Health Assessment Practice HESI

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1. The RN uses the min-mental state Attention to 7. A client who uses ipratropium reports Withhold
examination when assessing a client for details having nausea, blurred vision, medication and
admission to an assisted living facility. Which headaches, and insomnia after using report symptoms
finding is the RN assessing when requesting the inhaler. Which action should the and vital signs to
the client to count by 7s? RN implement first? HCP
2. The RN palpates a weak pedal pulse in the Diminished 8. While reviewing the client's EMR, the Closed angle
client's right foot. Which ass. findings should hair on legs RN assesses a client who is at risk for a glaucoma
the RN document that are consistent with Skin cool to possible interaction with OTC Chronic
diminished peripheral circulation? touch decongestant. Which client health hypertension
history should the RN report to the
3. Which action should the RN implement to Maintain eye
HCP concerning the OTC medication?
complete an ass. for a client while using an contact with
interpreter? the client 9. The RN is assessing a client who was Sphygmomanmeter
while listening discharged home after management of
to the chronic hypertension. Which
translation equipment should the RN instruct the
client to use at home?
4. A client with progressive hearing loss Face the
appears distressed when the RN asks open- client so the 10. The RN notifies the spouse of a client Denial
ended questions about the client's health client can see who was admitted to hospice with
history. Which forms of communication the RN's shallow respirations, of a change in the
should the RN use? mouth client's condition. Over the past hour,
Check if the the client's respiratory pattern has
client's changed to a Cheyne Stokes pattern.
hearing aides After receiving this information, the
are working client's spouse begins vacuuming
properly around the bed. Which stage of grief is
Reduce the spouse displaying during the visit?
environmental
11. A client is admitted for dehydration, Establish trust by
noise
weight loss, and a flat affect. After creating a safe
surrounding
reviewing the client's history, the RN atmosphere for
the client
discovers that the client's spouse died sharing
5. A RN is performing a mini-mental state Use simple 2 weeks ago. Which nursing Help the client
examination for a client who is being sentences interventions should the RN implement identify ways to
admitted to an assisted living community. during the to help the client begin the process of adapt lifestyles to
Which communication techniques should the examination dealing with loss? accommodate loss
RN implement to decrease anxiety in the Reduce Explore ways to
client? environmental assist the client to
detractors make new
during the emotional
examination investments
Ask questions
12. The RN is caring for a client with PUD. Hematemesis
one at a time
What ass. should the RN identify and Gastric pain on an
to decrease
document that is consistent with PUD? empty stomach
confusion
Intolerance of
6. A Muslim male client refuses to let the Request a spicy foods
female RN listen to his breath sounds during male nurse or
13. The RN is caring for a client with a Check pH of
the examination. How should the RN HCP to
newly placed NGT. Once the aspirated stomach
respond? perform the
placement of the NGT is verified by x- contents obtained
exam
ray, which technique should the RN use from the NGT
as a reliable method to ensure the NGT
is not displaced?
14. The RN is evaluating a client who presents Rebound 22. The RN reviews the new prescription, Consumption
with symptoms of viral gastroenteritis. Which abd. phenelzine, a monoamine oxidase inhibitor, of any
ass. finding should the RN report to the HCP? tenderness for a client on the psychiatric unit with alcohol or
over RLQ depression. Which info is most important for tyramine-rich
the RN to assess? foods
15. A client is newly diagnosed with Chronic
diverticulosis. The RN is ass. the client's basic constipation 23. The RN is assisting the HCP with the removal Prepare the
knowledge about the disease process. Which causes of a chest tube. Which intervention has the client for
statement by the client conveys the client's weakening highest priority and should be anticipated chest x-ray at
understanding of the etiology of diverticula? of colon by the RN after the removal of the chest the bedside
wall which tube?
result in out-
24. The RN is caring for a client who has a Polydipsia
pouching
closed head injury from a motor vehicle
sacs
collision. Which finding should the RN
16. The RN is teaching a client who is being Native assess the client for the risk of diabetes
discharged after treatment of TB. Which language insipidus?
cultural issues should the RN assess when Education
25. A male client is admitted after falling from A fracture
preparing the client for discharge? level
his bed. The HCP tells the family that he has that bends or
Type of
an incomplete fracture of the humerus. The splinters part
lifestyle
family ask the RN what this means. Which of the bone
Financial
type of fracture should the RN explain from
resources
these findings?
17. A female client is recently diagnosed with African
26. The RN is assessing common complications Fever related
Sarcoidosis. The client tells the RN that she American
related to a client's recent diagnosis, to infection
does not understand why she has this. When women
systemic lupus erythematosus. Which
teaching about the occurrence of sarcoidosis,
symptom should the RN instruct the client to
the RN should include that sarcoidosis most
report immediately?
commonly occurs with which ethnic group of
women? 27. The RN assesses a client's results for arterial pH 7.32,
blood gases who has emphysema. Which pCO2
18. The RN is making early morning rounds on a Rapid
finding is consistent with respiratory 46mmHg,
group of clients when a client begins resolution of
acidosis? HCO3 24
exhibiting symptoms of an acute asthma wheezing
mEq/L
attach. The RN administers a PRN Improved
prescription for a Beta 2 receptor agonist pulse 28. A client in an ambulatory clinic describes Heart Failure
agent. Which client response should the RN oximetry awaking in the middle of the night with
expect? values difficulty breathing and SOB related to
paroxysmal nocturnal dyspnea. Which
19. The RN is interviewing a female client who Phlegm
underlying condition should the RN identify
states she has a persistent productive cough production
in the client's history?
