Hesi NUR 112 Exam Questions & Answers with Rationales Updated
(Deeply & Well Explained Answers)
The healthcare provider prescribes methylergonovine maleate for a postpartum client with
uterine atony. What findings should indicate to the nurse to withhold the next dose of the
medication?
A. Excessive lochia.
B. Saturation of more than one pad per hour.
C. Hypertension.
D. Difficulty locating the uterine fundus. - Answer
C. Hypertension.
Rationale
Methylergonovine, an ergot alkaloid, has vasoconstrictive effects that can exaggerate primary
hypertension. The nurse should withhold the medication if the client's blood pressure is elevated
(C) and notify the healthcare provider. (A, B, and D) are signs of uterine atony and are
indications for the use of the medication.
The nurse has completed the diet teaching of a male client who is being discharged following
treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which
lunch choice by the client indicates that the teaching was effective?
A. A peanut butter sandwich with soda and cookies.
B. A tunafish sandwich with chips and ice cream.
C. A salad with three kinds of lettuce and fruit.
D. Vegetable soup, crackers, and milk. - Answer
B. A tunafish sandwich with chips and ice cream.
Rationale
(B) contains the highest amount of protein. Four ounces of tuna contains 11 g of protein, and ice
cream 5 g of protein per cup. Chips are a fat with virtually no protein value. (A) contains 4 grams
of protein per tablespoon. (C) contains only 1 gram of protein per 1 cup serving. (D) may have
beef flavoring but it consist mostly of vegetables and would therefore be low in protein.
The nurse discontinues a continuous IV heparin infusion for a male client on strict bed rest, and
is now preparing to administer the client's first dose of in enoxaparin (Lovenox). Prior to giving
this subcutaneous injection, which assessment finding requires additional intervention by the
nurse?
A. Current lab report indicates an aPTT at 1.5 times the client's control.
B. Several bruised areas are noted on the client's upper extremities bilaterally.
C. The client states that his right calf is aching, and wants pain medication.
D. The spouse is assisting the client who is shaving with an electric razor. - Answer
C. The client states that his right calf is aching, and wants pain medication.
,Rationale
A calf ache severe enough for the client to request pain medication (C) should be reported to the
healthcare provider immediately so that an adjustment in the anticoagulation therapy can be
made. Calf pain may be a sign of deep vein thrombosis indicative of ineffective anticoagulant
heparin therapy. (A and B) are expected findings. Shaving with an electric razor is recommended
to reduce the possibility of bleeding (D) and does not require intervention.
While the nurse is providing morning care for a client with chronic obstructive pulmonary
disease (COPD), the client becomes very dyspneic and starts to panic. What action should the
nurse implement first?
A. Instruct the client to perform diaphragmatic breathing.
B. Use a calm voice to tell the client to breathe slowly.
C. Administer two puffs of a metered-dose inhaler.
D. Assist the client to an upright position. - Answer
D. Assist the client to an upright position.
Rationale
The nurse should first assist the client to an upright position (D), which allows the lungs to
expand fully. After this, the nurse can implement (A, B, and C) as needed.
A female client's estranged husband arrives at the hospital and demands that his wife have no
other visitors. The client becomes angry and insists that the estranged husband be barred from
visiting her. Which intervention should the nurse implement?
A. Obtain a prescription to allow client to dictate who can visit.
B. Request a multidisciplinary care conference to discuss husband's demands.
C. Have the hospital's medical-legal department meet with the client.
D. Encourage the client to speak with husband regarding his disruptive behavior. - Answer
B. Request a multidisciplinary care conference to discuss husband's demands.
Rationale
A multi-disciplinary care conference involves the healthcare team to evaluate difficult situations
that conflict with client safety and autonomy. During this conference, the client's wishes
regarding her health care decisions can be clarified to all team members. All other options are
not indicated.
The nurse working in a critical care unit is assigned the care of two clients, one with pneumonia
who is being mechanically ventilated and the other who had a thoracotomy yesterday and is
complaining of incisional pain. What should the nurse to first?
