Exam (elaborations)
MS HESI 160 QUESTIONS AND ANSWERS
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MS HESI 160 QUESTIONS AND ANSWERS
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MS HESI 160 QUESTIONS AND ANSWERSThe nurse reviews the laboratory results of a client during an annual physical
examination and identifies a positive guar test of stool. Which additional serum
laboratory test result should the nurse review?
A. Glucose
B. Platelet count
C. White blood cell count
D. Amylase - answer- B
A client who had a bliliopancreatic diversion procedure (BDP) 3 months ago is admitted
with severe dehydration. Which assessment finding warrants immediate intervention by
the nurse?
A. Strong would smelling flatus
B. Gastrooccult positive emesis
C. Complaint of poor night vision
D. Loose bowel movements - answer- B
Patient had atrial fibrillation and then AED was used. One minute later, patient sudden
goes into ventricular tachycardia. What should the nurse do? - answer- Administer
Adenosine over 1-2 seconds IV
An older adult with heart failure is hospitalized during an acute exacerbation. To reduce
cardiac workload, which intervention should the nurse include in the client's plan of
care?
A. Assist with ambulation in the hallway
B. Encourage active range of motion exercises
C. Provide a bedside commode for toileting
D. Teach to sleep in side lying position - answer- C
External fixation device-what should the nurse do first? - answer- Assess for peripheral
pulse at the foot
An older adult man recently diagnosed with chronic obstructive pulmonary disease
(COPD) is admitted with shortness fo breath. The nurse observes the client sitting
upright and leaning over the bedside table, using accessory muscles to assist in
breathing. What action should the nurse take?
A. Assist the client to a high Fowler's position in bed
B. Observe the client for the presence of a barrel chest
C. Prepare to transfer the client to a critical care unit
D. Instruct the client in pursed cup breathing techniques - answer- D
An older adult women is seen in the clinic 3 months following her diagnosis of type 2
diabetes mellitus (DM). She tells the nurse that she has had a difficult time keeping her
blood sugar in control. The nurse reviews the client's current finger-stick and daily log of
,blood glucose levels. Which intervention is most important for the nurse to implement? -
answer- Review the clients glycosylated hemoglobin (A1C) level
The nurse is taking a client's blood pressure and observes carpal spasm after the
sphygmomanometer cuff is inflated. What action should the nurse implement next? -
answer- Assess the clients recent serum calcium level
A male client is recovering from an episode of urinary tract calculi. During discharge
teaching, the client also asks about the dietary restriction he should following. In
discussing fluid intake, the nurse should include which type of fluid limitation?
A. Low sodium soups
B. Over-all fluid intake
C. Tea and hot chocolate
D. Citrus fruit juices - answer- C
A patient is having a seizure is assisted to the floor. Which is priority? - answer- Monitor
for : apnea
A male client has urinary dripping at night: - answer- Palpate bladder above the pubic
symphysis
Patient is unable to wear his shoes: - answer- Ask about weight
Sodium level is 117 client may be in acute renal failure. With excessive water retention
the sodium levels appear decreased (dilution). Nursing diagnostic? - answer- Excess
fluid volume
Decreased peripheral pulses: - answer- Doppler sound
CVA occurs in: - answer- Carotid arteries
In teaching a client newly diagnosed with multiple sclerosis (MS), which approach
should the nurse emphasize as most likely to prevent an exacerbation of symptoms? -
answer- Develop preplanned mechanisms to avoid or minimize the effects of triggers
While assessing a client in a supine position, the nurse observes jugular vein distention.
The client's vital signs are: heart rate 110 beats/minute, respirations 28 breaths/minute,
and blood pressure 160/88. What action should the nurse take? - answer- Raise the
head of the bed 45 degrees
A client is recovering from a transurethral prostectomy. Which activity should be limited
until after the first postoperative visit with his healthcare provider? - answer- Driving a
car
A client who has a history of hypothyroidism was initially admitted with lethargy and
confusion. Which additional finding warrants the most immediate action by the nurse? -
answer- Further decline in level of consciousness
,After a computer tomography (CT) scan with intravenous medium, a client returns to the
room complaining of shortness of breath and itching. Which intervention should the
nurse implement? - answer- Prepare a dose of epinephrine (adrenalin)
A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions.
How should the nurse respond? - answer- Describe the use of an elimination diet to find
trigger foods
A female college student comes to the school's health clinic complaining of urinary
frequency and burning with right lower back pain. Which intervention should the nurse
implement first? - answer- Measure her temperature and pulse rate
When preparing a teaching plan for a client newly diagnosed with diabetes mellitus, the
nurse should describe which situation as requiring the most immediate action by the
client or family? - answer- Hypoglycemic shock
Client is about to go to physical therapy but before that she is having a wound
debridement (whirlpool therapy)? What should the nurse do? - answer- Give analgesic
An adult female client is diagnosed with restless leg syndrome and referred to the sleep
clinic. The Healthcare provider prescribes ferrous sulfate (Feosol) 325 mg PO daily.
Which lab values should the nurse monitor?
A. Serum electrolytes
B. Neutrophils and eosinophils
C. Serum iron and ferritin
D. Platelet count and hematocrit - answer- Check serum iron and ferritin
Patient complaining of pain in back/sacrum area - answer- Check vital signs first
Patient complaining of leg pain - answer- Check peripheral pulses
How should the patients wife cope with changes to this lifestyle? - answer- Ask what
she wants and how she would participate in her husband's care
The UAP has lowered the head of the bed for a client on tube feeding. What is the
nurses priority action? - answer- Priority intervention is to ensure client's bed is elevated
to reduce the risk for aspiration
What should the nurse put on the client before suctioning the oral cavity? - answer-
Protective gear should be worn
How should the nurse assess for a gag reflex? - answer- Place tongue blade on back
half of the tongue
, Which position reduces the risk for injury to the client? - answer- Feet positioned directly
on the floor in front of the wheelchair
Which mask is used? - answer- The top edge of a surgical mask should be secured
A client is approaching near death. What is the best response? - answer- Listen and
help goals preserve sense of hopelessness
What assessment for patient's gait and posture ADL's? - answer- Assess activity
tolerance before determining ability to perform ADL's
What is the most therapeutic response when her boyfriend is visiting? - answer- Broad
opening that encourages to talk
Before administering pain medication, what assessment is used? - answer- Pain level
scale
A patient is at risk for metabolic syndrome associated with obesity and physical
inactivity? - answer- Measurement of waist circumference (skills done by PN)
What may contraindicate function - answer- significant decrease in nuerosensory
function
Patient with obstructive sleep apnea syndrome (OSAS) Which teaching is effective? -
answer- Advise patient to avoid alcoholic beverages 3 hours prior to bedtime
Nasal canula-skin breakdown: - answer- Assess for skin damage that may occur
Clients inability to control the urinary sphincter when the urge to urinate is felt - answer-
Bedside commode 2 hour to train bladder
Navaso people: - answer- Direct eye contact interview is respect
Patient uses accessory muscles too breath. What does this mean? - answer- Indicates
increase respiratory effort by the client
What should the nurse talk do first when speaking with patient? - answer- Ask family
members to leave the room
When providing care for a client following a bronchoscopy, which assessment finding
should the nurse immediately report to the health care provider?
A. Slight blood tinged sputum
B. Dyspnea and dysphagia
C. Sore throat and hoarseness
D. No gag reflex after thirty minutes - answer- B
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