during the winter caused by bronchitis. Which and
additional finding should the RN assess for wheezing 29. A female client calls the clinic and talks with Consult with
bronchitis? the RN to inquire about a possible reaction HCP about
after taking amoxicillin for 5 days. She another
20. A client with chest pain, dizziness, and Serum
reports having vaginal discomfort, itching, treatment for
vomiting for the last 2 hours is admitted for troponin
and a white discharge. The RN should this effect
evaluation for Acute Coronary Syndrome.
discuss which action with the client?
Which cardiac biomarker should the RN
anticipate to be elevated if the client 30. An infant with heart failure receives a 0.7
experienced myocardial damage? prescription, digoxin 35 mcg PO. The RN
calculates the desired dose for
21. The RN is administering haloperidol 0.5mg IM Dystonia
administration using the available
PRN to a client for the first time. What side
concentration of digoxin labeled, 0.05
effects should the RN assess the client for
mg/mL. How many mL should the RN
during the initial dose?
prepare for administration?
31. The RN is caring for a client with acute Amylase 40. An older client is admitted to the hospital Orthostatic
pancreatitis and ass. the admission lab with severe diarrhea. The RN is completing hypotension
results. What lab value should the RN an ass. and notes the client has dry mucous
anticipate being elevated with this membranes and poor skin turgor. Which
diagnosis? ass. data should the RN gather to
determine if the client has a fluid volume
32. The RN is caring for a client who has taken Rise slowly
deficit?
atenolol for 2 years. The HCP recently when getting
changed the medication to enalapril to out of bed 41. The RN is assessing a male client who Ulcerative
manage the client's blood pressure. Which or chair arrives at the clinic with severe abd. colitis
instruction should the RN provide the client cramping, pain, tenesmus, and dehydration.
regarding the new medication? The RN discovers that the client has had 14-
20 loose stools with rectal bleeding. Which
33. The RN is teaching a client who is newly Promotes
condition should the RN ask the client
diagnosed with emphysema how to perform CO2
about his medical history?
pursed lip breathing. What is the primary elimination
reason for teaching the client this method of 42. The RN is caring for an Asian client who The client is
breathing? refuses to make eye contact during treating the
conversations. How should the RN assess nurse with
34. The RN is caring for a client with TB who is The
this client's response? respect.
taking a combination drug regimen. The development
client complains about taking "so many of resistant 43. The RN is caring for a client who developed Urine output
pills." What info should the RN provide to strains of TB oliguria and was diagnosed with sepsis and of 40
the client about the prescribed treatment? are dehydration 48 hours ago. Which ass. mL/hour
decreased finding indicates to the RN that the client is
with a stabilizing?
combination
44. A client with cirrhosis of the liver asks the Increased
of drugs
RN to explain how varicose veins can occur portal
35. The RN is caring for an older client who Dyspnea in the esophagus. Which statement should pressure
recently experienced a fracture pelvis from the RN provide to teach the client about the causes blood
a fall. Which ass. finding is most important physiological etiology? flow through
for the RN to report the HCP liver to be
shunted to
36. The Rn is caring for a young adult who is 140 mg/dL
the
having an oral glucose tolerance tests.
esophageal
Which lab results should the RN assess as a
vessels
normal value for the 2 hour postprandial
result? 45. While caring for a client who has Monitor
esophageal varices, which nursing infusing IV
37. The RN is caring for a client with aplastic Maintain
intervention is most important for the RN to fluids and any
anemia who is hospitalized for weight loss strict
implement? replacement
and generalized weakness. Lab values show protective
blood
a WBC of 2,500 and a platelet count of precautions
products
160,000. Which intervention is the primary
focus in the client's plan of care for the RN 46. 24 hours after a client returns from surgical Lethargy
to implement? gastric bypass, the Rn observes large
amounts of blood int he NGT cannister.
38. After a liver biopsy is performed at the Evaluate vital
Which ass. finding should the RN report as
bedside, the RN is assigned the care of the signs q10 to
early signs of hypovolemic shock?
client. Which nursing intervention is most 20 minutes
important for the RN to implement? for 2 hours 47. The RN is developing the plan of care for a The client will
after client who is admitted for alcohol remain free
procedure detoxification. Which goal should be most from injury
important for the RN to primarily focus the
39. The RN is caring for an older client who has Stiffness in
client's care?
been bedridden for 2 weeks. Which ass. right ankle
findings indicate to the RN that the client is joint
developing a complication related to
immobility?
48. The RN did not note that a prescription dose was recently changed and did not note the updated A med error report will
MAR. After giving the client the original dose, the RN reports the medication error to the nurse be completed and risk
manager. What consequences will the RN experience due to this error in med admin? management will be
notified
49. The RN places an ice pack on a middle school student who comes to the school clinic complaining of Reduced pain and
a sprained ankle. Which therapeutic response should the RN anticipate? minimized bruising
50. The RN recognizes which client group is at the greatest risk for developing a UTI? Older females
School-age female
Older males
Adolescent males