue to ask the mother questions about the child.

blankSecobarbital 150 mg is prescribed at bedtime for a male client who is scheduled for surgery in the morning. The scored tablets are labled 0.1 gram/tablet. How many tablets should the nurse administer? (Enter the numerical value only. If rounding is required, round to the nearest tenth. - ANSWER 1. 1,000 mg : 1 gram :: 0.1 gram X = 100 mg D/H = 150/100 = 1.5 tablets

A female client asks the nurse to find someone who can translate into her native language her concerns about treatment. 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.

Dark amber urine is characteristic of fluid volume deficit, and the client should be encouraged to increase fluid intake.

What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? a. It is more difficult to find a superficial vein in the feet and ankles. b. A decreased flow rate could result in the formation of thrombosis. c. A cannulated extremity is more difficult to move when the leg or foot is used. d. Veins are located deep in the feet and ankles, resulting in a more painful procedure. - ANSWER b Venous return is usually better in the upper extremities. Cannulation of the veins in the lower extremities increases the risk of thrombus formation, which, if dislodged, could be life-threatening.

An older client with a fractured left hip is on strict bed rest. Which nursing measure is essential to the client's nursing care? a. Massage any reddened areas for at least five minutes. b. Encourage active range of motion exercises on extremities. c. Position the client laterally, prone, and dorsally in sequence. d. Gently lift the client when moving into a desired position. - ANSWER d

At the time of the first dressing change, the client refuses to look at her mastectomy incision. The nurse tells the client that the incision is healing well, but the client refuses to talk about it. Which is the best response to this client's silence? a. "It is normal to feel angry and depressed, but the sooner you deal with this surgery, the better you will feel." b. "Looking at your incision can be frightening, but facing this fear is a necessary part of your recovery." c. "It is OK if you don't want to talk about your surgery. I will be available when you are ready." d. "I will ask a woman who has had a mastectomy to come by and share her experiences with you." - ANSWER c

When a client is reluctant to look at a surgical wound or refuses to talk about the surgery, the nurse should reflect that these feelings are OK and that the nurse is available when the client is ready. Such a response displays sensitivity and understanding without judging the client. On the other hand, telling a client how she should feel is judgmental and insensitive.

When evaluating a client's plan of care, the nurse determines that a desired outcome was not achieved. Which action should the nurse implement first? a. Establish a new nursing problem. b. Note which actions were not implemented. c. Add additional nursing orders to the plan. d. Collaborate with the healthcare provider to make changes. - ANSWER b First, the nurse should review which actions in the original plan were not implemented in order to determine why the original plan did not produce the desired outcome. Appropriate revisions can then be made, which may include revising the expected outcome or identifying a new nursing problem.

The nurse observes that a male client has removed the covering from an ice pack applied to his knee. Which action should the nurse take first? a. Observe the appearance of the skin under the ice pack. b. Instruct the client regarding the need for the covering. c. Reapply the covering after filling it with fresh ice. d. Ask the client how long the ice was applied to the skin. - ANSWER a The client has been using an ice pack without the protective covering. The first action the nurse should take is to assess the skin for any possible thermal injury. If no injury to the skin has occurred, the nurse can then explain the need for a cover and reapply the ice pack with the cover in place.

The nurse plans to obtain health assessment information from a primary source. Which option is a primary source for the completion of the health assessment? a. Client. b. Healthcare provider. c. A family member. d. Previous medical records. - ANSWER a

A male client with obesity discusses with the nurse his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide?

a. "Be sure to have a complete physical examination before beginning your planned exercise program." b. "Be careful that the exercise program doesn't simply add to your stress level, making you want to eat more."

The nurse is assessing a client's genetic medical history while conducting a client's health assessment and past medical history. Which information does genetic history provide? a. Inherited familial health disorders. b. Chronic health problems. c. Reason for seeking health care. d. Undetected disorders. - ANSWER a

A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse document that is most accurate? a. Demonstrates loss of remote memory. b. Exhibits expressive dysphasia. c. Has a diminished attention span. d. Is disoriented to place and time. - ANSWER d The client is exhibiting disorientation. Loss of remote memory refers to the memory of the distant past. The client is able to express himself without difficulty and does not demonstrate a diminished attention span.

The unlicensed assistive personnel (UAP) working on a chronic neuro unit asks the nurse to help determine the safest way to transfer an older client with left-sided weakness from the bed to the chair. Which method describes the correct transfer procedure for this client?

a. Place the chair at a right angle to the bed on the client's left side before moving. b. Assist the client to a standing position, then place the right hand on the armrest. c. Have the client place the left foot next to the chair and pivot to the left before sitting. d. Move the chair parallel to the right side of the bed, and stand the client on the right foot. - ANSWER d When positioning a client for transfer from bed to a chair when the client has a left-sided weakness, use the client's stronger side, the right side, for weight-bearing during the transfer. In this case, the client should stand on the right foot during the transfer.

