NUR 202 HESI REVIEWS Latest Update 2024-
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. A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a
diagnosis af eclampsia. She is not presently convulsing. Which intervention should the
nurse plan to include in this client's nursing care plan? - CORRECT ANSWER: Monitor
Blood pressure, pulse, and respirations q4h.
. A newborn with myelomeningocele is admitted to the neonatal intensive care unit.
Which preoperative nursing intervention should the nurse implement first? - CORRECT
ANSWER: place the infant on the abdomen to protect the sac
A 34-week primigravida with pregnancy induced hypertension (PIH) is receiving Ringer's
Lactate 500 ml with magnesium sulfate 20 grams at the rate of 3 grams/hour. How
many ml/hour should the nurse program the infusion pump? (Enter numeric value only)
- CORRECT ANSWER: 75
A 36-week primigravida is admitted to labor and delivery with severe abdominal pain
and bright red vaginal bleeding. Her abdomen is rigid and tender to touch. The fetal
heart rate (FHR) is 90 beats/minute, and the maternal heart rate is 120 beats/minute.
What action should the nurse implement first? - CORRECT ANSWER: obtain written
consent for an emergency cesarean section.
A 4-day postpartum client calls the clinic and reports that her nipples are so sore that
she does not know if she can continue to breastfeed her infant. What instruction is best
for the nurse to provide? - CORRECT ANSWER: apply hot packs before each feeding
A 5-year-old child is admitted to the pediatric unit fever and pain secondary to a sickle
cell crisis. Which intervention should the nurse implement first? - CORRECT ANSWER:
Initiate normal saline IV at 50ml/hr.
, A breastfeeding infant, screened for congenital hypothyroidism, is found to have low
levels of thyroxine (T4) and high levels of thyroid stimulating hormone (TSH). What is
the best explanation for this finding? - CORRECT ANSWER: The TSH is high because
of the low production of T4 by the thyroid.
A child admitted with diabetic ketoacidosis is demonstrating Kussmaul respiration. The
nurse determines that the increased respiratory rate is a compensatory mechanism for
wich acid base alteration? - CORRECT ANSWER: Metabolic Acidosis
A child who has been vomiting for 3 days is admitted for correction of fluid and
electrolyte imbalances. What acid base imbalance is this child likely to exhibit? -
CORRECT ANSWER: Metabolic Alkalosis
A child who received multiple blood transfusions after correction of a congenital heart
defect is demonstrating muscular irritability and is oozing blood from the surgical
incision. Which serum value is most important for the nurse to review before reporting to
the healthcare provider? - CORRECT ANSWER: Calcium
A client delivers a viable infant, but begins to have excessive uncontrolled vaginal
bleeding after the IV Pitocin is infused. When notifying the healthcare provider of the
client's condition, what information is most important for the nurse to provide? -
CORRECT ANSWER: Maternal BP
A client is receiving oxytocin (Pitocin) to augment early labor. Which assessment is most
important for the nurse to obtain each time the infusion rate is increased? - CORRECT
ANSWER: Contraction pattern
A client whose labor is being augmented with an oxytocin (Pitocin) infusion requests an
epidural for pain control. Findings of the last vaginal exam, performed 1 hour ago, were
3 cm cervical dilatation, 60% effacement, and a -2 station. What action should the nurse
implement first? - CORRECT ANSWER: Determine current cervical dilation.
A client with gestational diabetes is undergoing a non-stress test (NST) at 34-weeks
gestation. The baseline fetal heart rate (FHR) is 144 beats/minute. The client is
instructed to mark the fetal monitor paper by pressing a button attached to the fetal
monitor each time the baby moves. After 20 minutes, the nurse evaluates the fetal
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