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2013 Hesi Version 1

1. Pregnancy Induced Hypertension: high blood pressure, blurred vision, headache, Proteinuria,
Abdominal pain
2. A client is comatose upon arrival to the emergency room department after falling from the roof. The
client flexes with painful stimuli, and the nurse determines the clients Glasgow Coma Scale (GCS) is
6. Which intervention should the nurse prepare to implement to maintain the clients airway. A
nasopharyngeal tube.
3.A client with rheumatoid arthritis reports a new onset of increasing fatigue. What intervention should
the nurse implement first? Answer: Assess the client for pallor
4.A client experiencing intracranial hypertension from a traumatic brain injury is admitted to the
trauma unit. How should the nurse position the client? Elevated head of bed.
5.Risk management: pt fell while using some equipment charge nurse trying to find out what
happened- how? - hospital polices
6. The nurse is assessing a 48-year-old client with Guillain-Barre syndrome. What symptom is this
client most likely to exhibit? Decreased mobility of the legs.
7. Preop pt should be npo and pt had a glass of h2o-what to do- Alert surgeon/physician.
8. The nurse is caring for a client diagnosed with myasthenia gravis. Which nursing action is best to
promote independence in this client? Teach the client and family energy conservation techniques.
9. The nurse is assessing a 2-week-old breastfeeding infant. To obtain information about the adequate
nutrition, which question should the nurse ask the breastfeeding mother? How many diapers does the
infant wet daily?
10. Zyvox & suprainfection stomatitis
11. Potassium Chloride- Client able to void, assuring kidney function is present.
12. The nurse has identified four nursing problems for a 13-year-old admitted for depression and
anxiety. What is the priority problem? Risk for self directed violence related to history of self
13. (Audio/visual)- ask to hear heart sounds- murmur (know difference between S1/S2 sounds
14. The nurse is teaching a client newly diagnosed with diabetes mellitus the signs of hypoglycemia.
What symptom should be included in the description of early signs of hypoglycemia? Tremors.
15. When you are giving asthma med which one would you give 1st: 1. bronchodilator 2. Steroid
16. A male client diagnosed with hypertension has a nursing goal of, the client will be able to
verbalize ways to decrease blood pressure. What statement by the client indicates that this outcome
has been met? if I loose weight, quit smoking, and exercise regularly I may not have to take any

17. (Select all that apply) Determining pain level for 3mo old infant- infant will clinch fists, increase
pulse, restlessness, increased respiratory effort
18 Penicillin G procaine (Wycillin) 135,000 units IM is prescribed for an infant with a middle ear
infection. The drug is available in a vial of 1,200,000 units /2ml. How many ml should the nurse
administer? 0.23. 1,200,000 : 2 ml :: 135, 000 : X 270/1200X = 0.225 ml = 0.23ml
19. Depressed client and best activity- assist client with making cut out cookies
20.The nurse is teaching a clients caregiver how to cleanse around a wound drain. What is the besy
way to explain the proper cleansing technique? Start at the drain site, to avoid bringing skin bacteria
toward the wound.
21. CPR priority Arrange in other -1. Establish unresponsiveness. 2. Call for help. 3. Assess patent
airway. 4. Assess pt carotid pulses. 155. A client with endometrial carcinoma is receiving
brachytherapy and has radioactive Cesium (Cs) loaded in a vaginal applicator. What action should the
nurse implement? Wear a dosimeter film badge when in the clients room
22. Math question with heparin you are given the ml/hr and the units you have to figure out how much
the patient is receiving which the answer is 2500
23.Alupent administration- The usual single dose is two to three inhalations. With repetitive dosing,
inhalation should usually not be repeated more often than about every three to four hours. Total dosage
per day should not exceed 12 inhalations. Alupent (metaproterenol sulfate USP) Inhalation aerosol is
not recommended for children under 12 years of age.
24. In scheduling home visits, which client is best for the home health charge nurse to begin to assign
to the licensed practical nurse? A bedfast client who needs daily irrigation of a stage 4 pressure ulcer.
25. A 65-year-old female client arrives in the emergency department with shortness of breath and chest
pain. The nurse accidentally administers 10 mg of morphine sulfate instead of 4 mg as prescribed by
the healthcare provider. Later, the client's respiratory rate is 10 breaths/minute, oxygen saturation is
98%, and she states that her pain has subsided. What is the legal status of the nurse? Answer: The
client would not be able to prove malpractice in court.
26. In completing the treatment plan for an 11-year-old who has bipolar disorder, the nurse plans
outcomes for the nursing diagnosis, Risk for violence towards peers related to impulsivity.Which
outcome is important? Seeks out staff when having thoughts of harming others. The most important
outcome is for the client to seek staff when thoughts of harming others occur.
27. The nurse is teaching a childbirth education class t prospective parents and describing possible
signs of labor. Class participants should be taught that which sign should be reported to the healthcare
provider immediately? Answer Leaking of fluid from the vagina
28.The nurse is performing a surgical hand scrub prior to entering the operating room. In what order
should the nurse perform the steps of this procedure? (Arrange from first on top on the last bottom).
Scrape under the nails with a nail pick. Rinse from the fingertips to the elbow. Use a soapy brush to

