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WorksheetsHesi 1
Total questions: 88
Worksheet time: 47mins
The client reports getting up 5–6 times nightly to urinate but can hold it until reaching the bathroom. What urinary pattern is this?
Stress incontinence
Urge incontinence
Nocturia
Overflow incontinence
The client now voids spontaneously without recognizing the urge to void. How should this be documented?
Functional incontinence
Reflex incontinence
Incontinence
Stress incontinence
For bladder training, which instruction should be given to the UAP?
Measure urine output every hour
Remind the client to void every 2 hours while awake
Restrict fluids after lunch
Encourage nighttime voiding
The client is frustrated about persistent incontinence. Which intervention is appropriate?
Limit fluid intake
Apply restraints
Discuss coping strategies
Discontinue bladder training
After an incontinence episode, which spouse statement indicates correct skin care understanding?
Use hot water after each episode
Apply powder to keep the area dry
Wash with mild soap and water, then apply ointment
Avoid cleansing the area unless irritated
Bladder training continues with little improvement. What should the nurse assess for?
Hypertension
Skin breakdown
Hyperthermia
Blood in urine
For an external catheter, which intervention is most important?
Apply snugly around the shaft
Remove every 24 hours
Assess skin integrity frequently
Keep the tubing dependent
First step in inserting a male indwelling urinary catheter?
Inflate the balloon first
Wash perineal area with soap and water
Apply sterile gloves immediately
Advance catheter until urine returns
What physiologic change in adult males may affect catheter insertion?
Decreased bladder elasticity
Prostate enlargement
Reduced urethral length
Increased urinary pH
During insertion, the student inflates the balloon at 4 inches and client cries out. What happened?
Balloon inflated in urethra
Balloon ruptured
Catheter too small
Catheter contaminated
A client with immobility is at immediate risk for which complications?
Deconditioning
Constipation
Venous thromboembolism
Osteoporosis
Orders that prevent VTE in immobile clients include: (Select all)
Ambulate 3x/day
Restrict fluids
Sequential compression devices
Daily enoxaparin
Compression stockings
The UAP reports client chewing slowly and spitting food out. What likely explains this?
Dysphagia from stroke
Edentulism
Dehydration
Medication side effect
Post-op constipation risk: which medication is most likely responsible?
Ibuprofen
Promethazine
Cefazolin
Morphine
A 1000 mL/day fluid intake causes what bowel effect?
Prevents constipation
Causes diarrhea
Contributes to constipation
Has no effect
Priority postop constipation assessment question:
How often do you walk?
Do you use the incentive spirometer?
When was dressing last changed?
Are compression devices on?
In ulcerative colitis, diarrhea is typically:
Bloody
Green frothy
Clay colored
Fatty gray
Ongoing rectal bleeding causes what symptom?
Hypertension
Fatigue/light-headedness
Joint stiffness only
Urinary retention
After a barium enema, what should the client be instructed to do?
Avoid fluids for 24 hours
Limit fluids
Resume normal fluids
Drink extra fluids
In pancreatitis, which diet is expected on admission?
Regular diet
Low fat
Clear liquids
NPO
During bladder training, the nurse obtains a prescription for an external catheter. What is the MOST important part of care?
Keep the drainage bag above the bladder
Use alcohol wipes to cleanse the skin
Frequently assess for skin breakdown
Remove and replace every 3 days
Which complication of immobility is the nurse MOST concerned about due to risk of obstructed venous return?
Pneumonia
Venous thromboembolism
Hyperglycemia
Hypertension
An immobile client is ordered SCDs. What is the purpose?
Reduce edema
Prevent skin breakdown
Promote venous blood flow to prevent clots
Strengthen leg muscles
A client with Parkinson-related shuffling gait needs safety teaching. Which instruction is correct?
Encourage the client to take small steps and keep feet apart when walking.
Advise the client to walk quickly to avoid freezing.
Suggest the client to walk with hands in pockets.
Tell the client to look down at their feet while walking.
Which instruction is correct for a client with Parkinson's when walking?
Look down at your feet when walking
Keep arms stiff at sides
Walk with a wide-based stance
Take long steps to increase stride length
A client with Parkinson’s tends to lean forward while ambulating. Which instruction improves safety?
Take rapid steps
Increase arm swing
Use a toe-heel gait pattern
Walk backward first to gain balance
A Parkinson’s client has difficulty starting movement from a chair. This is best described as:
Hemiparesis
Bradykinesia
Hyperreflexia
Spasticity
The nurse observes a Parkinson’s client with slow speech and difficulty communicating. Which nursing diagnosis is appropriate?
Risk for infection
Impaired verbal communication
Unilateral neglect
Altered sensory perception
A client shows difficulty swallowing associated with Parkinson’s disease. What diet adjustment is appropriate?
