HESI COMPREHENSIVE EXAM

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HESI COMPREHENSIVE EXAM

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-Guarantee passing score -100 Questions and Answers -format set of multiple-choice -Expert-Verified Explanation Question 1: A nurse is caring for a client undergoing skeletal traction of the left leg. The client complains of severe pain in the leg. The nurse checks the client's alignment in bed and notes that proper alignment is being maintained. Which action should the nurse take next?Providing pin care Medicating the client Notifying the primary health care provider Removing some weight from the traction

Answer:

Notifying the primary health care provider Rationale: The nurse realigns the client and, if this is ineffective in relieving the pain, should next notify the primary health care provider. A client in traction who complains of severe pain may require realignment or may have traction weights that are too heavy. Severe leg pain, once traction has been established, indicates a problem. Provision of pin care is not related to the problem as described. The client should be medicated after an attempt has been made to determine and treat the cause; the cause of the severe pain should be investigated first. The nurse should never remove the weights from the traction without a specific prescription to do so.Question 2: A nurse provides instructions to a client who is preparing for discharge after a radical vulvectomy for the treatment of cancer. Which statement by the client indicates a need for further instruction?"I can resume sexual activity in 4 to 6 weeks." "I need to avoid straining when I have a bowel movement." "I should wear support hose for 6 months and elevate my legs frequently."

"I need to contact my surgeon immediately if I feel any numbness in my genital area."

Answer:

"I need to contact my surgeon immediately if I feel any numbness in my genital area." Rationale: After radical vulvectomy, the client is instructed to wear support hose for 6 months and to elevate the legs frequently. The client should avoid straining during defecation and should be told that alteration in the direction of urine flow may occur. The client may resume sexual activity in 4 to 6 weeks; the nurse should discuss the possible need for lubrication and position changes during coitus. Genital numbness may be present, but it is not necessary to notify the surgeon immediately if numbness occurs.Question 3: The mother of an adolescent diagnosed with type 1 diabetes mellitus tells the nurse that her child is a member of the school soccer team and expresses concern about her child's participation in sports. What does the nurse tell the mother after providing information to the mother about diet, exercise, insulin, and blood glucose control?To always administer less insulin on the days of soccer games That it is best not to encourage the child to participate in sports activities That the child should eat a carbohydrate snack about a half-hour before each soccer game To administer additional insulin before a soccer game if the blood glucose level is 240 mg/dL (13.3 mmol/L) or higher and ketones are present.

Answer:

That the child should eat a carbohydrate snack about a half-hour before each soccer game Rationale: The child with diabetes mellitus who is active in sports requires additional food intake in the form of a carbohydrate snack about a half-hour before the anticipated activity. Additional food will need to be consumed, often as frequently as every 45 minutes to 1 hour, during prolonged periods of activity.If the blood glucose level is increased (240 mg/dL [13.3 mmol/L] or more) and ketones are present before planned exercise, the activity should be postponed until the blood glucose has been controlled.Moderate to high ketone values should be reported to the primary health care provider. There is no reason for the child to avoid participating in sports.Question 4: A nurse checking the fundus of a postpartum woman notes that it is above the expected level, at the umbilicus, and that it has shifted from the midline position to the right.What initial action should the nurse take?Document the findings Encourage the woman to walk Help the woman empty her bladder Massage the fundus gently until it becomes firm

Answer:

Help the woman empty her bladder Rationale: Ths initial action by the nurse is to help the woman empty her bladder. In the postpartum period, the fundus should be firmly contracted and at or near the level of the umbilicus. If the uterus is found to be higher than the expected level or shifted from the midline position (usually to the right), the bladder may be distended. The location of the fundus should be rechecked after the woman has

emptied her bladder. If the fundus is difficult to locate or is boggy (soft), the nurse stimulates the uterine muscle to contract by gently massaging the uterus. Encouraging the woman to walk is inappropriate at this time. The nurse would document fundal position, consistency, and height and any other interventions taken (e.g., uterine massage) after the woman has emptied her bladder.Question 5: A nurse is assessing a client who has been taking amantadine hydrochloride for the treatment of Parkinson's disease. Which finding from the history and physical examination would cause the nurse to determine that the client may be experiencing an adverse effect of the medication?Insomnia Rigidity and akinesia Bilateral lung wheezes Orthostatic hypotension

Answer:

Bilateral lung wheezes Rationale: Amantadine hydrochloride is an antiparkinson agent that potentiates the action of dopamine in the central nervous system (CNS). The medication is used to treat rigidity and akinesia. Insomnia and orthostatic hypotension are side effects of the medication. Adverse effects include congestive heart failure (evidenced by bilateral lung wheezes), leukopenia, neutropenia, hyperexcitability, convulsions, and ventricular dysrhythmias.Question 6: A nurse is developing a plan of care for a pregnant client with sickle-cell disease.Which concern does the nurse recognize as the priority?Inability to cope Decreased nutrition Decreased fluid volume Inability to tolerate activity

Answer:

Decreased fluid volume Rationale: Decreased fluid volume is the priority concern in this situation, followed by decreased nutrition. Inability to tolerate activity and inability to cope compete for third priority, depending on the client's specific signs/symptoms at the time. Sickle cell disease is a genetic disorder that is manifested as chronic anemia, pain, disability, organ damage, increased risk for infection, and early death. In this disorder the red blood cells assume a sickle shape, become rigid, and clump together. Dehydration can precipitate sickling of the red blood cells. Sickling can lead to life-threatening consequences for the pregnant woman and the fetus, including interruption of blood flow to the respiratory system and placenta.

Question 7: Enalapril maleate is prescribed for a hospitalized client. Which assessment does the nurse perform as a priority before administering the medication?Checking the client's blood pressure Checking the client's peripheral pulses Checking the most recent potassium level Checking the client's intake-and-output record for the last 24 hours

Answer:

Checking the client's blood pressure Rationale: Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor used to treat hypertension. One common side effect is postural hypotension. Therefore the nurse would check the client's blood pressure immediately before administering each dose. Checking the client's peripheral pulses, the results of the most recent potassium level, and the intake and output for the previous 24 hours are not specifically associated with this mediation.Question 8: A nurse in the postpartum unit is caring for a client who delivered a healthy newborn 12 hours ago. The nurse checks the client's temperature and notes that it is 100.4° F (38° C). On the basis of this finding, what should the nurse do?Notify the primary health care provider Recheck the temperature in 4 hours Encourage the client to breastfeed the newborn Institute strict bedrest for the client and notify the primary health care provider

Answer:

Recheck the temperature in 4 hours Rationale: The nurse would recheck the temperature in 4 hours. A temperature of 100.4° F (38°

• is common during the 24 hours after childbirth and may be the result of dehydration or normal

postpartum leukocytosis. If the increased temperature persists for more than 24 hours or exceeds 100.4° F (38° C), infection is a possibility, and the fever is reported. There is no reason to restrict place the client to strict bedrest or to notify the primary health care provider. Although the client would be encouraged to breastfeed her newborn, this action is unrelated to the client's temperature.Question 9: An adult client with chronic kidney disease who is oliguric and undergoing hemodialysis is under a fluid restriction. What percentage of the total amount of fluid can the client consume during the evening shift?10% 20% 40% 50%

Answer:

40% Rationale: When calculating how to distribute fluid to a client under fluid restriction, the nurse usually allows half or 50% of the allotted total oral fluids between 7 a.m. and 3 p.m., the period during which the client is more active, consumes two meals, and takes most of oral medications. Another two