Hesi version 2 Questions and Answers
The nurse assumes care of a postoperative adult client with diabetes mellitus and learns that the client has a current blood glucose level of 720 mg. When assessing the client what is the priority?
A. Assess for vital signs of fluid volume deficit.
B. Observe...
Hesi version 2 Questions and Answers
The nurse assumes care of a postoperative adult client with diabetes mellitus and
learns that the client has a current blood glucose level of 720 mg. When assessing the
client what is the priority?
A. Assess for vital signs of fluid volume deficit.
B. Observe wound drainage characteristics.
C. Measure the level of acute pain.
D. Determine when the client last ate.
A
A. Assess for vital signs of fluid volume deficit.
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a blood glucose level of 720 mg/dL is significantly elevated and may indicate a state of
hyperosmolar hyperglycemic state or diabetic ketoacidosis. Both conditions can lead to
fluid volume deficit. Assessing for signs of dehydration, such as altered vital signs and
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dry mucous membranes, is a priority.
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IS
A male client tells the nurse that he is concerned that he may have a stomach ulcer
because he is experiencing heartburn and a dull gnawing pain. Which is the best
response by the nurse?
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A. Encourage the client to obtain a complete physical exam since these symptoms are
consistent with an ulcer.
B. Assure the client that his symptoms may only reflect reflux, since ulcer pain is not
relieved with food.
C. Instruct the client that these mild symptoms can generally be controlled with changes
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in his diet.
D. Advise the client that he needs to seek immediate medical evaluation and treatment
for these symptoms.
A. encourage the client to obtain a complete physical exam since these symptoms are
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consistent with an ulcer
This response is the most appropriate because it encourages the client to seek a
professional medical evaluation, which is necessary to accurately diagnose and treat
potential ulcers. While the symptoms described by the client could indeed be indicative
of an ulcer, they could also be related to other gastrointestinal issues. A complete
physical exam by a healthcare provider is necessary to determine the exact cause and
appropriate treatment.
,A male client with stomach cancer returns to the unit following a total gastrectomy. He
has a nasogastric tube to suction and is receiving Lactated Ringer' IV. One hour after
admission to the unit, the nurse notes 300 mL of blood in the suction canister, the
client's heart rate is 155 beats/minute. In addition to reporting the findings to the
surgeon, which action should the nurse implement first?
A. Measure and document the client's urinary output.
B. Request the client's reserved unit of packed red blood cells.
C. Prepare for the placement of central venous catheter.
D. Increase the infusion rate of Lactated Ringer's solution.
A
D. increase the infusion rate of Lactated Ringer's solution
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The client's symptoms are indicative of acute blood loss and potential hypovolemia.
Increasing the infusion rate of IV fluids, such as Lactated Ringer's solution, is a critical
first step in managing potential hypovolemic shock. This will help to maintain circulatory
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volume and perfusion until blood products can be administered or other interventions
can be performed.
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A heparin infusion is prescribed for a client who weighs 220 pounds. After administering
a bolus dose of 80 units/kg the nurse calculates infusion rate for the heparin solution at
18 units/kg/hour. The available solution is Heparin Sodium 25,000 Units in 5% Dextrose
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Injection 250 mL. The nurse should program the infusion pump to how many mL/hour?
18
An adult male who fell 20 feet from the roof of his home has multiple injuries, including a
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right pneumothorax. Chest tubes were inserted in the emergency department prior to
his transfer to the intensive care unit (ICU). The nurse notes that the suction control
chamber is bubbling at the -10 cm H2O mark with fluctuation in the water seal, and over
the past hour 75 mL of bright red blood is measured in the collection chamber. Which
intervention should the nurse implement?
JP
A. Add sterile water to the suction control chamber
B. Give blood from the collection chamber as autotransfusion
C. Manipulate blood in tubing to drain into the chamber
D. Increase wall suction to eliminate fluctuation in water sea
C. manipulate blood in tubing to drain into the chamber
The presence of bright red blood in the collection chamber, especially after a significant
trauma like a 20-foot fall, indicates ongoing bleeding. The nurse should ensure that all
,blood in the chest tube is drained into the collection chamber to accurately monitor the
client's bleeding. This can involve gently milking or stripping the tubing to facilitate
drainage, although this must be done with care to avoid creating excessive negative
pressure in the chest tube system.
An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife
approaches the nurse and asks how she will know that her husband's death is imminent
because their two adult children want to be there when he dies. Which is the best
response by the nurse?
A
A. Gather information regarding how long it will take for the children to arrive
B. Explain that the client will start to lose consciousness and the body systems will slow
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down.
C. Reassure the spouse that the healthcare provider will notify when to call the children.
D. Offer to discuss the client's health status with each of the adult children.
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B. Explain that the client will start to lose consciousness and the body systems will slow
down.
in providing end-of-life care, it's important it communicate honestly and sensitively with
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family; explaining the expected changes in the client's condition as death approaches
can help prepare them for what to expect; symptoms such as loss of consciousness,
slowing of body systems, and changes in breathing patterns are common as the end of
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life nears
The charge nurse of a critical carry unit is informed at the beginning of the shift that
lesss than the optical number of registered nurses will be working that shift and planning
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assignments which client should receive the most care hours by registered nurse (RN)?
A. 48 year olds marathon runner with a central venous catheter who is experiencing
nausea and vomiting due to electrolyte disturbance following a race
B. 34 year old admitted today after an emergency appendectomy who has a peripheral
intravenous catheter and a Foley catheter
JP
C. 63-year-old chain smoker admitted with chronic bronchitis who is receiving oxygen
via nasal cannula and has a saline-locked peripheral intravenous catheter
D. An 82-year-old's client with Alzheimer's disease and newly fractured femur who has
a Foley catheter and soft wrist restraint supplied
D. An 82-year-old client with Alzheimer's disease and a newly fractured femur who has
a Foley catheter and soft wrist restraints applied
, This patient presents a complex care situation. The combination of Alzheimer's disease
and a new fracture suggests a high risk for confusion, agitation, and potential harm
(e.g., attempting to walk and further injuring themselves). The use of restraints also
necessitates close and frequent monitoring to prevent complications like skin
breakdown or more severe agitation.
The nurse is preparing a dose of 60 mcg of teriparatide. The medication is labeled "750
mg/2.4 mL." How many mL should the nurse administer?
0.2
A
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In caring for a client with Cushing's syndrome which serum laboratory value is most
important for the nurse to monitor?
A. Creatinine
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B. Lactate
C. Glucose
D. Hemoglobin
C. Glucose
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Cushing's syndrome is characterized by an excess of cortisol in the body, which can
significantly impact glucose metabolism. This excess cortisol can lead to hyperglycemia
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(high blood sugar levels), making it crucial to regularly monitor the client's glucose
levels. Managing blood sugar is an important aspect of caring for a client with Cushing's
syndrome to prevent complications associated with hyperglycemia.
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A client who received hemodialysis yesterday is experiencing a blood pressure of
200/100 mmHg, heart rate 110 beats/minute, and respiratory rate 36 breaths/minute.
The client is manifesting shortness of breath bilateral 2+ pedal edema in an oxygen
saturation on a room air of 89% which action should the nurse take first?
JP
A. Elevate the foot of the bed
B. Restrict the client's fluids
C. Begin supplemental oxygen
D. Prepare client for hemodialysis
C. Begin supplemental oxygen
the client is experiencing signs of fluid overload and respiratory distress, which could be
related to the recent hemodialysis
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