scrub the hands. Cleanse the arm with a lathered brush

29. How to do surgical scrubbing ( arrange in order)= clean nails, then hands, than arm, than u rinse the
whole thing off starting from fingertips to upper arm
30. An elderly client is admitted with a diagnosis of pneumonia. What sign or symptom would require
immediate intervention by the nurse? Has become agitated, aggressive and cinfused.
31. A client with gestational diabetes at 39-weeks gestation is in the second stage of labor. After
delivery of the fetal head, the nurse recognizes that shoulder dystocia is occurring. What intervention
should the nurse implement first? Answer Assist the client to sharply flex her thighs up against the
32.While assessing a clients blood pressure using an aneroid sphygmomanometer, the nurse inflates
the cuff to an initial reading of 160 mm calibration. Upon release of the air valve, the nurse
immediately hears loud Korotkoff sounds. What action should the nurse implement next? Answer:
Release the air and reinflate the cuff to 30 mm Hg above the clients previous systolic reading.
33. A 6-month-old male with bronchiolitis is admitted to the hospital. I monitoring the respiratory
status of the child, which symptom indicates to the nurse that he is experiencing respiratory distress?
Respiratory rate of 62 breaths/minute
34.Child w/ scabies what would u do to prevent complication- cut the nails and put mitten on
35 The healthcare provider prescribes oxytocin synthetic (Pitocin), 10 units/L via IV drip to augment a
clients labor because she is experiencing a prolonged active phase. Because the client is receiving
Pitocin, the nurse should closely monitor for which complication? Uterine Tetany
36. Hepatic encepahlopathy Ammonia.
37. A client with a deep vein thrombosis is receiving a heparin protocol based on a target partial
thromboplastin time (PPT) of 65 to 95 seconds. The clients current PTT result is 35 seconds. What
action should the nurse implement? Increasing the rate of the heparin infusion. Heparin acts to block
the conversion of prothrombin, which will effectively inhibit the formation of new clots. To achieve a
therapeutic heparinization and anticoagulation, the clients PTT should be within the therapeutic target
range of 65 to 95 seconds, so the nurse should increase the heparin infusion rate per protocol.
38. Female pt who being sexually and physically abused by bf and states I cant take it anymore= ask
her if she is thinking about suicide
39. A male Muslim client with pneumonia is scheduled to receive a dose of an intravenous antibiotic
but refuses to allow the nurse to begin the medication, stating he cannot allow fluids to enter his body
once he is cleansed for prayer. What action should the nurse implement? Reschedule administration of
the antibiotic until after he completes his prayers
40. Following the vaginal delivery of a 10-pound infant, the nurse assesses a new mothers vaginal
bleeding and finds that she has saturated two pads in 30 minutes and has a boggy uterus. What action
should the nurse take first? Perform fundal massage until firm

