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Hesi Level 2 Practice Questions with Complete Answers
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Hesi Level 2 Practice Questions with Complete Answers
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Hesi Level 2 Practice Questions withComplete Answers
What assessment finding should the nurse identify that indicates a client
with an acute asthma exacerbation is beginning to improve after treatment?
A. Vesicular breath sounds decrease
B. Bronchodilators stimulate coughing
C. Cough remains unproductive
D. Wheezing becomes louder - -Answer : Wheezing becomes louder.
In an acute asthma attack, air flow may be so significantly restricted that
wheezing is diminished. If the client is successfully responding to
bronchodilators and respiratory treatments, wheezing becomes louder (A) as
air flow increases in the airways. As the airways open and mucous is
mobilized in response to treatment, the cough becomes more productive, not
(B). Vesicular sounds are soft, low-pitched, gentle, rustling sounds heard
over lung fields (C) and is not an indicator of improvement during asthma
treatment. Bronchodilators do not stimulate coughing (D).
-A client with sickle cell anemia is admitted with severe abdominal pain and
the diagnosis is sickle cell crisis. What is the most important nursing action
to implement?
A. Evaluate the effectiveness of narcotic analgesics.
B. Limit the client's intake of oral fluids and food.
C. Teach the client about prevention of crises.
D. Encourage the client to ambulate as tolerated. - -Answer: Evaluate the
effectiveness of narcotic analgesics.
Pain management is the priority for a client during sickle cell crisis.
Continuous narcotic analgesics are the mainstay of pain control, which
should be evaluated (B) frequently to determine if the client's pain is
adequately controlled. (A, C, and D) are not indicated at this time.
-The nurse is assessing a middle-aged male client for risk factors related to
chronic illness. Which finding should the nurse assess further?
A. Thinning hair and dry scalp.
B. Increase in muscle tone but decreased muscle strength.
C. Increase in abdominal fat deposits.
D. Increase in appetite and taste-bud acuity. - -Answer: Increase in
abdominal fat deposits.
An increase in the abdominal girth (D) may be indicative of the onset of
metabolic syndrome, which places the client at risk for cardiac disease and
requires further assessment. During middle adulthood, common findings
include thinning hair, dry skin and scalp (A), changes in taste bud acuity (B),
and muscle size and strength (C), which are consistent with normal system
functioning during aging.
, -The nurse is caring for a male client who had an inguinal herniorrhaphy 3
hours ago. The nurse determines the client's lower abdomen is distended
and assesses dullness to percussion. What is the priority nursing action?
A. Assessment of the client's vital signs.
B. Determine the time the client last voided.
C. Document the finding as the only action.
D. Insert a rectal tube for the passage of flatus. - -Answer: Determine the
time the client last voided.
Swelling at the surgical site in the immediate postoperative period can
impact the bladder and prostate area causing the client to experience
difficulty voiding due to pressure on the urethra. To provide additional data
supporting bladder distention, the last time the client voided (C) should be
determined next. Documentation (B) should be made, but the client's
distended bladder requires additional intervention. (A and D) are not priority
actions based on the client's abdominal findings.
-The nurse is giving discharge instructions to a client with chronic prostatitis.
What instruction should the nurse provide the client to reduce the risk of
spreading the infection to other areas of the client's urinary tract?
A. Avoid consuming alcohol and caffeinated beverages.
B. Wear a condom when having sexual intercourse.
C. Have intercourse or masturbate at least twice a week.
D. Empty the bladder completely with each voiding. - -Answer: Have
intercourse or masturbate at least twice a week.
The prostate is not easily penetrated by antibiotics and can serve as a
reservoir for microorganisms, which can infect other areas of the
genitourinary tract. Draining the prostate regularly through intercourse or
masturbation (D) decreases the number of microorganisms present and
reduces the risk for further infection from stored contaminated fluids. (A, B,
and C) do not reduce the risk of spreading the infection internally.
-A 3-year-old boy is brought to the emergency room because of a possible
diazepam (Valium) overdose. He is lethargic and confused, and his vital signs
are: pulse rate 100 beats/minute, respiratory rate 20 breaths/minute, and
blood pressure 70/30. Which nursing intervention has the highest priority?
A. Insert an orogastric tube for gastric lavage.
B. Prepare a set-up for an endotracheal intubation.
C.Draw blood for stat chemistries and blood gases.
D. Insert a Foley catheter to monitor renal functioning. - -Answer: Prepare a
set-up for an endotracheal intubation.
Diazepam causes respiratory depression, so preparation for intubation (B) to
protect the airway is the priority intervention at this time. (A) may be
necessary, but the child is lethargic and confused, with a lowered respiratory
rate, so (B) takes priority. (C and D) are interventions that should be
implemented, but they are both secondary to ensuring an open airway.
