NUR 206 HESI REVIEW EXAM WITH 280 QUESTIONS

NUR 206 HESI REVIEW EXAM WITH 280+ QUESTIONS

& CORRECT ANSWERS

• The nurse is caring for an unresponsive terminally ill patient who has 20-second

periods of apnea followed by periods of deep and rapid breathing. Which action by the nurse would be appropriate?

• Suction the patient's mouth.
• Administer oxygen via face mask.
• Document Cheyne-Stokes respirations.

d. Place the patient in high Fowler's position. - ANSWER-ANS: C

Cheyne-Stokes respirations are characterized by periods of apnea alternating with deep and rapid breaths. Cheyne-Stokes respirations are expected in the last days of life and are not position dependent. There is also no need for supplemental oxygen by face mask or suctioning the patient.

• The nurse is caring for an adolescent patient who is dying. The patient's parents

are interested in organ donation and ask the nurse how the health care providers determine brain death. Which response by the nurse accurately describes brain death determination?

• "If CPR does not restore a heartbeat, the brain cannot function."
• "Brain death has occurred if there is not any breathing or brainstem reflexes."
• "Brain death has occurred if a person has flaccid muscles and does not awaken."
• "If respiratory efforts cease and no apical pulse is audible, brain death is

present." - ANSWER-ANS: B

The diagnosis of brain death is based on irreversible loss of all brain functions, including brainstem functions that control respirations and brainstem reflexes. The other descriptions describe other clinical manifestations associated with death but are insufficient to declare a patient brain dead. 1 / 4

• A patient in hospice is manifesting a decrease in all body system functions

except for a heart rate of 124 beats/min and a respiratory rate of 28 breaths/min.Which statement, if made by the nurse to the patient's family member, is most appropriate?

• "These vital signs will continue to increase until death finally occurs."
• "These vital signs are an expected response now but will slow down later."
• "These vital signs may indicate an improvement in the patient's condition."
• "These vital signs are a helpful response to the slowing of other body systems." -

ANSWER-ANS: B

An increase in heart and respiratory rate may occur before the slowing of these functions in a dying patient. Heart and respiratory rate typically slow as the patient progresses further toward death. In a dying patient, high respiratory and pulse rates do not indicate improvement or compensation, and it would be inappropriate for the nurse to indicate this to the family.

• A patient who has been diagnosed with inoperable lung cancer and has a poor

prognosis plans a trip across the country "to settle some issues with family members." The nurse recognizes that the patient is manifesting which psychosocial response to death?

• Protesting the unfairness of death
• Anxiety about unfinished business
• Fear of having lived a meaningless life

d. Restlessness about the uncertainty of prognosis - ANSWER-ANS: B

The patient's statement indicates that there is some unfinished family business that the patient would like to address before dying. There is no indication that the patient is protesting the prognosis, feels uncertain about the prognosis, or fears that life has been meaningless.

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• A patient with terminal cancer is being admitted to a family-centered inpatient

hospice. The patient's spouse visits daily and cheerfully talks with the patient about wedding anniversary plans for the next year. When the nurse asks about any concerns, the spouse says, "I'm busy at work, but otherwise things are fine." Which provisional nursing diagnosis is appropriate for the patient's spouse?

• Ineffective coping related to lack of grieving
• Anxiety related to complicated grieving process
• Hopelessness related to knowledge deficit about cancer

d. Caregiver role strain related to spouse's complex care needs - ANSWER-ANS:

A The spouse's behavior and statements indicate the absence of anticipatory grieving, which may lead to impaired adjustment as the patient progresses toward death. The spouse does not appear to feel overwhelmed, hopeless, or anxious.

• As the nurse admits a patient in end-stage renal disease to the hospital, the

patient tells the nurse, "If my heart or breathing stop, I do not want to be resuscitated." Which action should the nurse take first?

• Place a "Do Not Resuscitate" (DNR) notation in the patient's care plan.
• Invite the patient to add a notarized advance directive in the health record.
• Advise the patient to designate a person to make future health care decisions.
• Ask if the decision has been discussed with the patient's health care provider. -

ANSWER-ANS: D

A health care provider's order should be written describing the actions that the nurses should take if the patient requires CPR, but the primary right to decide belongs to the patient or family. The nurse should document the patient's request but does not have the authority to place the DNR order in the care plan. A notarized advance directive is not needed to establish the patient's wishes. The patient may need a durable power of attorney for health care (or the equivalent), but this does not address the patient's current concern with possible resuscitation.

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• A young adult patient with metastatic cancer, who is very close to death, appears

restless. The patient keeps repeating, "I am not ready to die." Which action is best for the nurse to take?

• Remind the patient that no one feels ready for death.
• Sit at the bedside and ask if there is anything the patient needs.
• Insist that family members remain at the bedside with the patient.
• Tell the patient that everything possible is being done to delay death. -

ANSWER-ANS: B

Staying at the bedside and listening allows the patient to discuss any unresolved issues or physical discomforts that should be addressed. Stating that no one feels ready for death fails to address the individual patient's concerns. Telling the patient that everything is being done does not address the patient's fears about dying, especially because the patient is likely to die soon. Family members may not feel comfortable staying at the bedside of a dying patient, and the nurse should not insist that they remain there.

• The nurse is caring for a terminally ill patient who is experiencing continuous

and severe pain. How should the nurse schedule the administration of opioid pain medications?

• Plan around-the-clock routine administration of analgesics.
• Provide PRN doses of medication whenever the patient requests them.
• Suggest small analgesic doses to avoid decreasing the respiratory rate.
• Offer enough pain medication to keep the patient sedated and unaware of

stimuli. - ANSWER-ANS: A

The principles of beneficence and nonmaleficence indicate that the goal of pain management in a terminally ill patient is adequate pain relief even if the effect of pain medications could hasten death. Administration of analgesics on a PRN basis will not provide the consistent level of analgesia the patient needs. Patients usually do not require so much pain medication that they are oversedated and unaware of stimuli. Adequate pain relief may require a dosage that will result in a decrease in respiratory rate.

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