HESI VERSION 2 EXAM QUESTIONS

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HESI VERSION 2 EXAM QUESTIONS

Actual Qs and Ans Expert-Verified Explanation

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-Guarantee passing score -100 Questions and Answers -format set of multiple-choice -Expert-Verified Explanation Question 1: The nurse is caring for four clients, Client A, who has emphysema and who's oxygen saturation is 94%. Client B, with the postoperative hemoglobin of 8.2 mg/dL (82 g/L). Client C, newly admitted with a potassium level of 3.8 mEq/L (3.8 mmol/L) and Client D, scheduled for an appendectomy who has a white blood cell (WBC) count of 14,000 mm3 (14 x 103/L). What intervention should the nurse implement?

• Move Client D into an isolation room 24 hours before surgery
• Increase Client A's oxygen to 4 L a minute per nasal cannula
• Ask the dietitian to add a banana to Client C's breakfast tray
• Verify that Client B has two units of packed cells available

Answer:

• Verify that Client B has two units of packed cells available

Client B, with a postoperative hemoglobin of 8.2 mg/dL (82 g/L), has a low hemoglobin level indicating anemia. Verifying the availability of packed red blood cells is important to address the potential need for a blood transfusion.

Question 2: When caring for a client with a traumatic brain injury (TBI) who had a craniotomy for increased intracranial pressure (ICP), the nurse assesses the client using the Glasgow coma scale (GCS) every two hours. For the past eight hours the client's GCS score has been 14. What does this GCS finding indicate about the client?

• Rehabilitative prognosis is an expected full recovery
• Risk for a reversible cerebral damage related to increased ICP
• Insertion of an ICP monitoring device is necessary
• Neurologically stable without indications of an increased ICP

Answer:

• Neurologically stable without indications of an increased ICP

The Glasgow Coma Scale (GCS) is used to assess a person's level of consciousness after a traumatic brain injury. It evaluates three aspects: eye opening, verbal response, and motor response. The total score ranges from 3 (deeply unconscious) to 15 (fully alert). A score of 14 is quite high and indicates that the client is neurologically stable and likely does not have severely impaired consciousness.However, it's important to note that the GCS score alone cannot provide a comprehensive picture of the client's overall neurological status or predict their long-term outcome. This score suggests that the client is relatively alert and responsive, which is a positive sign in the context of TBI and post-craniotomy for increased ICP. However, continuous monitoring is still crucial, as conditions can change rapidly.Question 3: While caring for a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider the nurse should review which of the client's laboratory values?

• Culture for sensitive organisms
• Serum blood glucose (BG) level
• Creatinine level
• Serum albumin

Answer:

• Culture for sensitive organisms

when observing purulent drainage at a wound site, the nurse should review the culture and sensitivity results to identify the specific organisms causing the infection and their susceptibility to antibiotics

Question 4: When caring for a client with full thickness burns to both lower extremities, which assessment findings warrant immediate invention? (Select all that apply)

• Sloughing tissue around wound edges
• Complaint of increased pain and pressure
• Change in the quality of the peripheral pulses.
• Loss of sensation to the left lower extremity
• Weeping serosanguineous fluid from wounds

Answer:

• Complaint of increased pain and pressure

• Change in the quality of the peripheral pulses.

• Loss of sensation to the left lower extremity

B: This could indicate the development of compartment syndrome, especially in the case of circumferential burns. Compartment syndrome is a medical emergency where pressure builds up within the muscles, which can lead to muscle and nerve damage. Increased pain and pressure in the context of burns are concerning signs that require urgent evaluation and intervention.C: Change in the quality of peripheral pulses: A change in the quality of peripheral pulses can indicate compromised blood flow to the affected extremities. This can be due to swelling or other circulatory issues related to the burn injury. It's crucial to assess and address any changes in circulation to prevent further complications.D: Loss of sensation to the left lower extremity: Loss of sensation could be an indication of nerve damage or severe tissue damage. This is a concerning sign, especially in the context of full thickness burns, and requires prompt assessment and intervention Question 5: The psychiatric nurse is caring for clients in an adolescent unit. Which client requires the nurses immediate attention?

• A 16 year-old client diagnosed with major depression who refuses to participate in group
• A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack
• An 18 year-old client with antisocial behavior who is being yelled at by other clients
• A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby

Answer:

• An 18-year-old client with antisocial behavior who is being yelled at by other clients

This scenario could potentially escalate into a more harmful situation. The immediate verbal conflict

suggests a risk of escalation into physical aggression or emotional harm. This situation requires prompt intervention to prevent potential violence or significant stress among the clients Question 6: When conducting diet teaching for a client who is on a postoperative full fluid diet, which foods should the nurse encourage the client to eat?

• Lentils
• Potato soap
• Tea
• Cheese
• Whole grain breads

Answer:

• Potato soap

• Tea

B: As long as it is blended or pureed to a liquid consistency without solid pieces, potato soup is suitable for a full fluid diet.C: Tea is a clear liquid and is appropriate for a full fluid diet. It's important to ensure that the tea does not contain any solid additives like leaves or herbs.Question 7: An older male was recently admitted to the rehabilitation unit with unilateral neglect syndrome as a result of a cerebral vascular accident (CVA). Which action should the nurse include in the plan of care?

• Use hands and arm gestures to improve communication and comprehension
• Provide additional light in the room to promote sensory stimulation
• Place a clock and calendar in the room to improve orientation
• Teach the client to turn his head from side to side to visual scanning

Answer:

• Teach the client to turn his head from side to side to visual scanning

Unilateral neglect syndrome is a condition in which a person is unaware of or neglects one side of the body or one side of the visual field. To address unilateral neglect, strategies often involve encouraging the individual to actively engage the neglected side. Teaching the client to turn his head from side to side for visual scanning is a specific intervention aimed at increasing awareness of the neglected side.