A. Assess the level of consciousness and vital signs for both clients.
B. Complete a head to toe assessment of the client with pneumonia.
C. Change the surgical dressing to observe the appearance of the incision.
D. Review the plan of care and the medications that are due for both clients. - Answer
A. Assess the level of consciousness and vital signs for both clients.
,Rationale
Assessing the level of consciousness and vital signs for both clients (A) provides a quick
measurement of priority need. Before a complete assessment (B) is done on one client, the nurse
should at least do a quick assessment of the other client. Changing the dressing and observing the
incision (C) may be indicated, but only after both clients are quickly assessed. Reviewing the
plan of care and medications due for administration (D) should wait until the nurse has evaluated
both clients for any urgent clinical needs.
A woman at 24 weeks gestation who has fever, bodyaches, and has been coughing for the last 5
days is sent to the hospital with admission prescriptions for H1N1 influenza. Which prescription
has the highest priority?
A. Obtain specimens for cultures.
B. Vital signs q4 hours.
C. Assign private room.
D. Ringers lactate IV 125 mL/8 hours. - Answer
C. Assign private room.
Rationale
Novel H1N1 ("swine flu virus"), a new subtype of influenza A virus, is exhibited by fever,
cough, sore throat, runny nose, body aches, headache, chills, fatigue, diarrhea, and vomiting.
According to the Center for Disease Control, it is best to place a client requiring Contact or
Droplet Precautions in a single client room, so to protect others, the client who is exhibiting signs
of Novel H1N1 influenza should be assigned to a private room (C). (A, B, and D) do not have
the right the priority of (C).
A client who received partial thickness (second degree) burns over the anterior surfaces of both
arms, legs, and chest in a burning vehicle collision receives a prescription for daily dressing
changes and therapeutic baths. The nurse determines that a hoist is required to move the
immobile client from a stretcher into the therapeutic bath. Which intervention should the nurse
implement first?
A. Obtain the hoist from the supply room.
B. Explain the procedure to the client.
C. Medicate the client with an analgesic.
D. Remove all bandages prior to moving the client. - Answer
B. Explain the procedure to the client.
Rationale
Before implementing any new procedure, an explanation of the procedure should be provided
(B). Bringing large pieces of equipment into the client's room (A), such as a mechanical lift, may
alarm the client if the procedure has not been explained. The client should be medicated (C), but
first explaining what is involved in the procedure helps prepare the client for subsequent actions.
Dressing bandages provide protection for the wounds and help eliminate exposure to air, which
can cause pain, so removal should be done immediately prior to submersion in the bath (D).
, A client develops urticaria on the trunk and neck shortly after a secondary infusion of
piperacillin is initiated. In what order should the nurse implement these interventions? (Arrange
the actions in order of priority, with the highest priority first and least priority last or at the
bottom.)
A. Stop the infusion.
B. Assess vital signs.
C. Contact the healthcare provider.
D. Initiate adverse event report.
E. Document reaction to the drug. - Answer
1. Stop the infusion.
2. Assess vital signs.
3. Contact the healthcare provider.
4. Document reaction to the drug.
5. Initiate adverse event report.
Rationale
The client is exhibiting a drug reaction and quick action is required. When a drug reaction is
suspected, first the infusion should be stopped. Then vital signs and airway compromise should
be assessed and the findings reported to the healthcare provider. Documentation of the
occurrence, including a description of the rash and details of the reaction should be completed
after the healthcare provider is notified. Finally, and adverse drug reaction or adverse event
report should be completed.
The nurse is conducting intake interviews of children at a city clinic. Which child is most
susceptible to contracting lead poisoning?
A. An adolescent who works part time in a paint factory.
B. A 10-year-old who is an insulin-dependent diabetic (Type 1).
C. An 8-year-old who lives in a housing project.
D. A 2-year-old who plays on aging outdoor playground equipment. - Answer
D. A 2-year-old who plays on aging outdoor playground equipment.
Rationale
Children who ingest dust and soil and paint from playground equipment usually practice pica—
the habitual, purposeful, and compulsive ingestion of non-food products, characteristic of
toddlers (D). Lead enters the system by ingestion or inhalation, usually from paint, gasoline, dust
and soil, food, and water. Though (A) may present a hazard, governmental regulations decrease
the risk of contracting lead poisoning by requiring use of respirators in lead paint areas. (B) is not
related to lead poisoning. (C) does not practice pica the way a toddler does.
While changing a client's postoperative dressing, the nurse observes a red and swollen wound
with a moderate amount of yellow and green drainage and a foul odor. Given there is a positive
methicillin-resistant Staphylococcus aureus (MRSA), which is the most important action for the
nurse to take?
