HESI Questions with Correct Answers

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When performing blood pressure measurement to assess for orthostatic hypotension, which action should the nurse implement first? A: Apply the blood pressure cuff securely. B: Record the client's p ... ulse rate and rhythm. C: Position the client supine for a few minutes. D: Assist client to stand at bedside. -ANSWERS-C: Position the client supine for a few minutes. The home health nurse is reviewing the personal care of an elderly client who lives alone. Which client assessment findings indicate the need to assign the UAP to provide routine foot care and file the client's toenails?(SATA) A: Syncope when bending. B: Hand tremors. C: Diminished visual acuity. D: Urinary incontinence. E: Shuffling gait. -ANSWERS-A, B, C An older woman with end-stage heart disease is hospitalized for severe heart failure. She is alert, oriented, and requests that no heroic measures are implemented if her breathing stops. What actions should the nurse take first? A: Discuss with the client her meaning of heroic measures. B: Obtain a DNR. C: Set up a family conference to discuss the client. D: Consult the palliative care team about the client's care. -ANSWERS-A: Discuss with the client her meaning of heroic measures. **When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next? A: Modify the nursing interventions to achieve the client's goals. B: Determine if the expected outcomes were realistic. C: Review related professional standards of care. D: Obtain current client data to compare with expected outcomes. -ANSWERS-D: Obtain current client data to compare with expected outcomes. A client with limited tolerance for activity needs to walk in the hallway with assistance. Which instructions should the nurse give to the UAP who is assisting with the client's care?(SATA) A: Instruct the client about signs of orthostatic hypertension. B: Determine if the client needs to have a gait belt applied. C: Measure the client's vital signs before the client walks. D: Offer to assist the client to void prior to walking in the hall. E: Report the onset of any dizziness or lightheadedness. -ANSWERS-C: Measure the client's vital signs before the client walks. D: Offer to assist the client to void prior to walking in the hall. E: Report the onset of any dizziness or lightheadedness. A client is in contact isolation due to a stage IV coccyx wound infected with methicillin resistant staphylococcus aureus (MRSA). The nurse plans interventions to prevent multiple re-entries to the client's room. In which order should the nurse perform the interventions? A: Change coccyx dressing, perform tracheostomy care, restart the IV. B: Perform tracheostomy care, change coccyx dressing, restart the IV. C: Restart the IV, perform tracheostomy care, change coccyx dressing. D: Change coccyx dressing, restart the IV, perform tracheostomy care. -ANSWERS-C: Restart the IV, perform tracheostomy care, change coccyx dressing. A male Native American presents to the clinic with complaints of frequent abdominal cramping and nausea. He states that he has chronic constipation and had not had a bowel movement in 5 days, despite trying several home remedies. Which intervention is most important for the nurse to implement? A: Determine what home remedies were used. B: Assess for the presence of an impaction. C: Obtain list of prescribed home medications. D: Evaluate stool sample for presence of blood. -ANSWERS-A: Determine what home remedies were used. What information is most important for the nurse to obtain in determining a client's need for referral for obesity counseling? A: Body weight 10% over ideal weight. B: Body mass index greater than 35. C: Daily caloric intake of 3500 calories. D: Client's expressed desire to lose 50 pounds. -ANSWERS-B: Body mass index greater than 35. [Show More]

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