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MCA II- HESI Practice Test With Questions And 100% ALL SURE ANSWERS
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JACKLINEMCA II- HESI Practice Test With Questions And 100% ALL SURE ANSWERS
Terms in this set (100)
What instruction should the nurse include in the A. Catheterize every 3 to 4 hours.
discharge teaching for a client who needs to
perform self-catheterization technique at home? The average interval between catheterization for adults is every 3 to 4 hours. Although sterile
technique is indicated in healthcare facilities, clean technique is often followed by the client when
A. Catheterize every 3 to 4 hours. performing self-catheterization at home.
B. Maintain sterile technique.
C. Use the Cred maneuver before catheterization.
D. Drink 500 ml of fluid within 2 hours of
catheterization.
MCA II- HESI Practice Test
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,What is the priority nursing action while caring C. Use a bag-valve-mask resuscitator while removing the client from the area.
for a client on a ventilator when an electrical fire
occurs in the intensive care unit? A client on a ventilator should have respirations maintained with a manual bag-valve-mask
resuscitator while being moved away from the oxygen wall outlet and fire source. the other are
A. Tell another staff member to bring extinguishing not the priority in maintaining safety during a fire int he client care area.
equipment to the bedside.
B. Close the doors to the client's area when
attempting to extinguish the fire.
C. Use a bag-valve-mask resuscitator while
removing the client from the area.
D. Implement an emergency protocol to remove
the client from the ventilator.
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A client in the preoperative holding area C. Withhold the drug until the client validates understanding of the surgical procedure and signs
receives a prescription for midazolam (Versed) the consent form.
IV. The nurse determines that the surgical
consent form needs to be signed by the client. Midazolam, a benzodiazepine sedative, is commonly used for conscious-sedation
Which action should the nurse implement? intraoperatively and interferes with the client's cognition and level of consciousness, so the
consent form should be signed before the drug is administered. The validity of legal documents
A. Give the drug and allow the client to read and will be in question if a client signs them while under the influence of any central nervous system
sign the consent form. depressant drug.
B. Counter-sign the client's initials on the consent
form after giving the drug.
C. Withhold the drug until the client validates
understanding of the surgical procedure and signs
the consent form.
D. Call the healthcare provider to explain the
surgical procedure before the client signs the
consent.
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MCA II- HESI Practice Test
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,9/21/24, 8:19 AM
Which method elicits the most accurate D. Use reliable assessment tools for older adults.
information during a physical assessment of an
older client? Specific assessment tools (D) for an older adult, such as Older Adult Resource Services Center
Instrument, mini-mental assessment, fall risk, depression, or skin breakdown risk, consider age-
A. Ask the client to recount one's health history. related physiologic and psychosocial changes related to aging and provide the most accurate
B. Obtain the client's information from a caregiver. and complete information. A and B are subjective and may vary in reliability based on the client's
C. Review the past medical record for memory and caregiver's current involvement. Although C is a good resource to identify
medications. polypharmacy, a written record may not be available or currently accurate.
D. Use reliable assessment tools for older adults.
The healthcare provider prescribes high-protein, D. It is slow to leave the stomach.
high-fat, low-carbohydrate diet with limited
fluids during meals for a client recovering from This type of diet is slowly digested and is slow to leave the stomach. Because of its density from
gastric surgery. The client asks the nurse what proteins and fats, and the reduction of fluids with the meal, the possibility of dumping syndrome
the purpose is for this type of diet. Which is reduced.
rationale should be included in the nurse's
explanation to this client?
A. It is quickly digested.
B. It does not cause diarrhea.
C. It does not dilate the stomach.
D. It is slow to leave the stomach.
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The unlicensed assistive personnel (UAP) reports A. Document the temperature reading on the vital sign graphic sheet.
that an 87-year-old female client who is sitting in
a chair at the bedside has an oral temperature of A subnormal temperature of 97.2 F (36.4 C) (orally) is a common finding in elderly clients, so the
97.2 F ( 36.4 C). Which intervention should the nurse should document the findings and continue with the plan of care.
nurse implement?
A. Document the temperature reading on the vital
sign graphic sheet.
B. Report the temperature to the healthcare
provider immediately.
C. Instruct the UAP to take the client's temperature
again in 30 minutes.
D. Advise the UAP to assist the client in returning
to her bed.
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MCA II- HESI Practice Test
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, 9/21/24, 8:19 AM
The nurse is assessing a client with a cuffed D. Observe the client for coughing colored sputum after drinking a small amount of colored
tracheostomy tube in place who is breathing water.
spontaneously. To evaluate if the client can
tolerate cuff deflation to promote speaking and To evaluate the risk for aspiration after the cuff is deflated, the client should be instructed to
swallowing, what action should the nurse swallow a small amount of colored water, then observed for coughing up colored sputum, or the
implement? tracheostomy should be suctioned for the presence of colored water.
A. Ask the client to try to speak.
B. Assess for respiratory distress.
C. Auscultate for pulmonary crackles after the
client drinks a small amount of clear water.
D. Observe the client for coughing colored
sputum after drinking a small amount of colored
water.
A client with Meniere's disease is incapacitated D. Turn off the television and darken the room.
by vertigo and is lying in bed grasping the side
rails and staring at the television. Which nursing To decrease the client's vertigo during an acute attack of Meniere's disease, any visual stimuli or
intervention should the nurse implement? rotational movement, such as sudden head movements or position changes, should be
minimized. To effectively manage the client's symptoms, turn off the television, darken the room
A. Encourage fluids to 3000 ml per day. by minimizing fluorescent lights, flickering television lights, and distracting sounds
B. Change the client's position every two hours.
C. Keep the head of the bed elevated 30 degrees.
D. Turn off the television and darken the room.
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MCA II- HESI Practice Test
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