HESI A2 NEW FILE TESTED- 2023 CRITICAL THINKING

HESI A2 NEW FILE TESTED- 2023 CRITICAL THINKING 1.The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective? I will limit my intake of beef to 4 ounces per week. 2. The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client? Move the chair parallel to the right side of the bed, and stand the client on the right foot. 3. 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? Reposition in a Sim's position with the client's weight on the anterior ilium. 4. 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? Blood transfusions are forbidden. 5. The nurse observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first? Observe the appearance of the skin under the ice pack. 6. 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. What action is best for the nurse to take? After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. 7. A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the nurse advise the client to follow? 8 a.m., 4 p.m., and midnight. 8. A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the nurse set the client's intravenous infusion pump? To calculate this problem correctly, remember that the dose of KCl is not used in the calculation. 250 ml/4 hours = 63 ml/hour. 9. An obese male client 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? Be sure to have a complete physical examination before beginning your planned exercise program. 10. The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler? During the inhalation. 11. Which action is most important for the nurse to implement when donning sterile gloves? Keep gloved hands above the elbows. 12. A client with chronic renal failure selects a scrambled egg for his breakfast. What action should the nurse take? Commend the client for selecting a high biologic value protein. 13. A client who is 5' 5" tall and weighs 200 pounds is scheduled for surgery the next day. What question is most important for the nurse to include during the preoperative assessment? What vitamin and mineral supplements do you take? 14. During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement? Encourage additional oral intake of juices and water. 15. Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention? Assess for bladder distention. 16. The nurse assigns a UAP to obtain vital signs from a very anxious client. What instructions should the nurse give the UAP? Report the results of the vital signs to the nurse. 17. An adult 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. What should be the nurse's first response? It is important that you continue your medication while learning to meditate. 18. The nurse is completing a mental assessment for a client who is demonstrating slow thought processes, personality changes, and emotional lability. Which area of the brain controls these neuro-- cognitive functions? Frontal lobe. 19. 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? is disoriented to place and time. 20. An African-American grandmother tells the nurse that her 4-year-old grandson is suffering with "miseries." Based on this statement, which focused assessment should the nurse conduct? Inquire about the source and type of pain. 21. The nurse notices that the Hispanic parents of a toddler who returns from surgery offer the child only the broth that comes on the clear liquid tray. Other liquids, including gelatin, popsicles, and juices, remain untouched. What explanation is most appropriate for this behavior? Hot remedies restore balance after surgery, which is considered a "cold" condition. 22. During a physical assessment, a female client begins to cry. Which action is best for the nurse to take? Acknowledge the client's distress and tell her it is all right to cry. 23. A female client asks the nurse to find someone who can translate into her native language her concerns about a treatment. Which action should the nurse take? Request and document the name of the certified translator. 24. The nurse is teaching a client with numerous allergies how to avoid allergens. Which instruction should be included in this teaching plan? Avoid any types of sprays, powders, and perfumes 25. The Patient: A 54-year-old male who weighs 275 pounds. He is 5’ 10” tall and has many family members who have died of heart disease. The Situation: He comes to the clinic stating that he has had several episodes of “chest pain” in the last week. The Question: What is the most important action for the nurse to take? Answer – Ask the patient to describe the chest pain. 26. The Patient: A 7-year-old child. The Situation: A nurse arrives with an injection containing preoperative sedation that must be given to the child now. The child asks the nurse if the shot will hurt. The Question: What response should the nurse offer to this child? Answer – “Yes, but it won’t last very long and soon you will be sleepy” 27. The Patient: A 35-year-old female. The Situation: The patient is admitted with a diagnosis of abdominal pain and diarrhea. The Question: Which action should the nurse take first? Answer – Initiate Intravenous fluids. 28. The Patient: A 51-year-old male. The Situation: The patient is pale, has dark circles under his eyes, and responds to questions with a soft, low voice. He tells the nurse that he has not slept well for months, but denies any type of pain. The Question: What information is most important for the nurse to obtain? Answer – The existence of a significant life in the last year that has caused anxiety. 29. The Patient: A 19-year-old male who has previously been healthy. The Situation: The patient complains that he is losing weight despite “eating all the time.” The Question: Considering this patient’s age and complaint, which diagnostic test is likely to provide the most important information? Answer – A fingerstick for blood sugar level. 30. The Patient: An adult with diabetes mellitus who was just given a morning does of insulin which lowers the blood sugar. The Situation: The patient’s breakfast tray arrives, and the nurse notices that the pancake syrup and sugar packets have not been substituted with products containing artificial sweeteners. The Question: What should the nurse do first in this situation? Answer – Remove foods containing sugar and offer sugar substitutes.