HESI LEVEL 1 PRACTICE EXAM LATEST

HESI LEVEL 1 PRACTICE EXAM LATEST

2023(Already graded A+) The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take?

• Infuse normal saline at a keep vein open rate.
• Discontinue the IV and flush the port with heparin.
• Infuse 10% dextrose and water at 54 ml/hour.
• Obtain a stat blood glucose level and notify the healthcare provider. - Correct Answer

C A crying toddler has a blood pressure measurement of 120/70 mm Hg. What action should the nurse implement?

• Notify the healthcare provider of the measurement.
• Quiet the child and retake the blood pressure.
• Ask the parent if the child has a history of hypertension.
• Document the finding and recheck in 4 hours. - Correct Answer B

The mother of a neonate asks the nurse why it is so important to keep the infant warm.What information should the nurse provide?

• The kidneys and renal function are not fully developed.
• Warmth promotes sleep so the infant will grow quickly.
• A large body surface area favors heat loss to the environment.
• The thick layer of subcutaneous fat is inadequate for insulation. - Correct Answer C

What action by the nurse demonstrates culturally sensitive care?

• Asks permission before touching a client.
• Avoids questions about male-female relationships.
• Explains the differences between Western medical care and cultural folk remedies.
• Applies knowledge of a cultural group unless a client embraces Western customs. -

Correct Answer A A client has a nursing diagnosis of, "Spiritual distress related to a loss of hope, secondary to impending death." What intervention is best for the nurse to implement when caring for this client?

• Help the client to accept the final stage of life.
• Assist and support the client in establishing short-term goals.
• Encourage the client to make future plans, even if they are unrealistic.
• Instruct the client's family to focus on positive aspects of the client's life. - Correct

Answer B A client who is 5 foot 5 inches tall and weighs 200 pounds is scheduled for surgery the next day. Which question is most important for the nurse to include during the preoperative assessment? 1 / 3

• "What is your daily calorie consumption?"
• "What vitamin and mineral supplements do you take?"
• "Do you feel that you are overweight?"
• "Will a clear liquid diet be okay after surgery?" - Correct Answer B

The nurse working in the emergency department is assessing four clients' ability to tolerate pain. Which client is likely to tolerate a higher level of pain?

• A 10-year-old who was burned by a camp fire earlier today.
• A 70-year-old who has a postoperative infection from a surgery one week ago.
• A 23-year-old woman who sprained her knee while bicycling.
• A 55-year-old woman who has had moderate low back pain for three months. -

Correct Answer D A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take?

• Record the coughing incident. No further action is required at this time.
• Stop the feeding, explain to the family why it is being stopped, and notify the

healthcare provider.

• After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the

tube.

• Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling. -

Correct Answer C In evaluating client care, which action should the nurse take first?

• Determine if the expected outcomes of care were achieved.
• Review the rationales used as the basis of nursing actions.
• Document the care plan goals that were successfully met.
• Prioritize interventions to be added to the client's plan of care. - Correct Answer A

A female client asks the nurse to find someone who can translate her treatment concerns into her native language. Which action should the nurse take?

• Explain that anyone who speaks her language can answer her questions.
• Provide a translator only in an emergency situation.
• Ask a family member or friend of the client to translate.
• Request and document the name of the certified translator. - Correct Answer D

An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP?

• Position the client on the right side of the bed in reverse Trendelenburg.
• Fill the enema container with 1000 mL of warm water and 5 mL of castile soap.
• Reposition in a Sims' position with the client's weight on the anterior ilium.
• Raise the side rails on both sides of the bed and elevate the bed to waist level. -

Correct Answer C 2 / 3

A child with a penetrating eye injury comes to the school clinic. What action should the nurse implement?

• Remove the object impaled in the eye and then apply a regular eye patch.
• Place an ice bag over the eye until the healthcare provider is seen.
• Irrigate the affected eye copiously with a cool sterile saline solution.
• Apply a Fox shield to the affected eye and any type of patch to the other eye. -

Correct Answer D When making the bed of a client who needs a bed cradle, which action should the nurse include?

• Teach the client to call for help before getting out of bed.
• Keep both the upper and lower side rails in a raised position.
• Keep the bed in the lowest position while changing the sheets.
• Drape the top sheet and covers loosely over the bed cradle. - Correct Answer D

A male client with venous incompetence stands up and his blood pressure subsequently drops. Which finding should the nurse identify as a compensatory response?

• Bradycardia.
• Increase in pulse rate.
• Peripheral vasodilation.
• Increase in cardiac output. - Correct Answer B

When assessing a preschooler, which finding warrants further assessment by the nurse?

• Able to ride a tricycle.
• Talks about an imaginary friend.
• Dresses independently.
• Gains 2 pounds (0.9kg) in 12 months. - Correct Answer D

The nurse completes visual inspection of a client's abdomen. What technique should the nurse perform next in the abdominal examination?

• Percussion.
• Auscultation.
• Deep palpation.
• Light palpation. - Correct Answer B

The nurse is assessing a postmenopausal woman who is complaining of urinary urgency and frequency and stress incontinence. She also reports difficulty in emptying her bladder. These complaints are most likely due to which condition?

• Cystocele.
• Bladder infection.
• Pyelonephritis.
• Irritable bladder. - Correct Answer A

What action should the nurse implement when adding sterile liquids to a sterile field?

• Use an outdated sterile liquid if the bottle is sealed and has not been opened.
• / 3