HESI RN
HESI Maternity Test Bank
1. When can a woman who thinks she may be pregnant use a home pregnancy test to diagnose pregnancy?
- A. A home pregnancy test can be used right after your first missed period.
- B. These tests are most accurate after you have missed your second period.
- C. Home pregnancy tests often give false positives and should not be trusted.
- D. The test can provide accurate information when used right after ovulation.
Correct answer: A
Rationale: The correct answer is A. Home pregnancy tests detect hCG, a hormone produced during pregnancy, and are most accurate after the first missed period when hCG levels are higher. Testing too early may result in a false negative. Waiting until after the first missed period increases the reliability of the test results. Choice B is incorrect as waiting until after the second missed period is unnecessary and may delay seeking appropriate healthcare. Choice C is incorrect as home pregnancy tests are generally reliable when used correctly. Choice D is incorrect because ovulation occurs before the period, and testing immediately after ovulation may not provide accurate results.
2. A client receiving heparin therapy develops sudden chest pain and dyspnea. What should the nurse do first?
- A. Administer oxygen and elevate the head of the bed.
- B. Administer sublingual nitroglycerin as prescribed.
- C. Assess for signs of bleeding at the injection site.
- D. Administer a PRN dose of albuterol.
Correct answer: A
Rationale: In this scenario, the priority action for the nurse is to administer oxygen and elevate the head of the bed. These interventions help relieve dyspnea and chest pain, which can be indicative of a pulmonary embolism or other complications during heparin therapy. Administering nitroglycerin (Choice B) is not the initial priority in this situation as the client's symptoms are not suggestive of angina. Assessing for bleeding (Choice C) is important but not the first action needed to address chest pain and dyspnea. Administering albuterol (Choice D) is not indicated unless there are specific respiratory issues requiring it, which are not described in the scenario.
3. The healthcare provider provides dietary instructions about iron-rich food to a client with iron deficiency anemia. Which food selection made by the client indicates a need for additional instructions?
- A. Liver
- B. Kidney beans
- C. Oranges
- D. Leafy green vegetables
Correct answer: C
Rationale: Oranges are not a good source of iron, so selecting oranges indicates a need for additional instructions. Oranges are high in vitamin C, which can enhance iron absorption from other sources, but they are not rich in iron themselves. Liver, kidney beans, and leafy green vegetables are good sources of iron and would be beneficial for a client with iron deficiency anemia. Therefore, the correct answer is C.
4. A client is undergoing hemodialysis. The client’s blood pressure at the beginning of the procedure was 136/88 mm Hg, and now it is 110/54 mm Hg. What actions should the nurse perform to maintain blood pressure? (Select all that apply.)
- A. Adjust the rate of extracorporeal blood flow.
- B. Place the client in the Trendelenburg position.
- C. Administer a 250-mL bolus of normal saline.
- D. All of the above
Correct answer: D
Rationale: During hemodialysis, a drop in blood pressure can occur due to fluid removal. To maintain blood pressure, the nurse should consider adjusting the rate of extracorporeal blood flow to optimize fluid removal without causing hypotension. Placing the client in the Trendelenburg position can help improve venous return and cardiac output. Administering a bolus of normal saline can help increase intravascular volume and support blood pressure. Therefore, all the actions listed in choices A, B, and C are appropriate measures to maintain blood pressure during hemodialysis. Choice D, 'All of the above,' is the correct answer as it encompasses all the relevant actions to address the dropping blood pressure effectively. Choices A, B, and C, when implemented together, can help manage hypotension during hemodialysis.
5. An emergency department nurse assesses a client with kidney trauma and notes that the client’s abdomen is tender and distended, and blood is visible at the urinary meatus. Which prescription should the nurse consult the provider about before implementation?
- A. Assessing vital signs every 15 minutes
- B. Inserting an indwelling urinary catheter
- C. Administering intravenous fluids at 125 mL/hr
- D. Typing and crossmatching for blood products
Correct answer: B
Rationale: In a client with kidney trauma and blood visible at the urinary meatus, inserting a urinary catheter via the urethra should be avoided until further diagnostic studies are completed to prevent potential urethral tears. The nurse should consult the provider about the need for a catheter; if necessary, a suprapubic catheter can be used instead. Assessing vital signs every 15 minutes is important for continuous monitoring of the client's condition. Administering intravenous fluids at 125 mL/hr is crucial to maintain hydration and support kidney function. Typing and crossmatching for blood products is necessary in case the client requires blood transfusion due to potential blood loss from the trauma.