41. A 16-year-old female client who attempted suicide that morning is admitted to the psychiatric unit.
To determine the seriousness of the adolescents suicide attempt which question is most important for
the nurse to ask the family? How did she attempt to kill herself
42. What nursing intervention should the nurse include in the plan of care for a client following a bone
marrow aspiration? Use of a compression dressing for firm pressure to the site.
43.A client is admitted to the emergency room because of an overdose of acetaminophen (Tylenol).
Following gastric lavage, the nurse should expect to administer which medication? Answer
Acetylcysteine (Mucomyst) The antidote for acetaminophen (Tylenol) is acetylcysteine (Mucomyst)
44. The nurse observes that a client who is to avoid any weight-bearing on the left leg is using a 3point crutch gait for ambulation. What is the best action for the nurse to initiate? Encourage continues
use of the 3-point gait by the client
45.For increase magnesium level - Give calcium gluconate.
46.The practical nurse (PN) reports the patterns of urinary frequency and volume for several clients.
Which finding necessaitates assessment by the RN? Voiding 50ml cloudy urine every hour. The
symptoms of voiding cloudy urine, at frequent intervals, in small amounts is abnormal and may
indicate urinary retention and infection.
47. Feedings for low albumin Nepro, Ensure or TPN if pt is NPO.
48. Prioritrize question about tube feeding and how do you check it. Label, patient ID band, against the
MAR, and the physicians order.
49. A client with endometrial carcinoma is receiving brachytherapy and has radioactive Cesium (Cs)
loaded in a vaginal applicator. What action should the nurse implement? Wear a dosimeter film badge
when in the clients room
50. A client who suffered a stroke and is now on a ventilator receives nutritional supplements by the
tube feedings three times a day. The nurse checks the client for a residual volume before administering
the next feeding. Which statement best describes the rationale for this nursing intervention? Retention
of feeding in the stomach increase the likelihood of regurgitation and aspiration.
51.Motion sickness give transdermal scopolamine 4 hours before sailing in the sea for vacation.
52. Which client is at the greatest risk for suicide and should be managed with close observation? A
widowed white male who is a veteran of the Korean War.
54.Know the best diet for Crohns Disease- select High protein, high calorie, low fat diet with limited
lactose (Grilled chicken sandwich, pasta, etc was answer)
55. Is concerned about the type of legal consequences that can result from breaching client
confidentiality. What source states the legal requirements nurses must follow to protect client
confidentiality in a nurse-patient relationship? State Nurse Practice Acts
56.Which nursing intervention has the highest priority when completing discharge teaching for a client

