Exam (elaborations)
HESI EXAM 2 (1
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Exam of 31 pages for the course AH1 NCLEX at AH1 NCLEX (HESI EXAM 2 (1)
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HESI EXAM 2The nurse is completing the admission assessment of a 3-year-old who is admitted with
bacterial meningitis and hydrocephalus. Which assessment finding is evidence that the child is
experiencing increased intracranial pressure?
a. Tachycardia and tachypnea
b. Sluggish and unequal pupillary responses
c. Increased head circumference
d. Blood pressure fluctuations and syncope - ANS-b. Sluggish and unequal pupillary responses
A client with acute pancreatitis is admitted with severe, piercing abdominal pain and an elevated
serum amylase. Which additional information is the client most likely to report to the nurse?
a. Abdominal pain decreases when lying supine
b. Pain lasts and hour and leaves the abdomen tender
c. Right upper quadrant pain refers to right scapula
d. Drinks alcohol until intoxicated at least twice weekly - ANS-a. Abdominal pain decreases
when lying supine
A child newly diagnosed with sickle cell anemia is being discharged from the hospital. Which
information is most important for the nurse to provide to the parents prior to discharge?
a. Instructions about how much fluid the child should drink daily
b. Signs of addiction to opioid pain medications
c. Information about non-pharmaceutical pain relief measures
d. Referral for social services for the child and family - ANS-
After receiving report on an inpatient acute care unit, which client should the nurse assess first?
a. The client with an obstruction of the large intestine who is experiencing abdominal distention
b. The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowl
sounds
c. The client with a small bowel obstruction who has a nasogastric tube that is draining greenish
fluid
d. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity -
ANS-d. The client with a bowel obstruction due to a volvulus who is experiencing abdominal
rigidity
1. A teenager presents to the emergency department with palpitations after vaping at a party.
The client is anxious, fearful, and hyperventilating. The nurse anticipates the client developing
which acid base imbalance?
a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
Metabolic alkalosis - ANS-b. Respiratory alkalosis
,The nurse is taking the blood pressure measurement of a client with Parkinson's disease. Which
information in the client's admission assessment is relevant to the nurse's plan for taking the
blood pressure reading?
a. Frequent syncope
b. Occasional nocturia
c. Flat affect
d. Blurred vision
e. Frequent drooling - ANS-a. Frequent syncope
c. Flat affect
d. Blurred vision
While caring for a client's postoperative dressing, the nurse observes purulent drainage at the
wound. Before reporting this finding to the healthcare provider, the nurse should review which of
the client's laboratory values?
a. Serum albumin
b. Culture for sensitive organisms
c. Serum blood glucose (BG) level
d. Creatinine level - ANS-b. Culture for sensitive organisms
A preschool-aged boy is admitted to the pediatric unit following successful resuscitation from a
near drowning incident. While providing care to the child, the nurse begins talking with his
preadolescent brother who rescued the child from the swimming pool and initiated resuscitation.
The nurse notices the older boy becomes withdrawn when asked about what happened. Which
action should the nurse take?
a. Develop a water safety teaching plan for the family
b. Ask the older brother how he felt during the incident
c. Tell the older brother that he seems depressed
d. Commend the older brother for his heroic actions - ANS-b. Ask the older brother how he felt
during the incident
A male client with psoriasis has jaundice and puritis. He tells the nurse that he has been
soaking in hot baths at night with no relief of his discomfort. Which action should the nurse
take?
a. Encourage the client to use cooler water and apply calamine lotion after soaking
b. Obtain a PRN prescription for an analgesic that the client can use for symptom relief
c. Suggest that the client take brief showers and apply oil based lotion after showering
d. Explain that the symptoms are caused by liver damage and cannot be relieved - ANS-a.
Encourage the client to use cooler water and apply calamine lotion after soaking
An older client with a long history of coronary artery disease, hypertension, and heart failure
arrives at the emergency department in respiratory distress. The health care provider prescribes
furosemide IV. Which therapeutic response to fursemide should the nurse expect in the client
with acute heart failure?
