HESI Health Assessment EXAM (Latest
2024/ 2025 Update) Questions and Verified
Answers |100% Correct| Grade A
What is gamma globulin and when is it used?
Gamma globulin, which is an immune globulin, contains most of the antibodies circulating in the
blood. When injected into an individual, it prevents a specific antigen from entering a host cell.
So the antigen is neutralized by the antibodies gamma globulin supplies. Used when a pt is
exposed to Hep A
A nurse is obtaining a health history from the newly admitted client who has chronic pain in the
knee. What should the nurse include in the pain assessment? Select all that apply.
1
Pain history, including location, intensity, and quality of pain
2
Client's purposeful body movement in arranging the papers on the bedside table
3
Pain pattern, including precipitating and alleviating factors
4
Vital signs, such as increased blood pressure and heart rate
5
The client's family statement about increases in pain with ambulation
1&3
Why not others?? Physiological responses such as elevated blood pressure and heart rate are
most likely to be absent in the client with chronic pain. Pain is a subjective experience, and
therefore the nurse has to ask the client directly instead of accepting the statement of the
family members.
.
Pressure Ulcers and stages
,stage I pressure ulcer- an area of persistent redness with no break in skin integrity.
stage II pressure ulcer-partial-thickness wound with skin loss involving the epidermis, dermis, or
both; the ulcer is superficial and may present as an abrasion, blister, or shallow crater
stage III pressure ulcer- full-thickness tissue loss with visible subcutaneous fat. Bone, tendon,
and muscle are not exposed.
stage IV- full thickness tissue loss with exposed bone, tendon, muscle, bone (slough or eschar
may be present within wound bed)
unstageable- contains necrotic tissue, necrotic tissue must be removed before the wound can
be staged.
While assessing a client's skin, a nurse notices that the skin is dry. What is the probable etiology
of the condition? Select all that apply.
The use of hard soap and frequent bathing may result in dry skin. A skin allergy may result in
skin rashes, but not dry skin. Using tanning pills and petroleum products may result in skin
cancer.
The community nurse is assessing an elderly client who lives alone at home. the client refrains
from physical activity for fear of falling when walking. Which interventions by the nurse are
most beneficial to promote a healthy lifestyle?
Encourage the client to wear nonskid shoes.
Suggest that the client use an assistive device.
Help the client rearrange furniture in the house.
Which features distinguish nursing diagnoses from medical diagnoses? Select all that apply.
1
Nursing diagnoses involve the client when possible.
2
Nursing diagnoses are based on results of diagnostic tests and procedures.
3
Nursing diagnoses are the identification of a disease condition in the client.
4
Nursing diagnoses involve the sorting of health problems within the nursing domain.
5
Nursing diagnoses involve clinical judgment about the client's response to health problems.
Nursing diagnoses involve (client participation) the client when possible.
Nursing diagnoses involve the sorting of health problems within the nursing domain.
Nursing diagnoses involve clinical judgment about the client's response to health problems.
WRONG ANSWER:
Nursing diagnoses are based on results of diagnostic tests and procedures.
WRONG ANSWER:
Nursing diagnoses are the identification of a disease condition in the client.
,.
A 50-year-old client with a 30-year history of smoking reports a chronic cough and shortness of
breath related to chronic obstructive pulmonary disease (COPD). The clinical data on admission
are as follows: a heart rate of 100, a blood pressure of 138/82, a respiratory rate of 32, a
tympanic temperature 36.8 °C, and an oxygen saturation of 80%. Which vital signs obtained by
the nurse during the therapy indicates a positive outcome? Select all that apply.
1
Radial pulse: 70
2
Temperature: 37 °C
3
Respiratory rate: 14
4
Blood pressure: 110/70
5
Oxygen saturation: 96%
3,4,5
Why not 1&2? The radial pulse indicates a positive outcome of the therapy if the client has a
history of heart disease. A body temperature reading of 36.8 °C is considered normal and not a
sign of COPD.
Which client is at an increased risk for right-sided heart failure?
Client A:
R Jugular Venous Pressure: 2.5 cm
L Jugular Venous Pressure: 3.0 cm
Client B:
RJVP = 2.0
LJVP = 1.5
Client C:
RJVP = 1.5
LJVP = 1.0
Client A
Bilateral pressures higher than 2.5 cm are considered elevated and are a sign of right-sided
, heart failure. Client A has both right and left jugular venous pressure above 2.5 cm. Therefore
this client is at risk for right-sided heart failure.
why not B/C: One-sided pressure elevation is caused by obstruction, as observed in clients B, C
Right sided heart failure risk
Bilateral pressures higher than 2.5 cm are considered elevated and are a sign of right-sided
heart failure. Client A has both right and left jugular venous pressure above 2.5 cm. Therefore
this client is at risk for right-sided heart failure. One-sided pressure elevation is caused by
obstruction, as observed in clients B, C, and D. in clients B,C, D the right jugular venous pressure
is .5 cm high than the left jugular venous pressure
The community nurse is assessing an elderly client who lives alone at home. The nurse finds
that the client refrains from physical activity for fear of falling when walking. Which
interventions by the nurse are most beneficial to promote a healthy lifestyle? Select all that
apply.
1
Instruct the client to apply bed side rails.
2
Encourage the client to wear nonskid shoes.
3
Suggest that the client use an assistive device.
4
Ask the client to install hand rails in the bathroom.
5
Help the client rearrange furniture in the house.
2,3,5
Why not 1,4? The bed side rails protect the client from falling from the bed. The hand rails in
the bathroom assist provide support while using the bathroom.
.
What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? Select all
that apply.
1
Tetany
2
Seizures
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller a-grade. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $10.49. You're not tied to anything after your purchase.