with Helicobacter pylori (H.pylori) induced peptic ulcer disease (PUD)? Instruct the client to take all
the antibiotics, proton pump inhibitors and Pepto-Bismol.
57. An older client is transferred to the rehabilitation unit with the diagnosis of cerebrovascular
accident with left sided hemiplegia. The nurse addresses the client from the right side, and the client
points to the left leg and states, There is someones leg in my bed! What is the best response by the
nurse? Your stroke has impaired your ability to recognize that it is your leg
58. A mother tells the clinic that the healthcare provider wants her to begin introducing solid foods to
her 4-month-old infant. The nurse should recommend introducing foods in what order? (Arrange first
on top and last on the bottom) Rice cereal, starined apple, strained green and strained pureed.
59. Cultural Stereotyping know how to prevent that when you work with patient of different
60. The nurses assessment of a client admitted with a diagnosis of diabetic ketoacidosis (DKA)
include: scant urinary output, serum potassium level of 2.5 mEq/l, blood pH of 7.26, temperature 98F,
pulse 128 beats/minute, respirations 36 breaths/minute, and blood pressure 90/52. Which prescription
is most important for the nurse to implement? Pottasium IV at 20 mEq/250 ml over 1 hour.
61. Hep A- preicteric phase- know S/S Initial flu-like stage, patients may experience respiratory and
gastrointestinal tract symptoms, which may include malaise, fatigue, myalgia)
62.Fluids are restricted for a 4-year-old boy with acute poststreptococcal glomerulonephritis (AP
SGN). Which nursing intervention makes the fluid restriction less obvious to the child? Play a game of
tea party and serve the allowed amount of liquids in small medicine cups.
63. The nurse tests a clients visual acuity and determines that the uncorrected vision is 20/100 in the
right eye and 20/80 in the left eye. What does this finding indicate? Difficulty visualizing objects at a
distance also known as myopia.
64. The nurse knows that the blood urea nitrogen (BUN) can be expected to change as one ages. Which
statement best explains this expected change? BUN increases because of a decrease in renal
functioning and a decrease in cardiac output.
65. An infant has a medical diagnosis of tracheosophageal fistula (TEF). What nursing intervention is
indicated for his infant prior to surgical repair? Keep suction equipment available at all times.
66. Mechanical life support- equipment used
67. An Elderly man is having trouble urinating and unsteady he uses a wheelchair to walk to the
bathroom what should the nurse implement? provide a raised toilet seat.
68. The healthcare provider hands a newborn to the circulating nurse during a cesarean delivery. What
action should the nurse implement first? Dry the infant under a warming unit.
69 Treatment for VF- Vasopressin
70.A client is known to have an irregular respiratory rate with periods of apnea lasting 10 to 15
seconds. Currently, the nurse counts 22 respiratory cycles in a 30 second interval followed by an apneic

period. What intervention should the nurse implement?

71. A patient with inverted nipples what should the nurse do for the client? provide a breast shield.
72. Anterior Fontanel- to protect, sit baby up
73. The alarm of a clients pulse oximeter sounds and the nurse notes that the oxygen saturation rate is
indicated at 85%. What action should the nurse take first? Administer oxygen by face mask.
74. A client who developed Syndrome of inappropriate Antidiuretic Hormone (SIADH) associated with
small cell carcinoma of the lung is preparing for discharge. When teaching the client about selfmanagement with demeclocycline (Declomycin), the nurse should instruct the client to report which
condition to the healthcare provider?
75. Prioritrize question about tube feeding and how do you check it the answers are label, patient ID
band, against the MAR, and the physicians order.
76. 147. Community Planning Interventions for Mothers- most beneficial to provide vitamins to high
risk pregnant mothers in the area
77. Which approach is best for the nurse to use when communicating with a client with amyotrophic
lateral sclerosis (ALS) Demonstrate a positive caring a demeanor
78. What action should the nurse implement first when delegating nursing activities to an unlicensed
assistive personnel (UAP) Answer: Evaluate the experience of the UAP
79. At 28 wks gestation- pulse increases is normal
80. The nurse is triaging victims of a tornado that hit a housing area outside of town. Which client
would the nurse issue a black disaster tag to? A 59-year old
81. Genital herpes medication Acyclovir.
82. An adult male who admits to abusing IV drugs obtains the results of HIV testing. When informed
that the results are positive, he states that he does not want his wife to know. What action should the
nurse take? Counsel the client about the importance of notifying his sexual partner.
83. The nurse observes that a client who is to avoid any weight-bearing on the left leg is using a 3point crutch gait for ambulation. What is the best action for the nurse to initiate? Encourage continues
use of the 3-point gait by the client
84. 5yr old burn victim has pot of hot liquid fall on him,what should nurse tell mother to do
first- nurse should tell mother to remove clothing and place in cool bath
85. When planning nursing care for immobilized clients, the nurse should consider which physiological
alterations that frequently occur with immobility? (Select all that apply.) Urinary stasis, Venous
pooling and Bony demineralization.
86. Secondary polycythemia increases stimulation of red blood cells, increase exposure

