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HESI Practice Test 225 -2 Questions and Complete Solutions Graded A+
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HESI Practice Test 225 -2 Questions and Complete Solutions Graded A+
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HESI Practice Test 225 #2 Questions andComplete Solutions Graded A+
As the nurse prepares the equipment to be used to start an IV on a 4-year-old boy in the treatment
room, he cries continuously. What intervention should the nurse implement?
Take the child back to his room.
Recruit others to restrain the child.
Ask the mother to be present to soothe the child.
Show the child how to manipulate the equipment. - Answer: Ask the mother to be present to soothe the
child.
Rationale
A 4-year-old typically has a vivid imagination and lacks concrete thinking abilities. The mother's
assistance (C) can provide a stabilizing presence to help soothe the preschooler, who may perceive the
invasive procedure as mutilating. To preserve the child's sense of security associated with the hospital
room, it is best to perform difficult or painful procedures in another area (A). (B) may be necessary to
prevent injury if the child is unable to cooperate with the mother's coaxing. (D) is best done before
going to the treatment room when the child feels less threatened.
In evaluating client care, which action should the nurse take first?
Determine if the expected outcomes of care were achieved.
Review the rationales used as the basis of nursing actions.
Document the care plan goals that were successfully met.
Prioritize interventions to be added to the client's plan of care.
Submit - Answer: Determine if the expected outcomes of care were achieved.
Rationale
In evaluating care, the nurse should first determine if the expected outcomes of the plan of care were
achieved.
,How should the nurse handle linens that are soiled with incontinent feces?
Put the soiled linens in an isolation bag, then place it in the dirty linen hamper.
Place an isolation hamper in the client's room and discard the linens in it.
Place the soiled linens in a pillow case and deposit them in the dirty linen hamper.
Ask the housekeeping staff to pick up the soiled linen from the dirty utility room. - Answer: Place the
soiled linens in a pillow case and deposit them in the dirty linen hamper.
Rationale
The nurse should be careful to keep the soiled linens from contaminating the fresh linens, and should
handle the soiled linens like any other dirty linen (C). (A, B, and D) are not indicated.
What action should the nurse implement when adding sterile liquids to a sterile field?
Use an outdated sterile liquid if the bottle is sealed and has not been opened.
Consider the sterile field contaminated if it becomes wet during the procedure.
Remove the container cap and lay it with the inside facing down on the sterile field.
Hold the container high and pour the solution into a receptacle at the back of the sterile field. - Answer:
Consider the sterile field contaminated if it becomes wet during the procedure.
Rationale
Wet or damp areas on a sterile field allow organisms to "wick" from the table surface and permeate into
the sterile area, so the field is considered contaminated if it becomes wet (B). Outdated liquids may be
contaminated and should be discarded, not used (A). The container's cap should be removed, placed
facing up, and off the sterile field, not (C). To prevent contamination of the sterile field, liquids should be
held close (6 inches) to the receptacle when pouring to prevent splashing, and the receptacle should be
placed near the front edge to avoid reaching over or across the sterile field (D).
The nurse formulates the nursing diagnosis of, "Ineffective health maintenance related to lack of
motivation" for a client with Type 2 diabetes. Which finding supports this nursing diagnosis?
Does not check capillary blood glucose as directed.
Occasionally forgets to take daily prescribed medication.
,Cannot identify signs or symptoms of high and low blood glucose.
Eats anything and does not think diet makes a difference in health. - Answer: Eats anything and does not
think diet makes a difference in health.
Rationale
The nursing diagnosis of ineffective health maintenance refers to an inability to identify, manage, and/or
seek out help to maintain health, and is best exemplified in the client belief or understanding about diet
and health maintainance (D). (A) indicates noncompliance with an action to be done in the management
of diabetes. (B) represents inattentiveness. (C) reflects knowledge deficit.
What intervention should the nurse include in the plan of care for a client who is being treated with an
Unna's paste boot for leg ulcers due to chronic venous insufficiency?
Check capillary refill of toes on lower extremity with Unna's paste boot.
Apply dressing to wound area before applying the Unna's paste boot.
Wrap the leg from the knee down towards the foot.
Remove the Unna's paste boot q8h to assess wound healing. - Answer: Check capillary refill of toes on
lower extremity with Unna's paste boot.
Rationale
The Unna's paste boot becomes rigid after it dries, so it is important to check distally for adequate
circulation (A). Kerlix is often wrapped around the outside of the boot and an ace bandage may be used
to cover both, but no bandage should be put under it (B). The Unna's paste boot should be applied from
the foot and wrapped towards the knee (C). The Unna's paste boot acts as a sterile dressing, and should
not be removed q8h. Weekly removal is reasonable (D).
The nurse is digitally removing a fecal impaction for a client. The nurse should stop the procedure and
take corrective action if which client reaction is noted?
Temperature increases from 98.8 to 99.0 F.
Pulse rate decreases from 78 to 52 beats/min.
Respiratory rate increases from 16 to 24 breaths/min.
, Blood pressure increases from 110/84 to 118/88 mm/Hg. - Answer: Pulse rate decreases from 78 to 52
beats/min.
Rationale
Parasympathetic reaction can occur as a result of digital stimulation of the anal sphincter, which should
be stopped if the client experiences a vagal response, such as bradycardia (B). (A, C, and D) do not
warrant stopping the procedure.
Which client care activity requires the nurse to wear barrier gloves as required by the protocol for
Standard Precautions?
Removing the empty food tray from a client with a urinary catheter.
Washing and combing the hair of a client with a fractured leg in traction.
Administering oral medications to a cooperative client with a wound infection.
Emptying the urinary catheter drainage bag for a client with Alzheimer's disease. - Answer: Emptying the
urinary catheter drainage bag for a client with Alzheimer's disease.
Rationale
Possible contact with body secretions, excretions, or broken skin is an indication for wearing barrier
(nonsterile) gloves. Emptying a urine drainage bag requires the use of gloves (D). (A, B, and C) do not
require gloves.
When the nurse enters a client's room to do an initial assessment, the client shouts, "Get out of my
room! I'm tired of being bothered!" How should the nurse respond?
"There is no reason to be so angry."
"Why do I need to leave your room?"
"What is concerning you this morning?"
"Let me call the client advocate for you." - Answer: "What is concerning you this morning?"
Rationale
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