HESI-Saunders Online Review- Module 10- Physiological Health
Problems Exam Latest Update 2024-2025 Questions and Verified
Correct Answers Guaranteed A+
A cardiac monitor alarm sounds, and a nurse notes a straight line on the monitor screen. The
nurse immediately: -Correct Answer: B. Assesses the client.
Explanation: If a monitor alarm sounds, the nurse should first assess the clinical status of the
client to see whether the problem is an actual dysrhythmia or a malfunction of the monitoring
system. Asystole should not be mistaken for an unattached electrocardiogram wire. If the client is
alert and the client's status is stable, the problem is likely an unattached cardiac lead or wire.
Calling a code and obtaining a rhythm strip from the monitor device are unnecessary if the client's
condition is stable.
A child with a diagnosis of pertussis (whooping cough) is being admitted to the pediatric unit. As
soon as the child arrives to the unit, the nurse first: -Correct Answer: C. Attaches the child to a
pulse oximeter.
Explanation: To adequately determine whether the child is getting enough oxygen, the nurse
attaches the child to a pulse oximeter. The pulse oximeter will then provide ongoing information
on the child's oxygen level. The child is also immediately attached to a cardiorespiratory monitor
to provide early identification of periods of apnea and bradycardia. Next the nurse performs an
assessment, including the child's temperature and weight, and asks the parents about the child.
An antibiotic may be prescribed, but the child's airway status must be assessed first.
A client arrives at the emergency department with complaints of a headache, hives, itching, and
difficulty swallowing. The client states that he took ibuprofen (Motrin) 1 hour earlier and believes
that he is experiencing an allergic reaction to this medication. After ensuring that the client has a
patent airway, which intervention does the nurse prepare the client for first? -Correct Answer: D.
Administration of a subcutaneous injection of epinephrine (Adrenalin).
Explanation: Once airway has been established, the client would be given subcutaneous
epinephrine. IV corticosteroids and IV fluids may also be prescribed. Pain medication may or may
not be prescribed.
A client arrives in the emergency department for treatment of a surface injury sustained when
sand blew into the eye. Which action does the nurse take first? -Correct Answer: A. Assessing
the client's vision.
Explanation: When a client has sustained a surface injury of the eye as a result of the introduction
of a foreign body, the nurse must first assess visual acuity. The eye is then assessed for corneal
abrasions; this is followed by irrigation with sterile normal saline solution to gently remove the
particles. Ice would be placed on the eye if the client had sustained an eye contusion.
A client has an arteriovenous fistula in place for hemodialysis. What should the nurse do to
assess the patency of the fistula? -Correct Answer: C. Palpate for a vibrating sensation at the
fistula site.
Explanation: An arteriovenous fistula is created in a surgical procedure in which an anastomosis is
created between an artery and a vein in the arm in an end-to-side, side- to-side, side-to-end, or
end-to-end fashion. In a patent fistula (or graft), a "thrill," or vibrating sensation, should be
palpable and a bruit should be audible with a stethoscope. An arteriovenous fistula is the client's
lifeline, and the nurse does not irrigate or infuse solutions into it. It is used only for hemodialysis.
A client has just had a plaster leg cast applied, and the nurse has given the client instructions on
,cast care. Which statement by the client indicates the need for further instruction? -Correct
Answer: D. "I can dry the cast faster if I use a hairdryer on the hot setting."
Explanation: Using a blow dryer on the hot setting to dry the cast is not advised because it may
burn the client's skin under the cast and crack the cast. While the cast is still damp, the client may
feel cold and may experience a decrease in body temperature. The client should never insert any
item under the cast because of the risk skin compromise. An odor coming from the cast could
indicate the presence of infection, warranting physician notification.
A client has undergone creation of an Indiana pouch for urine diversion after cystectomy, and the
nurse provides instructions about reservoir catheterization. The nurse tells the client: -Correct
Answer: A. To plan to drain the reservoir every 2 to 3 hours initially.
Explanation: An Indiana pouch is a continent internal ileal reservoir, and the nurse instructs the
client in the technique of catheterization. Initially the client drains the reservoir every 2 to 3 hours.
Each week thereafter, the interval is increased by 1 hour until finally catheterization is completed
every 4 to 6 hours during the day. The catheter is never forced into the reservoir. If resistance is
met, the client is instructed to pause and apply only gentle pressure while slightly rotating the
catheter. A 16F to 20F catheter is used; 26F is too large and could damage the reservoir. Mucus
is expected, and the client is instructed to irrigate the reservoir with 50 to 60 mL of normal saline
solution to prevent excessive mucus buildup.
A client in the third trimester of pregnancy is experiencing painless vaginal bleeding, and placenta
previa is suspected. For which of the following interventions does the nurse prepare the client? -
Correct Answer: A. An ultrasound examination.