87. A female client with fibromyalgia asks the nurse to arrange for hospice care to help her manage the
severe, chonic pain. Which interdisciplinary team member should the nurse consult to assist the client?
Pain specialist
88. A one-day old neonate is awaiting surgical correction of a myelomeningocele. During the
preoperative period what is the priority nursing intervention? Observe for CNS infection related to sac
89. Chest tube disconnect( Put the end of the tube in a sterile bottle fill with Normal saline and connect
back to patient)
90. A 50 year old male client has just been informed that he will require open heart surgery. He tells the
nurse, This will change my whole life. Nothing will ever be the same again. What action should the
nurse implement? Encourage the client to discuss his perceptions of the changes his life will undergo.
91. Client has a Lithium Rx level of 0.54 (know Lithium ranges- Low, so the answer is to ask client if
they have been taking their medication everyday
92. The nurse is assessing a client with hypothyroidism and knows that these clients are at risk for
myxedema coma. What symptoms indicate that the client is developing this condition? A Hypothermia,
decreased cardiac output, and decreased respiratory functioning
93. In establishing goals for the clients plan of care, which information is most important for the nurse
to consider? Nursing diagnoses.
94. You conduct CPR on intubated client and detects palpable pulse during 2-min cycle of chest
compressions, absent breath sounds over left lung, what to do Next- prepare for the endotracheal tube
to be repositioned
95. Mother believes baby is evil- mother exhibiting delusional thoughts
96. Following a precipitous labor, a client has a continuous trickling of bright red blood from her
vagina. Her uterus is firm and her vital signs are within normal limits. The nurse determines that the
clients symptoms may indicate which condition? A cervical laceration
97. Pre bed bath assessment what would you say to CNA on the activity level of the pt
98. The nurse is administering sodium polystyrene sulfonate (Kayexalate) to a client in acute renal
failure. Which normal finding indicates that the medication has been effective? Serum potassium level
of 4.3 mEq/L.
99. Pressure Ulcer: Turning the pt n noticing no pressure, redness, and pt doesnt complain of pain
100. Before administering a prescribed dose of tetracycline (ACHROMYCIN), what serum lab test
should the nurse monitor? Creatine.
101. Diabetes Insipidus fluid imbalance and that hypophysectomy leads to DI and the patho
102. An infant admitted to the neonatal intensive care unit is tachypneic, tachycardia, and has bounding

