HESI 235 Nightingale Study Guide

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Sample questions from HESI 235 Nightingale Study Guide

This material has 24 questions with answers and rationales. Here are the first 5.

1. 1.An older adult hospitalized after a stroke has left-sided weakness, intact skin, and an established repositioning schedule. The client requires two-person assistance for transfers. Which task should the registered nurse delegate to experienced unlicensed assistive personnel (UAP)?

   • A.Assess the client's heels for early pressure injury.
   • B.Reposition the client according to the established schedule.
   • C.Teach the client how to transfer safely to a chair.
   • D.Determine whether the current mobility plan remains appropriate.

   Rationale: UAP may perform routine repositioning according to an established plan, using the prescribed assistance and reporting skin changes. Assessing the heels requires nursing judgment. Initial transfer teaching is the nurse's responsibility. Evaluating the effectiveness of the mobility plan also requires the registered nurse's assessment and judgment.

2. 2.A client receiving IV morphine by patient-controlled analgesia after abdominal surgery is difficult to arouse. Respirations are shallow at 6/min, and oxygen saturation is 84%. After stopping the opioid infusion and activating emergency assistance, which action should the nurse take next?

   • A.Obtain an arterial blood gas specimen before intervening further.
   • B.Apply oxygen by nasal cannula and reassess in 15 minutes.
   • C.Open the airway and assist ventilation with a bag-mask device and oxygen.
   • D.Raise the head of the bed and coach the client to use an incentive spirometer.

   Rationale: Severe opioid-induced hypoventilation requires immediate airway support and assisted ventilation. Naloxone should also be administered promptly according to protocol while respiratory support continues. An arterial blood gas must not delay treatment. Oxygen by nasal cannula alone does not correct inadequate ventilation, and waiting is unsafe. A poorly responsive client cannot reliably perform incentive spirometry.

3. 3.Thirty minutes after a vaginal birth, a client has heavy vaginal bleeding, a boggy uterus, a heart rate of 124/min, and a blood pressure of 86/50 mm Hg. While another nurse activates the postpartum hemorrhage protocol, which action should the primary nurse take first?

   • A.Massage the uterine fundus.
   • B.Assist the client to walk to the bathroom.
   • C.Wait for the hemoglobin result before initiating treatment.
   • D.Inspect the perineum for a laceration before addressing uterine tone.

   Rationale: A boggy uterus with heavy postpartum bleeding indicates uterine atony. Immediate fundal massage promotes contraction and helps control the source of bleeding; uterotonics and rapid circulatory support are also needed. Walking is unsafe with hypotension and suspected shock. Treatment must not wait for laboratory results. Lacerations can cause bleeding, but restoring uterine tone takes priority when the uterus is boggy.

4. 4.A 10-year-old with diabetic ketoacidosis has begun prescribed isotonic IV fluid replacement. Laboratory results show glucose 480 mg/dL, pH 7.18, and potassium 2.8 mEq/L. An IV regular insulin infusion is prescribed but has not started. Which action should the nurse take?

   • A.Start the insulin infusion because correction of hyperglycemia is the immediate priority.
   • B.Administer the prescribed potassium dose by IV push before starting insulin.
   • C.Stop fluid replacement until the glucose concentration falls below 250 mg/dL.
   • D.Withhold insulin temporarily and notify the provider to obtain potassium replacement orders.

   Answer and rationale are in the full material.

5. 5.An alert client with metastatic cancer tells the nurse, "I do not want more chemotherapy. I want to go home and be comfortable." The client's spouse asks the nurse to persuade the client to continue treatment. Which response by the nurse is most appropriate?

   • A.Your spouse wants treatment continued, so we should postpone discussing comfort care.
   • B.Tell me what matters most to you so we can discuss your goals and available home support.
   • C.Stopping chemotherapy means that your healthcare team can no longer treat your symptoms.
   • D.Before making this choice, you should consider how guilty your family might feel.

   Answer and rationale are in the full material.