A nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the
nurse anticipate?
A. Initiate a low-residue diet.
Rationale: One of the manifestations of acute pancreatitis is abdominal pain. The nurse should anticipate
the provider will prescr...
hesi ati nursing care 2021
Detailed Answer Key
HESI Practice Fall 2019
1. A nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the
nurse anticipate?
A. Initiate a low-residue diet.
Rationale: One of the manifestations of acute pancreatitis is abdominal pain. The nurse should anticipate
the provider will prescribe withholding of foods and fluids. This serves to manage the client's
pain by limiting gastrointestinal activity and stimulation of the pancreas.
B. Pantoprazole 80 mg IV bolus twice daily
Rationale: The nurse should anticipate a provider's prescription for a proton pump inhibitor to decrease
gastric acid production, which ultimately decrease pancreatic secretions.
C. Ambulate twice daily.
Rationale: The nurse should anticipate a provider prescription for bed rest during the acute stage of
pancreatitis. Bed rest decreases the metabolic rate and the secretion of pancreatic enzymes.
D. Pancrelipase 500 units/kg PO three times daily with meals
Rationale: The nurse should identify that pancrelipase, an enzyme replacement medication, is used in the
treatment of clients who have chronic pancreatitis. It is not used in the treatment of acute
pancreatitis.
2. A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following
room assignments should the nurse make for the client?
A. A room with air exhaust directly to the outdoor environment
Rationale: A room with air exhaust directly to the outside environment eliminates contamination of other
client-care areas. This type of ventilation system is referred to as an airborne infection isolation
room.
B. A room with another nonsurgical client
Rationale: A two-bed room with another nonsurgical client exposes the other client to tuberculosis. A client
who has tuberculosis should have a private room.
C. A room in the ICU
Rationale: A client who has active tuberculosis and no other comorbidities is not critically ill.
D. A room that is within view of the nurses' station
Rationale: The client's room should be well ventilated and private, but it is not necessary for it to be close to
the nurses' station.
3. A nurse is caring for a client who has a new diagnosis of urolithiasis. Which of the following should the nurse
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, Detailed Answer Key
HESI Practice Fall 2019
identify as an associated risk factor?
A. Hypocalcemia
Rationale: Hypercalcemia is a risk factor associated with urolithiasis.
B. BMI less than 25
Rationale: Obesity, or having a BMI that is greater than 29, has been found to be a risk factor for the
development of urolithiasis.
C. Family history
Rationale: Family history is strongly correlated with the formation of urolithiasis. A nurse should assess a
client who has kidney stones for familial tendencies toward stone formation.
D. Diuretic use
Rationale: Medications such as antacids, vitamin D, laxatives, and aspirin have been associated with the
formation of urolithiasis. However, there is no indication that the use of diuretics place a client at
an increased risk for stone formation.
4. A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect?
(Select all that apply.)
A. Increased heart rate
B. Increased blood pressure
C. Increased respiratory rate
D. Increase hematocrit
E. Increased temperature
Rationale: Increased heart rate is correct. The nurse should expect the client who has fluid volume excess
to have tachycardia and increased cardiac contractility in response to the excess fluid.Increased
blood pressure is correct. The nurse should expect the client who has fluid volume excess to
have increased blood pressure and bounding pulse in response to the excess fluid.Increased
respiratory rate is correct. The nurse should expect the client who has fluid volume excess to
have increase in respiratory rate and moist crackles heard in lungs.Increased hematocrit is
incorrect. The nurse should expect the client who has fluid volume deficit to have an elevated
hematocrit because of hemoconcentration.Increase temperature is incorrect. The nurse should
expect the client who has fluid volume deficit to have an increase in temperature due to fluid
loss.
5. A nurse is administering a tap water enema to a client who is constipated. During the administration of the enema,
the client states he is having abdominal cramps. Which of the following actions should the nurse take to relieve the
client's discomfort?
A. Lower the height of the solution container.
Rationale:
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HESI Practice Fall 2019
If nausea or cramping occurs, the flow of water should momentarily be slowed or stopped by
lowering the device or clamping the tubing. This allows the intestinal spasm to pass while
leaving the catheter in place. The nurse should then continue administering the enema at a
slower rate once the cramping has passed.
B. Encourage the client to bear down.
Rationale: Bearing down will cause early release of the fluid, decreasing the effectiveness of the enema.
C. Allow the client to expel some fluid before continuing.
Rationale: Allowing the client to expel solution too early in the procedure will decrease the effectiveness of
the enema.
D. Stop the enema and document that the client did not tolerate the procedure.
Rationale: Cramping is a normal response to an enema. There are actions the nurse can take to decrease
the cramping.
6. A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to
assess in this client? (Select all that apply.)
A. Dyspnea
B. Bradycardia
C. Barrel chest
D. Clubbing of the fingers
E. Deep respirations
Rationale: Dyspnea is correct. Emphysema is a lung disease involving damage to the alveoli in which they
become weakened and collapse. Dyspnea is seen in clients with emphysema as the lungs try to
increase the amount of oxygen available to the tissues.
Bradycardia is incorrect. With emphysema, the heart rate will increase as the heart tries to
compensate for less oxygen to the tissues.
Barrel chest is correct. Clients with emphysema lose lung elasticity; the diaphragm becomes
permanently flattened by hyperinflation of the lungs; the muscles of the rib cage become rigid;
and the ribs flare outward. This produces the barrel chest typical of emphysema clients.
Clubbing of the fingers is correct. Clubbing results from chronic low arterial-oxygen levels. The
tips of the fingers enlarge and the nails become extremely curved from front to back.
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, Detailed Answer Key
HESI Practice Fall 2019
Deep respirations is incorrect. Clients with emphysema lose lung elasticity and have muscle
fatigue; consequently, respirations become increasingly shallow.
7. A nurse is assessing a client who is 48 hr postoperative following abdominal surgery. Which of the following
findings should the nurse report to the provider?
A. Blood pressure 102/66 mm Hg
Rationale: The nurse should identify this finding as within the expected reference range.
B. Straw-colored urine from an indwelling urinary catheter
Rationale: Straw-colored urine is an expected finding. More information is needed to determine whether to
take action in this case.
C. Yellow-green drainage on the surgical incision
Rationale: Thick yellow-green drainage is indicative of an infection and should be reported immediately.
D. Respiratory rate 18/min
Rationale: The nurse should identify this finding as within the expected reference range.
8. A client who has a history of myocardial infarction (MI) is prescribed aspirin 325 mg. The nurse recognizes that the
aspirin is given due to which of the following actions of the medication?
A. analgesic
Rationale: Although aspirin does have an analgesic effect, cardiac clients who take 325 mg daily are taking
it for a different purpose.
B. anti-inflammatory
Rationale: Although aspirin does have an analgesic effect, cardiac clients who take 325 mg daily are taking
it for a different purpose.
C. antiplatelet aggregate
Rationale: Aspirin is used to decrease the likelihood of blood clotting. It also is used to reduce the risk of a
second heart attack or stroke by inhibiting platelet aggregation and reducing thrombus
formation in an artery, a vein, or the heart.
D. antipyretic
Rationale: Although aspirin does have an antipyretic effect, cardiac clients who take 325 mg daily are
taking it for a different purpose.
9. A nurse is caring for an adolescent client who has a long history of diabetes mellitus and is being admitted to the
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