brachial pulses. The healthcare provider suspects that the infant has coarctation of the aorta. Which
intervention is most important for the nurse to include in this infants plan of care? Monitor for
congestive heart failure
103. The nurse is assessing an unresponsive client who ingested an unknown number of meperidine
(DEMOROL) 50mg tablets. Naloxone (NARCAN) 0.4mg IV is administered, and the client is now
responding to verbal stimuli. Which finding in the next hour requires immediate action by the nurse?
Difficulty in arousing.
104. The nurse is caring for a client in the Medical Intensive Care Unit. What problem is a client
probably experiencing who has an easily obliterated radial pilse and below-normal pressures, including
blood pressure (BP), central venous pressure (CVP), pulmonary artery pressure (PAP), and pulmonary
under pressure? Hypovolemic shock.
105. Cystic Fibrosis (Autosomal recessive) know the inheritance, what are the chances the children
will get it if both parents are carriers? Cystic fibrosis is an inherited chronic disease that affects
the lungs and digestive system, diagnosis in child before 1yr old, seen in whites, condition is
inherited in an autosomal recessive pattern, which means both copies of the gene in each cell have
mutations. The parents of an individual with an autosomal recessive condition each carry one copy of
the mutated gene, but they typically do not show signs and symptoms of the condition. When both
parents carry mutation, each child has a 1-in-4 chance of having CF
106. PRI interval - depolarization and repolarization
107. K+ and lasix its not potassium sparing Aldactone
109. The charge nurse is implementing a quality assurance policy and accompanies a nurse while
administering medications. The nurse identifies a male client by asking him to state his name prior to
administering the medication.Which action should the charge nurse implement? Tell the nurse in a
private area that the clients identification was incomplete.
110. Which surveillance clues are specific potential indicators of a bioterrorism attack? (Select all that
apply.) Geographic clustering of client illnesses and Unusual age distributions for a common disease.
111. While assigned to care for clients on a surgical unit, the nurse receives a personal phone call about
a family emergency that requires the nurse to leave immediately. What action by the nurse is most
important? Notify the charge nurse of the situation and of the need and leave immediately.
112. A female client is instructed to do Kegel exercises. What statement indicates to the nurse that the
client understands how to perform these exercises? When I urinate I should tighten those muscles and
stop the flow of urine for 10 seconds and repeat this 5 to 10 times
113. Which is the highest for carcinogenic shock= pt whom had a traumatic amputation from the groin
down, there one of the choice a pt w/ gunshot wound to the chest and abdomen HESI HINT: if
Cardiogenic shock exits in the presence of pulmonary edema (ex. from pump failure), position pt to
reduce venous return (high fowlers w/ legs down) in order to reduce further venous return to the left
114. When obtaining a health history a male client tells the nurse that, he has become impotent. What

part of his health information is likely to be most significant to the sexual dysfunction he is
experiencing? The client Was diagnosed with diabetes mellitus 10 years ago
115. Coreg Risk - contraindicated in asthma pt.
116. TURP assessment for pain- Transurethral resection of the prostate (TURP) is a type of prostate
surgery done to relieve moderate to severe urinary symptoms caused by an enlarged prostate. During
TURP, a combined visual and surgical instrument (resectoscope) is inserted through the tip of your
penis and into the tube that carries urine from your bladder (urethra). The urethra is surrounded by the
prostate. Using the resectoscope, your doctor trims away excess prostate tissue that's blocking urine
flow. benign prostatic hyperplasia (BPH
117. Drug: Percodia - drug containing aspirin It also has oxycodone (pain) and aspirin (salicylate)
118. Pathophysiology of Guillian Barr Syndrome!!! - Guillain-Barre Syndrome is a disorder in which
your body's immune system attacks the nerves. Weakness and tingling in the extremities are usually the
first symptoms. These sensations can quickly spread, eventually paralyzing your whole body. In its
most severe form, Guillain-Barre syndrome is a medical emergency requiring hospitalization. The
exact cause of Guillain-Barre syndrome is unknown, but it is often preceded by an infectious illness
such as a respiratory infection or the stomach flu. There's no known cure for Guillain-Barre syndrome,
but several treatments can ease symptoms and reduce the duration of the illness. Most people recover
from Guillain-Barre syndrome, though some may experience lingering effects from it, such as
weakness, numbness or fatigue.
119. Know which position for a pt that had bone marrow taken out. BM aspiration site: iliac crest.
120. A client admitted to the hospital is suspected of having meningitis. The nurse should plan to
prepare the client for which diagnostic test? Lumbar puncture
121. The nurse is performing an intake interview at a prenatal clinic. Which planned activities
described by the client who is at 6 weeks gestations will the nurse investigate first? Supervision of the
renovation of an old house the family just purchased due to teratogen defect.
122. A client in acute renal failure has a serum potassium level of 6.3 mEq/L. What medication can the
nurse expect the healthcare provider to prescribe? Kayexalate retention enema.
123. The nurse is administering oxygento a client with pulmonary edema when a family member asks
the nurse why the client needs oxygen. Which pathophysiological mechanism should the nurse explain
to his family member? Fluid collects in the chest cavity and keeps the lungs from expanding.
124. During shift report, the nurse learns that a postoperative client has atelectasis. What nursing
diagnosis should the nurse expect to include in the clients plan of care? Impaired gas exchange.
125. Fibrocystic Breast = Answer = Caffeine- the disease is painful, lumpy breasts Some women feel
that eating chocolate, drinking caffeine, or eating a high-fat diet can cause their symptoms, but there is
no clear proof of this, worse right before the menstrual period. Treatment- acetaminophen or
ibuprofen, Use heat or ice on the breast, wear a well-fitting bra
126. Triage - put in order: 1. wondering man, 2. woman w/blanket, 3. man holding baby, 4. parents

