HESI 2019 Version 2

Yellow Highlight = Unverified answer

1. The school nurse is preparing a presentation for a elementary school teachers to inform teachers to inform

them about when a child should be referred to the school clinic for further follow-up. The teachers should be

instructed to report which situations to the school nurse? (Select all that apply)

A. Refuses to complete written homework assignments.

B. Thirst and frequent requests for bathroom breaks.

C. Bruises on both knees after the weekend.

D. Sunburn with blisters on the face, arms, and hands.

E. Shaking that changes the child’s hand writing.

ANS: B D E

2. When preparing a client for discharge from the hospital following a cystectomy and a urinary diversion to

treat bladder cancer, which instruction is most important for the nurse to include in the client’s discharge

teaching plan?

A. Report any signs of cloudy urine output.

B. Frequent empty bladder to avoid distention.

C. Follow instructions for self-care toileting.

D. Seek counselling for body image.

ANS: A

3. A client with renal lithiasis is receiving morphine sulfate every four hours for pain and renal colic. Which

assessment finding should prompt the nurse to administer a PRN dose of naloxone?

A. Unresponsive to verbal or tactile stimuli.

B. Respiratory rate of 12 breath/minute.

C. Statements about visual hallucinations.

D. Complaints of increasing flank pain.

ANS: A

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4. The mother of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated

and red, but there are no blisters or bleeding. The mother reports no evidence of watery stools. Which nursing

intervention should the nurse implement?

A. Instruct the mother to change the child’s diaper more often.

B. Encourage the mother to apply lotion with each diaper change.

C. Ask the mother to decrease the infant’s intake of fruits for 24 hours.

D. Tell the mother to cleanse with soap and water at each diaper change.

ANS: A

5. The nurse is having difficulty palpating a client’s posterior tibial pulse while the client is lying in a supine

position?

A. Extend the client’s arm fully while supporting the elbow and attempt to repalpate.

B. Apply less pressure when palpating over the middle of the dorsum of the foot.

C. Use an ultrasound stethoscope place behind and below the medial bone.

D. Help the client to a prone position with the knee slightly flexed and palpate again.

ANS: D

6. The nurse implements a tertiary prevention program for type 2 diabetes in a rural health clinic. Which

outcome indicates that the program was effective?

A. Average client scores improved on specific risk factor knowledge tests.

B. Only 30% of clients did not attend self-management education sessions.

C. More that 50% of at-risk clients were diagnosed early in the disease process.

D. Client who developed disease complications promptly received rehabilitation.

ANS: D

7. A client is recovering in the critical care unit following a cardiac catheterization. IV nitroglycerin and heparin

are infusing. The client is sedated but responds to verbal instructions. After changing positions, the client

complains of pain at the right groin insertion site. What action should the nurse implement?

A. Stimulate the client to take deep breaths.

B. Evaluate the integrity of the IV insertion site.

C. Assess distal lower extremity capillary refill.

D. Check femoral site for hematoma formation.

ANS: B

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8. A 7-year old is admitted to the hospital with persistent vomiting, and nasogastric tube attached to low

intermittent suction is applied. Which finding is most important for the nurse to report to the healthcare

provider?

A. Shift intake of 640 ml IV fluids plus 30 ml PO ice chips.

B. Serum pH of 7.45

C. Serum potassium of 3.0 mg/dl.

D. Gastric output of 100 ml in the last 8 hours.

ANS: C

9. A morbidly obese client is scheduled for gastric bypass surgery. The client completes the required

preoperative nutritional counselling and signs the operative permit. To promote effective discharge planning,

which intervention is most important for the nurse to implement?

A. Discuss small, low fat, low sugar meal preparation techniques.

B. Advise the client to arrange for dietary counselling after discharged.

C. Encourage the client to keep a daily diary for two weeks.

D. Suggest that the client’s spouse do the family grocery shopping.

ANS: A

10.The nurse is admitting a client from the post anesthesia unit to the postoperative surgical care unit. Which

prescription should the nurse implement first?

A. Cefazolin 1-gram IVPB q6 hours.

B. Complete blood cell count (CBC) in AM.

C. Straight catherization if unable to void.

D. Advance from clear liquid as tolerated.

ANS:

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11. Which needle should the nurse use to administer intravenous fluids (IV) via a client’s implanted port?

ANS: C

12. An older client is referred to a rehabilitation facility following a cerebrovascular accident (CVA). The client

is aphasic with left-side paresis and is having difficulty swallowing. Which intervention is most important for

the nurse to include in the client’s plan of care?

A. Use pictures and gestures to communicate.

B. Arrange for daily home care assistance.

C. Facilitate a consultation for speech therapy.

D. Initiate passive range of motion exercises.

ANS: C

13. A client has had several episodes of clear, watery diarrhea that started yesterday. What action should the

nurse implement?

A. Assess the client for the presence of hemorrhoids.

B. Administer a prescribed PRN antiemetic.

C. Check the client’s hemoglobin level.

D. Review the client’s current list of medications

ANS: D

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