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HESI RN Exit Comprehensive V1
(5 Sets of V1 Exams)
HESI RN Exit Comprehensive V1 Exam
Set 1
- The nurse is monitoring neurological vital signs for a male client who lost
consciousness after falling and hitting his head.Which assessment finding isthe earliest and most sensitive indication of altered cerebral function?
a. Unequal pupils.
b. Loss of central reflexes.
c. Inability to open the eyes.
d. Change in level of consciousness
ANS D
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(Neurological vital signs include serial assessments of TPR, blood pressure, and
components of the Glasgow coma scale (GCS), which includes verbal, musculoskeletal, and pupillary responses. A change in the client’s level of consciousness,as indicated by responses to commands during the GCS, is the first and the most
sensitive sign of change in cerebral function. The other assessment data choices
are late signs of altered cerebral function.)
- A nurse is planning to teach self-care measures to a female client about
prevention of yeast infections. Which instructions should the nurse provide?a. Use a douche preparation no more than once a month.
b. Increase daily intake of fiber and leafy green vegetables.
c. Select nylon underwear that is loose-fitting, white, and comfortable.
d. Avoid tight-fitting clothing and do not use bubble-bath or bath salts
ANS D
(A common genital tract infection in females is candidiasis, which is an overgrowthof the normal vaginal flora of Candida albicans that thrives in an environment that iswarm and moist and is perpetuated by tight-fitting clothing, underwear, or pantyhosemade of nonabsorbent materials.The client should wear clothing that is loose fittingand absorbent, such as cotton underwear, and avoid using bubble-bath or bath
salts which further irritate sensitive genital tissue. Douching is not recommended
because it can irritate vaginal tissue, alter pH, and contribute to fungal growth.Whileincreasing dietary fiber intake encourages healthy, nutritional guidelines, it is not the
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focus of the teaching. Cotton, not nylon undergarments, provide absorbancy and
reduce moisture in the perineal area.) - A client who has active tuberculosis (TB) is admitted to the medical unit.
What action is most important for the nurse to implement?
a. Place an isolation cart in the hallway.
b. Fit the client with a respirator mask.
c. Don a clean gown for client care.
d. Assign the client to a negative air-flow room
ANS D
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(Active tuberculosis requires implementation of airborne precautions, so the client
should be assigned to a negative pressure air-flow room. Although isolation gownsand isolation carts should be implemented for clients in isolation with contact
precautions, it is most important that air flow from the room is minimized when the
client has TB. The respirator mask should be implemented when the client leaves
the isolation environment.)
- The nurse is planning to conduct nutritional assessments and diet teachingto clients at a family health clinic.Which individual has the greatest nutritionaand energy demands?
a. A pregnant woman.
b. A teenager beginning puberty.
c. A 3-month-old infant.
d. A school-aged child
ANS A
A pregnant woman’s metabolic demands are 20 to 24% more than the basic metabolic rate. The other clients require only 15 to 20% more than the basic metabolic
rate. - What nursing delivery of care provides the nurse to plan and direct care ofa group of clients over a 24-hour period?
a.Team nursing.
b. Primary nursing.
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