looking for son.

127. A hospitalized clients bronchoscopy specimen culture result indicates the presence of the
Mycobacterium tuberculosis organism. Which intervention is most important for the nurse to
implement? Put the client in a room with negative airflow system.
128. A client with gestational diabetes at 39-weeks gestation is in the second stage of labor. After
delivery of the fetal head, the nurse recognizes that shoulder dystocia is occurring. What intervention
should the nurse implement first? Assist the client to sharply flex her thighs up against the abdomen
129. While assessing a client with wrist restraints the nurse first slides two fingers under the restraints
and then notes that the ties are secured to the side rail using a quick-release tie. What action should the
nurse implement? Reposition the restraints ties, securing them to the bed frame
130. While reporting a clients blood glucose results to the nurse the LPN states that, the glucometer
was not calibrated prior to use because the report given by the night shift staff ran late. What action is
most important for the nurse to perform? Advise the LPN of the implications involved by not
calibrating the glucometer
131. Patient is on radioactive chemotherapy = have the nurse be in the pt room for 30min with cluster
care (this was a hard one just look up nursing care for pt on chemo)
132. Understand the reason for Z track method( it use for IM) prevent leakage
133. A client from a nursing home is admitted with urinary sepsis and has a single-lumen, peripherallyinserted central catheter (PICC). Four medications are prescribed for 9:00 a.m.and the nurse is running
behind schedule. Which medication should the nurse administer first : (Zosyn) over 30 minutes q8
134. During a family baseball game, an adult male is hot on the head with a bat, and he is suspected of
sustaining an epidural bleed. What Is the most important information for the emergency center nurse to
obtain form the clients spouse, who witnessed his injury? Was your husband knocked out by the
135. An 86-year-old female client complains to the nurse that she does not like to eat as much as she
used to because things taste differently to her now that she is older. The nurses response should be
based on which fact? A loss of appetitie often occurs in older adults as a result of a decreased sense of
136. A client with a compound fracture of the left ankle is being discharged with a below-the-knee cast.
Before being discharged, the nurse should provide the client with what instructions?
137. A 9-month old child with diarrhea, vomiting and malaise= Ask the mother on the onset of
138. An infant who is jittery and I think it said crying, what should the nurse do firs t= Assess blood
139. A client in acute renal failure has serum potassium of 7.5mEq/L. based on this finding, the nurse

should anticipate implementing which action? Administer a retention enema of Kayexalate

