HESI Comprehensive Exam A Practice

HESI Comprehensive Exam A Practice 1 .A 2-day postpartum mother who is breastfeeding asks, "Why do I feel this tingling in my breasts after the baby sucks for a few minutes?" Which information should the nurse provide?

• This feeling occurs during

feeding with a breast infection.

• This sensation occurs as breast

milk moves to the nipple.

• The baby does not have good

latch-on.

• The infant is not positioned

correctly.

• This sensation occurs as breast milk

moves to the nipple.

Rationale:

When the mother's milk comes in, usually 2 to 3 days after delivery, women often report they feel a tingling sensation in their nipples (B) when let- down occurs. (A, C, and D) provide inaccurate information.2 .A 40-year-old office worker who is at 36 weeks' gestation presents to the occupational health clinic complaining of a pounding headache, blurry vision, and swollen ankles. Which intervention should the nurse implement first?

• Check the client's blood

pressure.

• Teach her to elevate her feet

when sitting.

• Obtain a 24-hour diet history to

evaluate for the intake of salty foods.

• Assess the fetal heart rate.
• Check the client's blood pressure.

Rationale:

The blood pressure (A) should be assessed first. Preeclampsia is a multisystem disorder, and women older than 35 years and have chronic hypertension are at increased risk.Classic signs include headache, visual changes, edema, recent rapid weight gain, and elevated blood pressure. (B, C, and D) can be done if the blood pressure is normal.3 .A 50-year-old man arrives at the clinic with complaints of pain on ejaculation. Which action should the nurse implement?

• Teach the client testicular self-

examination (TSE).

• Assess for the presence of blood
• Ask about scrotal pain or blood in

the semen.

Rationale:

Orchitis is an acute testicular inflammation resulting from recurrent urinary tract infection, recurrent sexually transmitted disease (STD), or Stuvia.com - The Marketplace to Buy and Sell your Study Material

Downloaded by: dennys | [email protected]

Distribution of this document is illegal

HESI COMPREHENSIVE EXAM A PRACTICE 1 / 4

Stuvia.com - The Marketplace to Buy and Sell your Study Materialin the urine.

• Ask about scrotal pain or blood

in the semen.

• Inquire about a history of kidney

stones.an indwelling urethral urinary catheter causing pain on ejaculation, scrotal pain, blood in the semen, and penile discharge, so the nurse should determine the presence of other symptoms (C). Although all men should practice TSE, the client's symptoms are suggestive of an inflammatory syndrome rather than testicular cancer (A). Although hematuria (B) is associated with renal disease or calculi (D), the client's pain is associated with ejaculate, not urine.4 .A 77-year-old female client states that she has never been so large around the waist and that she has frequent periods of constipation.Colon disease has been ruled out with a flexible sigmoidoscopy.Which information should the nurse provide to this client?

• As women age, they often become

rounder in the middle because they do not exercise properly.

• Further assessment is indicated

because loss of abdominal muscle tone and constipation do not occur with aging.

• With age, more fatty tissue

develops in the abdomen and decreased intestinal movement can cause constipation.

• Because there is no evidence of a

diseased colon, there is no need to worry about abdominal size.

• With age, more fatty tissue

develops in the abdomen and decreased intestinal movement can cause constipation.

Rationale:

With aging, the abdominal muscles weaken as fatty tissue is deposited around the trunk and waist. Slowing peristalsis also affects the emptying of the colon, resulting in constipation (C). (A) is not the primary reason for the changes in body structure. (B) is not indicated because loss of muscle tone and constipation are age-related changes. (D) dismisses the client's concerns and does not help her understand the changes that she is experiencing.5 .According to Erikson, which client should the nurse identify as having difficulty completing the developmental stage of older adults?