Thin liquids only
High-fiber raw vegetables
Soft foods and thickened liquids
Dry crackers and nuts
After abdominal surgery, the client develops absent bowel sounds and abdominal distention. What is the likely condition?
Liver failure
Paralytic ileus
Cholecystitis
Bowel perforation
Priority management for paralytic ileus includes:
Increase oral intake
Administer antidiarrheals
Keep NPO and insert NG tube
Give stimulant laxatives early
A client with pancreatitis reports severe LUQ pain radiating to the back. Which assessment supports this diagnosis?
Pain relieved with eating
Pain worsens with eating
Pain relieved by lying flat
Pain only at night
For acute pancreatitis, which intervention reduces pancreatic stimulation?
Encourage small frequent meals
Provide low-fat snacks
Keep the client NPO
Increase oral hydration
NG tube to low intermittent suction is used in pancreatitis to:
Increase bowel motility
Reduce HCl and pancreatic stimulation
Reduce urine output
Treat hyperkalemia
Which finding indicates improvement in pancreatitis?
Increasing abdominal distention
Diminished bowel sounds
Decreased pain and nausea
Persistent vomiting
In ulcerative colitis, what complication can occur due to inability to absorb water and electrolytes?
Metabolic alkalosis
Fluid and electrolyte imbalance
Hypervolemia
Kidney stones
Which dietary recommendation is appropriate during a UC flare?
High-fiber diet
Raw vegetables and fruits
High-calorie, high-protein, low-fiber diet
High-fat diet
A client with UC reports joint pain and eye sensitivity to light. The nurse explains:
These are unrelated symptoms
These are expected extraintestinal manifestations
These indicate kidney involvement only
These occur only with Crohn’s disease
For a stool guaiac test, which instruction is correct?
Avoid red meat for 3 days before testing
Increase Vitamin C intake
Eat citrus fruits before the test
Restrict fluids for 24 hours
After a barium enema, which statement indicates correct teaching?
I should avoid liquids today.
I should expect white stools and drink extra fluids.
I will remain NPO for 12 hours.
I should avoid all movement to prevent cramping.
A client with malabsorption from IBD has low albumin. This indicates:
Adequate protein stores
Excessive protein intake
Poor nutritional status
Normal metabolism
A client with immobility is at risk for constipation. What is the BEST prevention strategy?
Decrease fluid intake
Increase fiber and fluids
Provide antidiarrheals
Encourage bed rest
Which factor MOST contributes to postoperative constipation?
Hypothermia
Opioid analgesics (correct)
A nurse notes a distended abdomen, nausea, and absent bowel sounds in a postop client. What is the priority?
Encourage the client to ambulate
Give ice chips
Keep NPO and notify the provider
Provide a high-fiber meal
A client with Parkinson’s disease demonstrates shuffling gait. Which nursing instruction improves safety?
Take large steps
Walk at a faster pace
Use a wide-based stance
Lean forward when walking
Which characteristic of Parkinson’s disease directly contributes to fall risk?
Increased blinking
Muscle rigidity
Tachycardia
Fine motor tremors only
A Parkinson’s client struggles with initiation of movement. The nurse recognizes this as:
(a)
What is the MOST effective intervention to prevent skin breakdown in an incontinent client?
Apply talcum powder
Clean with harsh soap
Clean with mild soap and water, then apply barrier ointment
Keep the area open to air only
During bladder training, which finding indicates improvement?
Increased frequency at night
Decreased episodes of incontinence
Dark, concentrated urine
Needing to void every hour
A client is unable to reach the toilet in time due to weakness after surgery. This type of incontinence is:
Stress
Urge
Overflow
Functional
Which instruction should be provided to the UAP assisting with bladder training?
A client with a UTI asks why hydration is important. The nurse explains that fluids:
Decrease urine pH
Dilute urine and help flush bacteria
Eliminate the need for antibiotics
Reduce kidney function
Which manifestation of pyelonephritis differentiates it from a lower UTI?
Dysuria
Frequency
Flank pain and fever
Cloudy urine
The nurse teaches prevention of recurrent UTIs. Which instruction is correct?
Take bubble baths regularly
Void every 3–4 hours
Avoid drinking water at night only
Restrict all caffeine permanently
Which manifestation is common in older adults with UTIs?
Confusion
Hematuria
Rash
Chest pain
A client shows weak urine stream and lower abdominal fullness. This indicates:
Urge incontinence
Stress incontinence
Urinary retention
Polyuria
In urinary retention, which finding requires immediate intervention?
Frequent small voids
Palpable bladder distention
Clear yellow urine
Decreased postvoid residual
When preparing to insert a male catheter, the nurse first:
Advance the catheter 6 inches
Put on sterile gloves
Clean perineal area with soap and water
Inflate the balloon to test it
Which complication is associated with indwelling catheters?
