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HESI HEALTH ASSESSMENT EXAM 2
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HESI HEALTH ASSESSMENT EXAM 2
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BSN 246 PRACTICE HESI (1 & 2)The registered nurse (RN) is caring for a young adult who is having an oral
glucose tolerance tests (OGTT). Which laboratory result should the RN assess as
a normal value for the two hour postprandial result?
140 mg/dl.
160 mg/dl.
180 mg/dl.
200 mg/dl.
140 mg/dl.
Rationale
The two hour postprandial level should be less 140 mg/dl for a young adult client.
The registered nurse (RN) is caring for a client who has a closed head injury from
a motor vehicle collision. Which finding should the RN assess the client for the
risk of diabetes insipidus (DI)?
High fever.
Low blood pressure.
Muscle rigidity.
Polydipsia.
Polydipsia.
Rationale
A characteristic finding of DI is excretion of large quantities of urine (5 to
20L/day), and most clients compensate for fluid loss by drinking large amounts of
water (polydipsia). DI can occur when there has been damage or injury to the
pituitary gland or hypothalamus as a result of head trauma, tumor or an illness
such as meningitis. This damage interrupts the ADH production, storage and
release causing the excessive urination and thirst.
The registered nurse (RN) is caring for a client who developed oliguria and was
diagnosed with sepsis and dehydration 48 hours ago. Which assessment finding
indicates to the RN that the client is stabilizing?
Urine output of 40 mL/hour.
,Apical pulse 100 and blood pressure 76/42.
Urine specific gravity 1.001.
Tented skin on dorsal surface of hands.
Urine output of 40 mL/hour.
Rationale
A decrease in urinary output is a sign of dehydration. When the urine output
returns to a normal range, 40 mL/hour, the client's kidneys are perfusing
adequately and indicates the client's status is stablizing.
A client who is uses ipratropium reports having nausea, blurred vision,
headaches, and insomnia after using the inhaler. Which action should the
registered nurse (RN) implement first?
Withhold medication and report symptoms and vital signs to healthcare provider.
Give PRN medication for nausea and vomiting and evaluate client in 30 minutes.
Reassure client that the ipratropium given will alleviate the symptoms.
Delay administration of ipratropium until next maintenance medication is scheduled.
Withhold medication and report symptoms and vital signs to healthcare provider.
Rationale
Headache, nausea, blurred vision and insomnia are symptoms of excessive use
of ipratropium, so withholding the medication until the healthcare provider is
notified should be initiated to maintain client safety.
The registered nurse (RN) is assessing a client who was discharged home after
management of chronic hypertension. Which equipment should the RN instruct
the client to use at home?
Exercise bicycle.
Sphygmomanometer.
Blood glucose monitor.
Weekly medication box.
Sphygmomanometer.
Rationale
Self-awareness is the best way for a client to manage chronic hypertension, so
the client should obtain a sphygmomanometer and learn how to monitor blood
pressure daily and maintain a record.
, The registered nurse (RN) is teaching a client who is newly diagnosed with
emphysema how to perform pursed lip breathing. What is the primary reason for
teaching the client this method of breathing?
Decreases respiratory rate.
Increases O2 saturation throughout the body.
Conserves energy while ambulating.
Promotes CO2 elimination.
Promotes CO2 elimination.
Rationale
Pursed lip breathing helps eliminate CO2 by increasing positive pressure within
the alveoli increasing the surface area of the alveoli making it easier for the O2
and CO2 gas exchange to occur .
The registered nurse (RN) reviews the new prescription, phenelzine (Nardil), a
monoamine oxidase inhibitor (MAOI), for a client on the psychiatric unit with
depression. Which information is most important for the RN to assess?
Consumption of any alcohol or tyramine-rich foods.
Complaints of nausea or vomiting.
Therapeutic serum drug levels.
Blood pressure and pulse prior to taking each dose.
Consumption of any alcohol or tyramine-rich foods
Rationale
The consumption of any type of tyramine containing foods such as aged
cheeses, fermented fruits and vegetables, smoked or cured meats, dark wines
and other alcoholic products should be avoided when a client is prescribed a
MAOIs due to the a food-drug interaction causing a hypertensive crisis which can
lead to a hemorrhagic stroke.
A registered nurse (RN) is performing a mini-mental state examination (MMSE) for
a client who is being admitted to an assisted living community. Which
communication techniques should the RN implement to decrease anxiety in the
client? (Select all that apply.)Select all that apply
Use simple sentences during the examination.
Move to another question if the client seems confused.
Reduce environmental detractors during the examination.
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