140. A pt with COPD who state that he is using is inhaler right, what should the nurse indicate the pt is
not using the inhaler properly= Pt states that he only uses the inhaler when he is having respiratory
141. CPR for a pregnant lady= will give Heimlich w/ chest compression HESI HINT: At 20wks
gestation & beyond, the gravid uterus should be shifted to the left by placing the women in a 15-30
degree angled, left lateral position or by using a wedge under her right side to tilt her to her left
142. Pyelonephritis symptoms - elevates temperature
143. The nurse observes tha a client has received 250 ml of 0.9% normal saline through the IV line in
the last hour. The client is now tachypneic, and has a pulse rate of 120 beats/minute, with a pulse
volume of +4. In addition to reporting the assessment findings to the healthcare provider, what action
should the nurse implement? Decrease the saline keep-open rate. The nurse should decrease the rate of
the IV solution to keep-open rate to avoid further fluid volume overload while awaiting a change in
prescription from the healthcare provider.
144. On osteoporosis= weight bearing physical activity
145. Education about DM= to increase knowledge on the disease process and treatment
146. Cerebral palsy prognosis neurological disorders that appear in infancy or early childhood and
permanently affect body movement and muscle coordination. Cerebral palsy doesnt always cause
profound disabilities. While one child with severe cerebral palsy might be unable to walk and need
extensive, lifelong care, another with mild cerebral palsy might be only slightly awkward and require
no special assistance. Supportive treatments, medications, and surgery can help many individuals
improve their motor skills and ability to communicate-symptoms, paraplegia, quadriplegia, hemiplegia,
seizure, retardation, learning issues, behavior, bladder bowel bone issues
147. A 60yrs Pt with advance prostate cancer which response indicate that he accept his prognosis or
illness = Pt admits that he has support of family & friends use your judgment on this one)
Community primary prevention
148. The risk for metabolic shock syndrome Toxic Shock Syndrome
149. Side effects of aspirin- (Reye syndrome in kids) Overdose may happen if your kidneys do not
work correctly or when you are dehydrated. Signs include ringing in the ears, deafness, hyperactivity,
dizziness,drowsiness, seizures, coma, Treatment-fluids, activated charcoal, laxative, IV of potassium,
sodium bicarb
150. The nurse is reviewing the medical history of a client who is scheduled for a parathyroidectomy.
Which disorder in the clients history is most likely to be impacted by the surgery? Osteoporosis.
151. A female client reports that she drank of a liter of a solution to cleanse her intestines for a
colonoscopy. How many ml of fluid intake should the nurse document? (Enter numeric value only. If
rounding is required, round to the nearest whole number.) 152. First convert the liter to ml: 1L 1000
= 1000ml. Next multiply 1000 by = 750 ml.

152. The nurse is instructing a client who is newly diagnosed with Addison's disease. Which of the
following should the nurse include when discussing the manifestations of this disease with the client?
Hyperkalemia, hyponatremia, and hypoglycaemia.
153. A client is admitted to the nursing unit with a possible bowel obstruction. The nurse osculates
high-pitched bowel sounds in the upper quadrants of the clients abdomen. What is the significance of
this finding? Provides data about the location of the obstruction. High-pitched bowels sounds may be
ausculated above the bowel obstruction early in the obstructive process as peristalsis initially increases,
and may help determine the location of the obstruction.
154. Inserting NG tube in client that becomes cyanotic- withdraw NG tube (1st action)
155. Client in labor, you call the provider and he has slurred words, loud noise in background, and
seems intoxicated- you should contact the healthcare providers associate, not the medical director
156. After a sexual assault, the nurse collects evidence for 6hrs then should do what- maintain
possession of the evidence collection kit at all times
157. A 93 year-old male client is brought to the emergency room by a group of fraternity brothers after
a hazing event at the university. The client arrives with a blood alcohol level (BAL) of 3.8 and a
Glasgow Coma Scale of 3. Which action should the nurse implement first? Initiate IV access using
Lactated Ringers solution 1000ml with thiamine 100mg. Hydrating the client and providing thiamine
(Vitamin B) to prevent neurological insult from ethanol toxicity are the highest priority interventions.
158. The nurse is preparing to administer vancomycin (Vancocin) 500mg in 200 ml of D6W, and
based on the manufacturers recommendation, the nurse plans to administer the dosage over 90
minutes. The secondary infusion pump should be set to administer how many ml/hour? (Enter numeric
value only. If rounding is required, round to the nearest whole number.) 133. 200ml of the antibiotic is
to infuse over 90minutes. 200ml divided by 90minutes/hour equals 133.33=133ml/hour.
159. BNP prescribed diuretic 500 indicates HF
160. Pancreatitis maintain IV: 125 ml/hr