Hesi Level 2 Practice Questions with complete solution Answers

Hesi Level 2 Practice Questions with complete solution Answers What assessment finding should the nurse identify that indicates a client with an acute asthma exacerbation is beginning to improve after treatment? A. Vesicular breath sounds decrease B. Bronchodilators stimulate coughing C. Cough remains unproductive D. Wheezing becomes louder Answer : Wheezing becomes louder. In an acute asthma attack, air flow may be so significantly restricted that wheezing is diminished. If the client is successfully responding to bronchodilators and respiratory treatments, wheezing becomes louder (A) as air flow increases in the airways. As the airways open and mucous is mobilized in response to treatment, the cough becomes more productive, not (B). Vesicular sounds are soft, low-pitched, gentle, rustling sounds heard over lung fields (C) and is not an indicator of improvement during asthma treatment. Bronchodilators do not stimulate coughing (D). A client with sickle cell anemia is admitted with severe abdominal pain and the diagnosis is sickle cell crisis. What is the most important nursing action to implement? A. Evaluate the effectiveness of narcotic analgesics. B. Limit the client's intake of oral fluids and food. C. Teach the client about prevention of crises. D. Encourage the client to ambulate as tolerated. Answer: Evaluate the effectiveness of narcotic analgesics. Pain management is the priority for a client during sickle cell crisis. Continuous narcotic analgesics are the mainstay of pain control, which should be evaluated (B) frequently to determine if the client's pain is adequately controlled. (A, C, and D) are not indicated at this time. The nurse is assessing a middle-aged male client for risk factors related to chronic illness. Which finding should the nurse assess further? A. Thinning hair and dry scalp. B. Increase in muscle tone but decreased muscle strength. C. Increase in abdominal fat deposits. D. Increase in appetite and taste-bud acuity. Answer: Increase in abdominal fat deposits. An increase in the abdominal girth (D) may be indicative of the onset of metabolic syndrome, which places the client at risk for cardiac disease and requires further assessment. During middle adulthood, common findings include thinning hair, dry skin and scalp (A), changes in taste bud acuity (B), and muscle size and strength (C), which are consistent with normal system functioning during aging. The nurse is caring for a male client who had an inguinal herniorrhaphy 3 hours ago. The nurse determines the client's lower abdomen is distended and assesses dullness to percussion. What is the priority nursing action? A. Assessment of the client's vital signs. B. Determine the time the client last voided. C. Document the finding as the only action. D. Insert a rectal tube for the passage of flatus. Answer: Determine the time the client last voided. Swelling at the surgical site in the immediate postoperative period can impact the bladder and prostate area causing the client to experience difficulty voiding due to pressure on the urethra. To provide additional data supporting bladder distention, the last time the client voided (C) should be determined next. Documentation (B) should be made, but the client's distended bladder requires additional intervention. (A and D) are not priority actions based on the client's abdominal findings. The nurse is giving discharge instructions to a client with chronic prostatitis. What instruction should the nurse provide the client to reduce the risk of spreading the infection to other areas of the client's urinary tract? A. Avoid consuming alcohol and caffeinated beverages. B. Wear a condom when having sexual intercourse. C. Have intercourse or masturbate at least twice a week. D. Empty the bladder completely with each voiding. Answer: Have intercourse or masturbate at least twice a week. The prostate is not easily penetrated by antibiotics and can serve as a reservoir for microorganisms, which can infect other areas of the genitourinary tract. Draining the prostate regularly through intercourse or masturbation (D) decreases the number of microorganisms present and reduces the risk for further infection from stored contaminated fluids. (A, B, and C) do not reduce the risk of spreading the infection internally. A 3-year-old boy is brought to the emergency room because of a possible diazepam (Valium) overdose. He is lethargic and confused, and his vital signs are: pulse rate 100 beats/minute, respiratory rate 20 breaths/minute, and blood pressure 70/30. Which nursing intervention has the highest priority? A. Insert an orogastric tube for gastric lavage. B. Prepare a set-up for an endotracheal intubation. C.Draw blood for stat chemistries and blood gases. D. Insert a Foley catheter to monitor renal functioning. Answer: Prepare a set-up for an endotracheal intubation. Diazepam causes respiratory depression, so preparation for intubation (B) to protect the airway is the priority intervention at this time. (A) may be necessary, but the child is lethargic and confused, with a lowered respiratory rate, so (B) takes priority. (C and D) are interventions that should be implemented, but they are both secondary to ensuring an open airway. The nurse is developing a plan of care for a newborn with a colostomy due to anal agenesis, and the infant has had three loose stools since surgery yesterday. Which nursing diagnosis has the highest priority? A. Pain related to postoperative condition. B. Potential for fluid volume deficit. C. Alteration in bowel elimination. D. Anxiety of parents related to newborn's condition. Answer: Potential for fluid volume deficit. All stated nursing diagnoses are appropriate for a postoperative colostomy client. However, fluid balance is the priority concern (A) for any newborn infant. Though three loose stools in 24-hours is not significant, depending on the amount of fluid lost with each stool, potential for fluid volume deficit is always a concern for a postoperative infant. Newborns are extremely vulnerable to fluid imbalances due to immature body systems and a larger percentage of their body weight consisting of fluid. (B, C, and D) do not have the priority of (A). The community health nurse teaches the parents of school-aged children about the need for fluoride as part of a dental health program. Which statement by the parents indicates that they understand the teaching? A. "Having our children brush with fluoride toothpaste is not effective." B. "Excessive amounts of fluoride will make teeth turn brittle and yellow." C. "Use of fluoride in water is mostly effective during initial tooth formation." D. "Dental caries can be prevented through fluoridation of public water." Answer: "Dental caries can be prevented