, -The nurse is developing a plan of care for a newborn with a colostomy due
to anal agenesis, and the infant has had three loose stools since surgery
yesterday. Which nursing diagnosis has the highest priority?
A. Pain related to postoperative condition.
B. Potential for fluid volume deficit.
C. Alteration in bowel elimination.
D. Anxiety of parents related to newborn's condition. - -Answer: Potential for
fluid volume deficit.
All stated nursing diagnoses are appropriate for a postoperative colostomy
client. However, fluid balance is the priority concern (A) for any newborn
infant. Though three loose stools in 24-hours is not significant, depending on
the amount of fluid lost with each stool, potential for fluid volume deficit is
always a concern for a postoperative infant. Newborns are extremely
vulnerable to fluid imbalances due to immature body systems and a larger
percentage of their body weight consisting of fluid. (B, C, and D) do not have
the priority of (A).
-The community health nurse teaches the parents of school-aged children
about the need for fluoride as part of a dental health program. Which
statement by the parents indicates that they understand the teaching?
A. "Having our children brush with fluoride toothpaste is not effective."
B. "Excessive amounts of fluoride will make teeth turn brittle and yellow."
C. "Use of fluoride in water is mostly effective during initial tooth formation."
D. "Dental caries can be prevented through fluoridation of public water." - -
Answer: "Dental caries can be prevented through fluoridation of public
water."
Dental caries can be prevented through fluoridation of public water (D).
Large amounts of fluoride (A) produces yellow and discolored teeth, not
brittle teeth. (B) is effective for young teeth. Fluoride is effective throughout
the life span, not just during initial tooth formation (C).
-A Spanish-speaking 5-year-old child starts kindergarten in an English-
speaking school. The child cries most of the time, appears helpless and
unable to function in the new situation. After assessing the child, how should
the school nurse document the situation?
A. Experiencing culture shock.
B. Refuses to participate in school activities.
C. Lacks the maturity needed in school.
D. Going through minority group discrimination. - -Answer: Experiencing
culture shock.
An inability to function may apply to persons of all ages undergoing
transitions, such as moving to a new country and adjusting to a subculture
within a larger culture that is unfamiliar. Culture shock (A) describes feelings
of discomfort and disorientation when adapting to new cultural settings.
Language barriers inhibit effective communication, so a child who is unable
, to communicate in the spoken language in the school environment may lack
the skills necessary to participate, and is not refusing to participate (C). The
child may be adequately mature (B), accepted by peers (D) within the
environment, but continues to not join in because of the impact of culture
shock.
-The nurse is assessing a child's skin turgor and grasps the skin on the
abdomen between the thumb and index finger, pulls it taut, and quickly
releases it. The tissue remains suspended and tented for a few seconds, then
slowly falls back on the abdomen. How should the nurse document this
finding?
A. Assessment inconclusive.
B. Poor skin turgor.
C. Adequate hydration.
D. Normal skin elasticity - -Answer: Poor skin turgor
Tissue turgor refers to the amount of elasticity in the skin and is one of the
best estimates of adequate hydration and nutrition. Elastic tissue
immediately resumes its normal position without residual marks or creases.
In a child with poor turgor (B), the skin remains tented or suspended for a
few seconds before returning to a normal position. (A, C and D) are
inaccurate.
-A 4-month-old breastfeeding infant is at the 10th percentile for weight and
the 75th percentile for height. How should the nurse interpret this finding?
A. Inadequate milk supply in mother.
B. Milk allergy.
C. Normal growth curve of a breast-fed infant.
D. Failure to thrive. - -Answer: Normal growth curve of a breast-fed infant.
When plotting weights and heights on a standard growth chart used for both
breast-fed and formula-fed infants, the breast-fed infant grows more rapidly
during the first 2 months of life, and then growth slows from 3 to 12 months.
A breast-fed infant is leaner and has less body fat than a formula-fed infant.
Normal patterns of infants who are breast fed (D) differ from those who are
formula fed. (A) is an incorrect interpretation of the data. This finding is not
consistent with failure to thrive (B) or an inadequate milk supply (C)
-The nurse is instructing an adolescent with bulimia and a low potassium
level about the risk for complications. Which medical problem should be the
focus of the nurse's instruction to this client?
A. Heightened neurologic reflexes.
B. Gastrointestinal reflux.
C. Anemia.
D. Cardiac arrhythmias. - -Answer: Cardiac arrhythmias.
An adolescent with bulimia who purges by frequent self-induced vomiting,
diuretic or laxative abuse can experience potassium depletion, which
increases the risk for cardiac arrhythmias (B). (A) is more likely related to
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