HESI ONLINE NCLX RN PRE-TEST

• HESI ONLINE NCLX RN PRE-TEST

QUESTIONS

• NURS 4020WINTER CLINICAL

• A nurse is evaluating outcomes for a client with Guillain-Barré syndrome. Which of the

following outcomes does the nurse recognize as optimal respiratory outcomes for the client? Select all that apply.

• Normal deep tendon reflexes
• Improved skeletal muscle tone
• Absence of paresthesias in the lower extremities
• Clear sounds in the lower lung fields bilaterally
• pO2 of 85 mm Hg and Pco2 of 40 mm Hg

• A nurse provides information to the mother of a child with diarrhea about signs and

symptoms that indicate the need to call the physician. Which statement by the mother indicates the need for further instruction?

• “I‟ll call the doctor if she gets dizzy and acts sick.”
• “I‟ll call the doctor if she has severe stomach cramps.”
• “I‟ll call the doctor if her temperature is 102°F (38.9°C) or higher.”
• “I‟ll call the physician if she goes longer than 6 hours without urinating.”

• A nurse is monitoring the neurological status of a client who underwent craniotomy 3

days ago. Which of the following signs or symptoms would prompt the nurse to notify the surgeon immediately?

• Disorientation to date
• Pupils equal and reactive at 4 mm
• Mild headache relieved by codeine sulfate
• Pain with forward flexion of the neck onto the chest

• A client with a diagnosis of preeclampsia suddenly begins to exhibit seizure activity.

The first action on the part of the nurse is:

• Calling the physician
• Inserting an oral airway
• Turning the client on her side
• Noting the time of the seizure

• A nurse is caring for a client who has just undergone cardioversion. Which of the

following interventions is the nurse‟s priority after this procedure?

• Administering oxygen
• Monitoring the blood pressure
• Administering antidysrhythmic medications
• Monitoring the client‟s level of consciousness

• A man calls the emergency department and tells the nurse that he sustained a bee

sting on his leg while working in his yard. The client states that he is not allergic to bees

and wants to know how to treat the sting. The nurse tells the client to first:

• Place a cool compress on the sting site
• Apply an antipruritic lotion to the sting site
• Apply a topical corticosteroid to the sting site
• Take an oral antihistamine such as diphenhydramine (Benadryl)

• client with diabetes mellitus who is scheduled to have blood drawn for determination

of the glycosylated hemoglobin (HbA1C) level asks the nurse why the test is necessary if he is performing blood glucose monitoring at home. The nurse tells the client that this

test is used specifically to:

• Detect diabetic complications
• Assess long-term glycemic control
• Determine whether the client is at risk for hypoglycemia
• Determine whether the prescribed insulin dosage is adequate

11.A nurse caring for a client with AIDS is monitoring the client for signs of complications.Which of the following findings would cause the nurse to suspect infection with Pneumocystis jiroveci? Select all that apply.

• Diarrhea
• Tachypnea
• Pedal edema
• Intermittent fever
• Dyspnea when ambulating
• Expectoration of frothy mucus

12.A nurse reviewing the record of a child with suspected acute poststreptococcal glomerulonephritis notes that the child recently had a streptococcal throat infection that was treated with antibiotics. Which of the following physician prescriptions that will confirm the presence of acute poststreptococcal glomerulonephritis does the nurse expect to find?

• Throat culture
• Blood urea nitrogen (BUN)
• Antistreptolysin (ASO) titer
• White blood cell (WBC) count

• A nurse is assigned to care for a client with chronic renal failure who is undergoing

hemodialysis through an internal arteriovenous (AV) fistula in the right arm. Which of the following interventions should the nurse implement in caring for the client? Select all that apply.

• Assessing the radial pulse in the right extremity
• Using the left arm to take blood pressure readings
• Drawing predialysis blood specimens from the left arm
• Assessing the area over the AV fistula for a bruit and thrill each shift
• Placing a pressure dressing over the site after each dialysis treatment

• Administering intravenous (IV) fluids through the venous site of the AV fistula as

needed

15.After a nonimmunocompromised client undergoes a Mantoux test for tuberculosis (TB) infection, an area of induration 6 mm wide develops. The client asks the nurse what this

result means. The nurse‟s best response is:

• “We‟ll have to repeat the test, because the result is inconclusive.”
• “The swollen area is small, so that means your test result is negative.”
• “You‟ve been exposed to tuberculosis, so you‟ll need to have a chest x-ray.”
• “You need to get started on medication right away, because you‟ve got

tuberculosis.”

16.A nurse is caring for a hospitalized child with newly diagnosed type 1 diabetes mellitus who received NPH and regular humulin insulin at 7:30 am. At 11 am the child suddenly

complains of dizziness, headache, and a shaky feeling. The nurse immediately:

• Contacts the physician
• Gives the child milk to drink
• Arranges to have the child‟s lunch tray delivered early
• Prepares to administer intravenous 5% dextrose solution

18.A nurse is preparing to administer digoxin (Lanoxin) to a client with heart failure. On assessing of the client, the nurse notes an apical pulse rate of 58 beats/min and the client complains of anorexia and nausea. Which action should the nurse take first on the basis of these assessment findings?

• Contacting the physician
• Administering an as-needed antiemetic
• Checking the most recent digoxin level
• Administering the digoxin with an antacid

19.A nurse provides dietary instructions to the mother of a child with iron-deficiency

anemia. The nurse should tell the mother that the food highest in iron is:

• Milk
• Cheese
• Orange juice
• Cream of Wheat

20.A nurse reviewing the medical history of an infant experiencing gastroesophageal reflux

(GER) would expect to note documentation of:

• Refusal to suck
• Frequent diarrhea
• Recurrent otitis media
• Inability to pass stools

21.A client has just been found to have deep vein thrombosis (DVT) of the right leg. Which of the following interventions does the nurse immediately implement?

• Elevating the foot of the bed 6 inches (15 cm)
• Placing ice packs on and under the right leg
• Documenting the need for hourly calf measurements
• Performing passive range-of-motion exercises of the right leg

23.A nurse provides home care instructions to an adolescent with sickle cell disease about measures to prevent vaso-occlusive crisis. The nurse should tell the adolescent to:

• Restrict fluid intake
• Take ibuprofen (Motrin) for discomfort
• Take acetylsalicylic acid (aspirin) immediately if a fever develops
• Be sure to spend plenty of time in the fresh air and sun each day

24.A client with a basilar skull fracture has clear fluid leaking from the ears. The nurse

should:

• Assess the clear fluid for protein
• Check the clear fluid for the presence of glucose
• Place cotton balls or dry gauze loosely in the ears
• Use an otoscope to assess the tympanic membrane for rupture

25.A nurse is assigned to conduct an admission assessment of a client who was treated in the emergency department after attempting suicide by cutting her wrists with a razor

blade. When the client arrives at the nursing unit, the nurse should first:

• Ask the client to sign a no-harm contract
• Ask the client to report any suicidal thoughts immediately
• Place the client under suicide precautions with 15-minute checks
• Check the dressings that were placed over the client‟s wrists in the emergency

department

26.A client is receiving parenteral nutrition (PN) solution at 60 mL/hr by means of infusion pump through a subclavian central line. The client calls the nurse and complains of difficulty breathing and chest pain. The nurse notes that the client‟s pulse rate is