Hesi Comprehensive Exam Version 3 (New 2024/ 2025 Update) Questions and Verified Answers| 100% Correct| A Grade
QUESTION
The nurse is planning a
... [Show More] community teaching program regarding the use of folic acid to prevent neural tube birth defects. Which community group is likely to benefit most from this program?
A. Parents of children with spina bifida
B. High school girls in a health class
C. Individuals interested in having children
D. Postpartum women attending a baby care class
Answer:
C
Folic acid is needed early in pregnancy to prevent neural tube defects; the group most likely to be considering pregnancy is (C). Parents with children who already have a neural tube defect such as spina bifida (A) are not as invested in the content as (C). High school age students (B) may have interest in the topic but as a group are less likely to anticipate the likelihood that problems could occur in their lives than (C). (D) may be interested if planning future pregnancies, but have higher learning priorities during the postpartum period.
QUESTION
25. The charge nurse of a medical surgical unit is alerted to an impending disaster requiring implementation of the hospital's disaster plan. Specific facts about the nature of this disaster are not yet known. Which instruction should the charge nurse give to the other staff members at this time?
A. Prepare to evacuate the unit, starting with the bedridden clients.
B. UAPs should report to the emergency center to handle transports.
C. The licensed staff should begin counting wheelchairs and IV poles on the unit.
D. Continue with current assignments until more instructions are received.
Answer:
D
When faced with an impending disaster, hospital personnel may be alerted but should continue with current client care assignments until further instructions are received (D). Evacuation is typically a response of last resort that begins with clients who are most able to ambulate (A). (B) is premature and is likely to increase the chaos if incoming casualties are anticipated. (C) is poor utilization of personnel.
QUESTION
A client who is on the outpatient surgical unit is preparing for discharge after a myringotomy with placement of ventilating tubes. Which response by the client indicates that further teaching is necessary?
A. "I will avoid coughing, sneezing, and forceful nose blowing. "
B. "Swimming can begin on the tenth postoperative day. "
C. "Any mild discomfort can be managed with acetaminophen. "
D. "Drainage from my ears is expected after the surgery. "
Answer:
B
The purpose of the ventilating tubes in the tympanic membrane is to equalize pressure and drain fluid collection from the middle ear. The tube's patency allows air and water to enter the middle ear, so the client should be reeducated if the client swims (B) or allows water to enter the external ear. (A, C, and D) reflect correct responses.
QUESTION
A male client with arterial peripheral vascular disease (PVD) complains of pain in his feet. Which instruction should the nurse give to the UAP to relieve the client's pain quickly?
A. Help the client dangle his legs.
B. Apply compression stockings.
C. Assist with passive leg exercises.
D. Ambulate three times a day.
Answer:
A
The client who has arterial PVD may benefit from dependent positioning, and this can be achieved with bedside dangling (A), which will promote gravitation of blood to the feet, improve blood flow, and relieve pain. (B) is indicated for venous insufficiency (C) and indicated for bed rest. Ambulation (D) is indicated to facilitate collateral circulation and may improve long-term complaints of pain.
QUESTION
Which situation demonstrates proper application of client confidentiality requirements for the Health Insurance Portability and Accountability Act (HIPAA)?
A. Clients' names are not used while they are in a public waiting room.
B. Nurses should not recommend any community self-help groups by specific name, such as Alcoholics Anonymous.
C. Clients must pick up their filled prescriptions from a pharmacy in person with a photo identification card.
D. Old medical records are kept in a locked file cabinet in the department.
Answer:
D
Past medical records must be "secured" and "reasonably protected" from inadvertent viewing (D). A locked room or file cabinet can serve this purpose, and when any protected health information (PHI) is discarded, it must be shredded. A person's name only (without their diagnosis or treatment) is not considered confidential or PHI (A). Nurses may suggest categories of community resources, with examples, such as Alcoholics Anonymous (B), but cannot market a specific program in which they have a financial interest. Others can pick up a client's filled prescriptions (C).
QUESTION
Prior to administering an oral suspension, which intervention is most important for the nurse to implement?
A. Assess the client's ability to swallow liquids.
B. Obtain applesauce in which to mix the medication.
C. Determine the client's food likes and dislikes.
D. Auscultate the client's breath sounds.
Answer:
A
An oral suspension is a liquid, so the nurse needs to assess the client's ability to swallow liquids (A) to ensure that the client will not choke. If the client has difficulty swallowing liquids, a thickening substance may be used (B). If a food product is used to thicken the liquid, (C) would be beneficial. (D) may also be warranted, but only if the client is at risk for aspiration, determined by (A).
QUESTION
A client with schizophrenia tells the nurse, "The world is coming to an end. All the violence in the Middle East is soon going to destroy the entire world!" How should the nurse respond?
A. "Let's play some dominoes for a few minutes. "
B. "I don't think the violence means the world is ending. "
C. "The news makes you have upsetting thoughts. "
D. "Listening to the news seems to be frightening you. "
Answer:
D
A client's delusional statements are best addressed by identifying the feeling associated with the delusion (D). Distraction (A) may be helpful but ignores the feelings that the client is experiencing. Delusional clients often argue with statements that contradict their belief system (B). The client is unlikely to understand the relationship between the news and the thoughts experienced (C).
QUESTION
A client with glomerulonephritis is scheduled for a creatinine clearance test to determine the need for dialysis. Which information should the nurse provide the client prior to the test?
A. Failure to collect all urine specimens during the period of the study will invalidate the test.
B. Blood is collected to measure the amount of creatinine and determine the glomerular filtration rate (GFR).
C. Dialysis is started when the GFR is lower than 5 mL/min.
D. Discard the first voiding, and record the time and amount of urine of each voiding for 24 hours.
Answer:
A
Glomerulonephritis damages the renal glomeruli and affects the kidney's ability to clear serum creatinine into the urine. Creatinine clearance is a 24-hour urine specimen test, so all urine should be collected during the period of the study or the results are inaccurate (A). As renal function decreases, the creatinine level will decrease in the urine (B). Dialysis is usually started when the GFR is 12 mL/min (C). There is no need to record the frequency and amount of each voiding (D) during the time span of urine collection. [Show Less]