• A 75-year-old woman who wishes

her friends were still alive so she could change some of the choices she made over the years Stuvia.com - The Marketplace to Buy and Sell your Study Material

Downloaded by: dennys | [email protected]

Distribution of this document is illegal 2 / 4

Stuvia.com - The Marketplace to Buy and Sell your Study MaterialA. A 60-year-old man who tells the nurse that he is feeling fine and really does not need any help from anyone

• A 78-year-old widower who has

come to the mental health clinic for counseling after the recent death of his wife

• An 81-year-old woman who states

that she enjoys having her grandchildren visit but is usually glad when they go home

• A 75-year-old woman who wishes

her friends were still alive so she could change some of the choices she made over the years

Rationale:

The older woman who wishes she could change the choices she has made in her lifetime is expressing despair and is still searching for integrity (D). The nurse uses Erikson stages of development over the life span to assess an older client's adjustment to aging and plans teaching strategies to assist the clients attain integrity versus despair. (A, B, and C) are normal developmental tasks of older adults.6 .After administration of an 0730 dose of Humalog 50/50 insulin to a client with diabetes mellitus, which nursing action has the highest priority?

• Ensure that the client receives

breakfast within 30 minutes.

• Remind the client to have a

midmorning snack at 1000.

• Discuss the importance of a

midafternoon snack with the client.

• Explain that the client's capillary

glucose will be checked at 1130.

• Ensure that the client receives

breakfast within 30 minutes.

Rationale:

Insulin 50/50 contains 50% regular and 50% NPH insulin. Therefore, the onset of action is within 30 minutes and the nurse's priority action is to ensure that the client receives a breakfast tray to avoid a hypoglycemic reaction (A). (B, C, and

• are also important nursing actions

but are of less immediacy than (A).7 .The antigout medication allopurinol (Zyloprim) is prescribed for a client newly diagnosed with gout. Which comment by the client warrants intervention by the nurse?

• "I take aspirin for my pain."
• "I frequently eat fruit and drink fruit

juices."

• "I drink a great deal of water, so I have

to get up at night to urinate."

• "I take aspirin for my pain."

Rationale:

The client should be taught to avoid aspirin (A) because the ingestion of aspirin or diuretics can precipitate an attack of gout. (B, C, and D) are all appropriate for the treatment of gout. The client's urinary pH can be increased by the intake Stuvia.com - The Marketplace to Buy and Sell your Study Material

Downloaded by: dennys | [email protected]

Distribution of this document is illegal 3 / 4

Stuvia.com - The Marketplace to Buy and Sell your Study MaterialD. "I observe my skin daily to see if I have an allergic rash to the medication." of alkaline ash foods, such as citrus fruits and juices, which will help reduce stone formation (B). Increasing fluids helps prevent urinary calculi (stone) formation and should be encouraged, even if the client must get up at night to urinate (C). Allopurinol has a rare but potentially fatal hypersensitivity syndrome, which is characterized by a rash and fever. The medication should be discontinued immediately if this occurs (D).8 .Because of census overload, the charge nurse of an acute care medical unit must select a client who can be transferred back to a residential facility. The client with which symptomology is the most stable?

• A stage 3 sacral pressure ulcer, with

colonized methicillin-resistant Staphylococcus aureus (MRSA)

• Pneumonia, with a sputum culture of

gram-negative bacteria

• Urinary tract infection, with positive

blood cultures

• Culture of a diabetic foot ulcer shows

gram-positive cocci

• A stage 3 sacral pressure

ulcer, with colonized methicillin-resistant Staphylococcus aureus

(MRSA)

Rationale:

The client with colonized MRSA (A) is the most stable client, because colonization does not cause symptomatic disease. The gram-negative organisms causing pneumonia are typically resistant to drug therapy (B), which makes recovery very difficult.Positive blood cultures (C) indicate a systemic infection.Poor circulation places the diabetic with an infected ulcer (D) at high risk for poor healing and bone infection.9 .The charge nurse of a 16-bed medical unit is making 0700 to 1900 shift assignments.The team consists of two RNs, two PNs,

• Assign the UAPs to take

vital signs and obtain daily weights. Stuvia.com - The Marketplace to Buy and Sell your Study Material

Downloaded by: dennys | [email protected]

Distribution of this document is illegal

• / 4