through fluoridation of public water." Dental caries can be prevented through fluoridation of public water (D). Large amounts of fluoride (A) produces yellow and discolored teeth, not brittle teeth. (B) is effective for young teeth. Fluoride is effective throughout the life span, not just during initial tooth formation (C). A Spanish-speaking 5-year-old child starts kindergarten in an English-speaking school. The child cries most of the time, appears helpless and unable to function in the new situation. After assessing the child, how should the school nurse document the situation? A. Experiencing culture shock. B. Refuses to participate in school activities. C. Lacks the maturity needed in school. D. Going through minority group discrimination. Answer: Experiencing culture shock. An inability to function may apply to persons of all ages undergoing transitions, such as moving to a new country and adjusting to a subculture within a larger culture that is unfamiliar. Culture shock (A) describes feelings of discomfort and disorientation when adapting to new cultural settings. Language barriers inhibit effective communication, so a child who is unable to communicate in the spoken language in the school environment may lack the skills necessary to participate, and is not refusing to participate (C). The child may be adequately mature (B), accepted by peers (D) within the environment, but continues to not join in because of the impact of culture shock. The nurse is assessing a child's skin turgor and grasps the skin on the abdomen between the thumb and index finger, pulls it taut, and quickly releases it. The tissue remains suspended and tented for a few seconds, then slowly falls back on the abdomen. How should the nurse document this finding? A. Assessment inconclusive. B. Poor skin turgor. C. Adequate hydration. D. Normal skin elasticity Answer: Poor skin turgor Tissue turgor refers to the amount of elasticity in the skin and is one of the best estimates of adequate hydration and nutrition. Elastic tissue immediately resumes its normal position without residual marks or creases. In a child with poor turgor (B), the skin remains tented or suspended for a few seconds before returning to a normal position. (A, C and D) are inaccurate. A 4-month-old breastfeeding infant is at the 10th percentile for weight and the 75th percentile for height. How should the nurse interpret this finding? A. Inadequate milk supply in mother. B. Milk allergy. C. Normal growth curve of a breast-fed infant. D. Failure to thrive. Answer: Normal growth curve of a breast-fed infant. When plotting weights and heights on a standard growth chart used for both breast-fed and formula-fed infants, the breast-fed infant grows more rapidly during the first 2 months of life, and then growth slows from 3 to 12 months. A breast-fed infant is leaner and has less body fat than a formula-fed infant. Normal patterns of infants who are breast fed (D) differ from those who are formula fed. (A) is an incorrect interpretation of the data. This finding is not consistent with failure to thrive (B) or an inadequate milk supply (C) The nurse is instructing an adolescent with bulimia and a low potassium level about the risk for complications. Which medical problem should be the focus of the nurse's instruction to this client? A. Heightened neurologic reflexes. B. Gastrointestinal reflux. C. Anemia. D. Cardiac arrhythmias. Answer: Cardiac arrhythmias. An adolescent with bulimia who purges by frequent self-induced vomiting, diuretic or laxative abuse can experience potassium depletion, which increases the risk for cardiac arrhythmias (B). (A) is more likely related to inadequate iron intake and absorption, not hypokalemia. (C) is related to frequent binging and gastric over-distention. Potassium depletion causes diminished reflexes, not (D) The parents of a toddler brought to the clinic for a well-child visit tell the nurse that their child becomes upset if even the smallest things change in the environment. What information should the nurse provide the parents? A. A child is insecure because trust is not fostered and developed during infancy. B. A toddler should be exposed to different routines to promote adapting to new experiences. C. Children of this age are comfortable with ritualism and display global thinking. D. Should be frequently moved in the environment to teach the child to acclimate to change. Answer: Children of this age are comfortable with ritualism and display global thinking. A 2-year-old is ritualistic and wants consistency and routine, so changes in the toddler's environment or schedule is upsetting. Another mark of the toddler's sensitivity to change is global thinking (change in one small part, such as a minor shift in room arrangement or changes in the whole environment), and the 2-year-old's equanimity disintegrates (C). There is not enough information to make the assumption the child did not develop trust (A). Frequent changes (B and D) in the schedule or the environment can lead to insecurity on the part of the toddler. An infant weighs 7 lb at birth. How much should the nurse expect the infant to weigh at age 6-months? A. 12 lb. B. 17 lb. C. 14 lb. D. 21 lb Answer: 14 lb. Infancy growth spurts double the birthweight by 4 to 6 months and triple it by one year. Twelve pounds (A) represents a lower-than-expected weight. A weight of 17 (C) or 21 (D) pounds is greater than expected. The father of an 8-year-old tells the nurse he is interested in seeing his child succeed in soccer. The nurse talks with the boy, who expresses a sincere interest in playing chess and feels like a failure at soccer. How should the nurse respond to this father? A. The father should decrease his expectations to give the son a chance to succeed. B. The child has an introverted personality and should be encouraged to play isolated games. C. The child should be given opportunities to achieve a sense of competency in an area he chooses. D. The father should encouraged the son to participate in team sports instead of less physical activities. Answer:The child should be given opportunities to achieve a sense of competency in an area he chooses. According to Erickson, the developmental stage "Industry versus inferiority" builds feelings of confidence, competence, and industry if there is achievement in an area of interest. If a child believes that he or she cannot measure up to society's expectations, the child loses confidence and may not find pleasure in the activity. Children should be encouraged to do the things they enjoy and succeed in (D). The father does not need to decrease his expectations (A), but should be encouraged to shift the expectation to an activity the child takes pleasure in. (B) does not encourage autonomy. (C) can cause a feeling of inadequacy.