(a)
Cognitive changes
Cognitive changes
Severe flank pain always
Pain-free urination
Which of the following is a common complication associated with urinary catheters?
Diabetes
CAUTI
Hypertension
Polycythemia
A client with UC is ordered to increase caloric intake. Which diet is appropriate?
High fat, high fiber
High protein, high calorie, low fiber
High dairy
High raw vegetables
A client with pancreatitis is NPO. The purpose of NPO status is to:
Reduce liver workload
Prevent aspiration
Reduce pancreatic enzyme secretion
Prevent electrolyte loss
Which finding requires the nurse to stop bladder training and reassess the client?
Sudden onset of severe lower abdominal pain
Gradual increase in urine output
Mild discomfort during voiding
Slightly cloudy urine
Select the correct answer.
Client reports mild urgency
Client voids small amounts frequently
Client develops skin redness or irritation
Client needs help to reach toilet
A client experiencing nocturia asks why it occurs. The nurse explains:
It is caused by diabetes
It is only seen in urinary retention
It is defined as frequent urination at night
It is caused by dehydration
A client with stress incontinence leaks urine when coughing. What is the cause?
Bladder overdistention
Sudden increase in intraabdominal pressure
Neurologic injury
Complete loss of sphincter control
Which client statement indicates understanding of functional incontinence?
My bladder contracts without warning.
I leak urine because I can’t reach the toilet in time.
I leak only with coughing.
My bladder is always full.
A client is placed on anticholinergic therapy for urge incontinence. Which side effect is expected?
Dry mouth
Diarrhea
Increased sweating
Insomnia
Which of the following is a common side effect?
Frequent urination
Dry mouth
Increased diarrhea
Wet skin
During assessment, the nurse notes cloudy urine, frequency, and dysuria. These findings indicate:
Pyelonephritis
Lower urinary tract infection
Stress incontinence
Overflow retention
Which nursing intervention prevents UTI in a female client?
Wipe back to front
Limit fluids to prevent frequency
Avoid voiding after intercourse
Wipe from front to back (correct)
A client with urinary retention may experience which finding?
Constant dribbling of urine
Dysuria only
Dark green urine
Frequent large voids
The nurse palpates a full bladder after the client reports inability to void. What is the priority?
Notify the healthcare provider immediately
Encourage the client to drink more fluids
Assist the client to the bathroom
Perform a bladder scan and prepare for catheterization
Which intervention is appropriate for a client with suspected urinary retention?
Encourage oral fluids
Apply heat to the abdomen
Obtain a bladder scan
Give diuretics
A client receiving an indwelling catheter asks how to prevent infection. The best response is:
Disconnect the tubing daily.
Keep the drainage bag below the bladder.
Apply powder around the catheter.
Clamp the tubing at night.
The nurse observes fever, costovertebral angle tenderness, and chills. These are signs of:
Lower UTI
Pyelonephritis
Bladder cancer
Kidney stones only
Which finding is most concerning in pancreatitis?
Pain relieved by food
LUQ pain radiating to the back
Normal bowel sounds
Increased appetite
A client with pancreatitis has nausea, vomiting, and abdominal distention. Which intervention is appropriate?
Encourage oral fluids
Apply heat to the abdomen
Obtain a bladder scan
Give diuretics
Which intervention is appropriate for a client with acute pancreatitis?
Encourage high-fiber diet
Keep NPO with NG suction
Promote early ambulation
Encourage carbonated beverages
Which complication of acute pancreatitis can impair lung function?
Pneumonia
Cataracts
Hypertension
Enlarged liver only
A UC client reports 8–10 bloody stools per day. Which complication is a priority?
COPD
Anemia
Kidney stones
Hepatic encephalopathy
Which statement shows understanding of UC diet education?
I will eat high-fiber raw vegetables.
I will increase spicy foods.
I will follow a high-calorie, high-protein, low-fiber diet during flares.
I will drink alcohol with meals.
A client with Crohn’s disease has weight loss and malabsorption. Which assessment finding supports this?
Steatorrhea
Bradycardia
Hypertension
Jaundice
Which of the following is a common finding in a client with ulcerative colitis (UC)?
Elevated albumin
Normal appetite
Low albumin
Decreased bowel movements
Which intervention helps reduce inflammation during an acute UC flare?
Encourage raw fruits
Provide high-fat meals
Administer prescribed corticosteroids
Avoid all protein sources
A nurse teaches a client with UC collecting stool samples. Which instruction is correct?
Avoid Vitamin C before testing
Avoid fluids
Increase red meat intake
Avoid all carbohydrates
After a barium enema, the client reports white stools. How should the nurse respond?
This is abnormal—return immediately.
This is expected; drink extra fluids.
You must avoid fluids today.
You should expect black, tarry stools.