,a. Increased cardiac contractility
b. Reduced preload
c. Relaxed vascular tone
d. Decreased afterload - ANS-b. Reduced preload
Which intervention should the nurse include in the plan of care for a child with tetanus?
a. Encourage coughing and deep breathing
b. Minimize the amount of stimuli in the room
c. Reposition from side to side every hour
d. Open window shades and provide natural light - ANS-b. Minimize the amount of stimuli in the
room
An adolescent who was diagnosed with diabetes mellitus type one at the age of 9, is admitted to
the hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of the
ketoacidosis?
a. Eaten extra peanut butter sandwich before gym class
b. Incorrectly administered too much insulin
c. Had a cold and ear infection for the past two days
d. Skipped eating lunch - ANS-c. Had a cold and ear infection
A client with a prescription for do not resuscitate begins to manifest signs of impending to death.
After notifying the family of the client status, what priority action should the nurse implement?
a. The impending signs of death should be documented
b. The client status should be conveyed to the chaplain
c. The client's needs for pain medication should be determined
d. The nurse manager should be updated on the client status - ANS-c. The client's needs for
pain medication should be determined
Which self-care measure is most important for the nurse to include in the plan of care of a client
recently diagnosed with type 2 diabetes mellitus?
a. Self injection techniques
b. Blood glucose monitoring
c. Diabetic diet meal planning
d. A realistic exercise plan - ANS-b. Blood glucose monitoring
A client who gave birth 48 hours ago has decided to bottle feed the infant. During the
assessment the nurse observes that both breasts are swollen, warm, and tender on palpation.
Which instructions should the nurse provide?
a. Apply ice to the breasts for comfort
b. Wear a loose fitting bra during the day to prevent nipple irritation
c. Run warm water over breasts
d. Express small amounts of milk from the breast to relieve pressure - ANS-a. Apply ice to the
breasts for comfort
, The nurse is preparing a client who had a below the knee amputation for discharge to home.
Which recommendation should the nurse provide to this client? Select all that apply.
a. Avoid range of motion exercises
b. User residual limb shrinker
c. Apply alcohol to the stump after bathing
d. Inspect skin for redness
e. Wash the stump with soap and water - ANS-b. Use residual limb shrinker
d. Inspect skin for redness
e. Wash the stump with soap and water
A toddler presenting with a history of intermittent rashes hives abdominal pain and vomiting that
occurs after ingesting of milk products arrives to the clinic accompanied by the parents. Which
type of testing should the nurse provide education to the toddlers family about?
a. Serum immunoglobulin E
b. Intradermal test
c. Atopy patch test
d. Placebo controlled food challenge - ANS-a. Serum immunoglobulin E
A client who is scheduled for a bronchoscopy in the morning is anxious and asking the nurse
numerous questions about the procedure and preparing for the client for the procedure. Which
intervention has the highest priority?
a. Allow the client to gargle with warm salt water
b. Administer sedative to alleviate anxiety
c. Instruct the client to write down the questions
d. Deny clients request for midnight snack - ANS-c. Instruct the client to write down the
questions
The nurse assesses a client one hour after starting a transfusion of packed red blood cells and
determines that there are no indications of a transfusion reaction. Which instruction should the
nurse provide the unlicensed assistive personnel who is working with the nurse?
a. Notify the nurse when the transfusion has finished, so further client assessment can be done
b. Continue to measure the clients vital signs every 30 minutes until the transfusion is complete
c. Monitor the client carefully for the next three hours and report the onset of a reaction
immediately
d. Since her reaction did not occur, the priority is to maintain client comfort during the
transfusion - ANS-b. Continue to measure the clients vital signs every 30 minutes until the
transfusion is complete
The health care provider describes the sepsis protocol for client with multi organ failure caused
by a ruptured appendix which intervention is most important for the nurse to include in the plan
of care?
a. Assess warmth of extremities
b. Keep head of bed raised 45 degrees
c. Monitor blood glucose level
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