Explanation: A manual pelvic examination or any action that would stimulate uterine activity is
contraindicated when vaginal bleeding is apparent in the third trimester until a diagnosis is made
and placental previa is ruled out. Digital examination of the cervix can lead to maternal and fetal
hemorrhage. A diagnosis of placental previa is made with the use of ultrasound. Electronic fetal
monitoring (external) is crucial in evaluating the status of the fetus that is at risk for severe
hypoxia, but internal fetal monitoring is contraindicated. Oxytocin would stimulate uterine
contractions and is therefore contraindicated.
A client is found to have AIDS. What is the nurse's highest priority in providing care to this client?
-Correct Answer: C. Instituting measures to prevent infection in the client.
Explanation: The client with AIDS has inadequate immune bodies and is at risk for infection. The
priority nursing intervention is protecting the client from infection. The nurse would also provide
emotional support to the client. Discussing the cause of AIDS and the ways in which AIDS is
contracted are not priority interventions.
A client is found to have viral hepatitis, and the nurse provides home care instructions to the
client. The nurse should tell the client to: -Correct Answer: D. Eat small frequent meals that are
low in fat and protein and high in carbohydrates.
Explanation: Fatigue is a normal response to hepatic cellular damage. During the acute stage,
rest is an essential intervention to reduce metabolic demand on the liver and increase its blood
supply, but strict bed rest is unnecessary. The client should avoid taking medications, including
acetaminophen (which is hepatotoxic), unless they are prescribed by the healthcare provider. The
client must avoid all alcohol consumption. The client should consume small frequent meals that
are low in fat and protein and high in carbohydrates to reduce the workload of the liver.
A client is transported to the recovery area of the ambulatory care unit after cataract surgery. In
which position does the nurse place the client? -Correct Answer: B. Semi-Fowler.
Explanation: After cataract extraction surgery, the client should be placed in the semi- Fowler
, position or on the unaffected side to prevent edema at the surgical site. Supine, on the affected
side, and prone are all incorrect because they will result in increased edema at the site.
A client who experienced a brain attack (stroke) exhibits right-sided unilateral neglect. The nurse
caring for this client plans to place the client's personal care items: -Correct Answer: B. Within
the client's reach on the right side
Explanation: Unilateral neglect is unawareness of one side of the body. The client behaves as if
that part is not there. The client does not look at the paralyzed limb when moving about. Unilateral
neglect results in increased risk for injury. It is possible for the client to relearn to look for and to
move the affected limb(s). Therefore in this condition the client's personal care items are placed
within the client's reach on the right side.nHemiparesis is a weakness of the face, arm, and leg on
one side. The client with one- sided hemiparesis benefits from having objects placed on the
unaffected side and within reach. This reduces client frustration and aids in ensuring client safety
because the client does not have to strain and reach for needed items. The nurse adapts the
client's environment to the deficit by focusing on the client's unaffected side and by placing the
client's personal care items on the affected side within reach. Placing items out of the client's
reach presents a risk of injury.
A client who experiences frequent episodes of chest pain is admitted to the hospital for cardiac
monitoring. The client suddenly complains of chest pain, and the nurse obtains a 12-lead
electrocardiogram (ECG). Which of the following findings would the nurse expect to note in the
event of an ischemic episode? -Correct Answer: B. ST- segment depression.
Explanation: An ECG taken in the presence of pain may reveal ischemic changes with ST-
segment elevation or depression. Peaked T waves may indicate hyperkalemia. PVCs are caused
by the firing of an irritable pacemaker in the ventricle. A widened QRS complex indicates a delay
in intraventricular conduction, such as bundle branch block.
A client who is recovering from a brain attack (stroke) has residual dysphagia. Which of the
following measures does the nurse plan to implement at mealtimes? -Correct Answer: B.
Alternating liquids with solids.
Explanation: The client with dysphagia may be started on a diet once the gag and swallow
reflexes have returned. Liquids should be thickened to help prevent aspiration. Food is placed on
the unaffected side of the mouth. Liquids are alternated with solids whenever possible to prevent
food from being left in the mouth. The client is assisted with meals as needed and is given ample
time to chew and swallow.
A client who sustained a fracture of the left arm requires the application of a plaster cast. The
nurse tells the client that the procedure for applying the cast involves: -Correct Answer: D.
Applying soft padding and stockinette over the fractured arm, followed by the application of the
cast material.
Explanation: To apply a cast, the skin is washed and dried well, but it is not soaked in a warm-
water bath. Padding is applied and a stockinette is placed smoothly and evenly over the area to
be casted. The plaster is then rolled onto the padding and the edges are trimmed or smoothed as
needed. Local anesthesia of the fractured extremity is not necessary, although an analgesic may
be administered to alleviate pain. A local anesthetic will block nerve sensation, and it is important
for the client to be able to report any changes in sensations after the cast is applied. If the client
has open wounds on the fractured extremity, a window will be cut in the cast to allow visualization
and treatment of the wound. A wound would not be covered with cast material.
A client with a leg fracture who has been placed in skeletal traction is transported to the
orthopedic unit after surgery. Which finding would indicate the need to contact the orthopedic
specialist? -Correct Answer: D. The traction ropes are unable to move over the pulleys.