Which assessment data provides the most accurate determination of the proper placement of a nasogastric tube? a. Aspirating gastric contents to assure a pH value of 4 or less. b. Hearing air pass in the stomach after injecting air into the tubing. c. Examining a chest x-ray obtained after the tubing was inserted. d. Checking the remaining length of the tubing to ensure that the correct length was inserted. - ANSWER c

Assessing the pH of gastric contents and listening for air in the stomach are both methods used to determine the proper placement of the nasogastric tube. However, the best indicator that the tube is properly placed is confirming with a chest x-ray.

The nurse is developing a plan of care for a client with dementia. Which feature of confusion in the older adult is accurate?

a. Bewilderment is to be expected and progresses with age. b. Disorientation often follows relocation to new surroundings. c. Uncertainty is a result of irreversible brain pathology. d. Being perplexed can be prevented with adequate sleep. - ANSWER b

When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. Which action should the nurse implement first? a. Loosen the right wrist restraint. b. Apply a pulse oximeter to the right hand. c. Compare hand color bilaterally. d. Palpate the right radial pulse. - ANSWER a

An older client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings through a gastrostomy tube (GT). Which is the best position for the client for administration of the bolus tube feedings? a. Prone. b. Fowler's. c. Lateral Recumbant. d. Supine. - ANSWER b A gastrostomy tube (GT), known as a PEG tube, due to placement by a percutaneous endoscopic gastrostomy procedure, is inserted directly into the stomach through an incision in the abdomen for long-term administration of nutrition and hydration in the debilitated client. The unresponsive client should be positioned in a semi-sitting (Fowler's) position during feeding through a gastrostomy tube to decrease the occurrence of aspiration.

The nurse is teaching a client the proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate the correct use of the inhaler? a. Immediately after exhalation. b. During the inhalation. c. At the end of three inhalations.

The center of gravity for adults is the hips. However, as the person grows older, a stooped posture is common because of the changes from osteoporosis and normal bone degeneration, and the knees, hips, and elbows flex. This stooped posture results in the upper torso becoming the center of gravity for older adults.

Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. Which is the best response by the nurse?

a. Reassure the client that he will become accustomed to the stoma appearance in time. b. Instruct the client that the stoma will become smaller when the initial swelling diminishes. c. Offer to contact a member of the local ostomy support group to help him with his concerns. d. Encourage the client to handle the stoma equipment to gain confidence with the procedure. - ANSWER b Postoperative swelling causes enlargement of the stoma. The nurse can teach the client that the stoma will become smaller when the swelling is diminished. This will help reduce the client's anxiety and promote acceptance of the colostomy.

Which response by a client with a nursing problem of "Spiritual distress," indicates to the nurse that a desired outcome measure has been met? a. Expresses concern about the meaning and importance of life. b. Remains angry at God for the continuation of the illness. c. Accepts that punishment from God is not related to illness. d. Refuses to participate in religious rituals that have no meaning. - ANSWER c

A client receives a prescription for azithromycin 500 mg PO × 3 days. Azithromycin is available as 250 mg scored tablets. How many tablets should the nurse administer per dose? (Enter a whole number.) - ANSWER 2 Using the formula(\frac {D} {H} = x)(\frac {500 \quad mg} {250 \quad mg} = 2 \quad tablets)

A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the nurse implement first?

a. Assist the ambulating client back to the bed. b. Encourage the client to ambulate to resolve pneumonia.

c. Obtain a prescription for portable oxygen while ambulating. d. Move the oximetry probe from the finger to the earlobe. - ANSWER a Oxygen saturation below 90% indicates inadequate oxygenation. First, the client should be assisted in returning to bed to minimize oxygen demands. Ambulation increases the aeration of the lungs to prevent the pooling of respiratory secretions, but the client's activity at this time is depleting the oxygen saturation of the blood. Increased activity increases respiratory effort, and oxygen may be necessary to continue ambulation, but first, the client should return to bed to rest.

A client is in the radiology department at 0900 when the prescription for levofloxacin 500 mg IV every 24 hours is scheduled to be administered. The client returns to the unit at

1300. Which is the best intervention for the nurse to implement?

a. Contact the healthcare provider and complete a medication variance form. b. Administer the levofloxacin at 1300 and resume the 0900 schedule in the morning. c. Notify the charge nurse and complete an incident report to explain the missed dose. d. Give the missed dose at 1300 and change the schedule to administer daily at 1300. - ANSWER d To ensure that a therapeutic level of medication is maintained, the nurse should administer the missed dose as soon as possible, and revise the administration schedule accordingly to prevent dangerously increasing the level of the medication in the bloodstream.

An older client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgment? a. The nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes. b. The nurse assigned to care for the client who was at lunch at the time of the fall. c. The nurse who transferred the client to the chair when the fall occurred. d. The charge nurse who completed rounds 30 minutes before the fall occurred. - ANSWER c

A client's daily PO prescription for aripiprazole is increased from 15 mg to 30 mg. The medication is available in 15 mg tablets, and the client already received one tablet today. How many additional tablets should the nurse administer so the client receives the total newly prescribed dose for the day? (Enter numeric value only.) - ANSWER 1 30 mg (total dose) - 15 mg (dose already administered) = 15 mg that still needs to be administered. Using the Desired/Have formula: 15 mg/15 mg = 1 tablet