HESI EXIT COMPREHENSIVE REVIEW EXAM B QUESTION AND ANSWERS EXPLAINED
1.Which information is most concerning to the nurse when caring for an older client w... [Show More] ith bilateral cataracts?
2.When caring for a client hospitalized with Guillain-Barré syndrome, which information is most important for the nurse to report to the primary health care provider?
3. A client is admitted with a diagnosis of leukemia. This condition is manifested by which of the following?
4. The nurse enters the examination room of a client who has been told by her health care provider that she has advanced ovarian cancer. Which response by the nurse is likely to be most supportive for the client?
5. A nurse working in the emergency department admits a client with full-thickness burns to 50% of the body. Assessment findings indicate high-pitched wheezing, heart rate of 120 beats/min, and disorientation. Which action should the nurse take first?
6. The nurse walks into the room and observes the client experiencing a tonic-clonic seizure. Which intervention should the nurse implement first?
7. Which intervention should be included in the plan of care for a client admitted to the hospital with ulcerative colitis?
8. A nurse implements an education program to reduce hospital readmissions for clients with heart failure. Which statement by the client indicates that teaching has been effective?
9. After assessing a 26-year-old client with type 1 diabetes mellitus, which data may indicate that the client is experiencing chronic complications of diabetes?
10. When caring for a client with a tracheostomy, which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)?
11. The charge nurse is making assignments for the upcoming shift. Which client is most appropriate to assign to the practical nurse (PN)?
12. A nurse performs an initial admission assessment of a 56-year-old client. Which factor(s) would indicate that the client is at risk for metabolic syndrome? (Select all that apply.)
13. Which clinical manifestation in the client with hyperthyroidism is most important to report to the health care provider?
14. The nurse administers atropine sulfate ophthalmic drops preoperatively to the right eye of a client scheduled for cataract surgery. Which response by the client indicates that the drug was effective?
15. A client with human immunodeficiency virus (HIV) develops a painful blistering skin rash on the right lateral abdominal area. Which drug should the nurse expect to administer to treat this condition?
16. When assessing a 38-year-old client with tuberculosis who is taking rifampin, which finding would be most important to report to the primary health care provider immediately?
17. A client with non-Hodgkin lymphoma has been prescribed cyclophosphamide IV for therapy. Which assessment finding would need to be reported immediately to the oncologist?
18. A nurse is assessing a client with heart failure who has been prescribed digoxin for therapy. Which finding indicates an issue with the medication management?
19. Which statement by the U.S. Food and Drug Administration (FDA) is an example of a black box or black label warning for the drug clopidogrel?
20. The nurse is caring for a client with an ischemic stroke who has a prescription for tissue plasminogen activator (t-PA) IV. Which actions should the nurse expect to implement? (Select all that apply.)
21. Which action by the nurse is consistent with culturally competent care?
22. The charge nurse reviews the charting of a graduate nurse. Which indicates a need for further education on documentation?
23. Which data obtained during a respiratory assessment for a 78-year-old client is most important to report to the primary health care provider?
24. The nurse hears a series of long-duration, discontinuous, low-pitched sounds on auscultation of a client's lower lung fields. Which documentation of this finding is correct?
25. The nurse empties a client's urinary drainage from an indwelling Foley catheter. Which finding should be reported to the primary health care provider?
26. When blood or blood products are administered, which task can be assigned to the licensed practical nurse (PN)?
27.The charge nurse observes a student nurse enter the room of a client who is prescribed airborne precautions. The application of which personal protective equipment by the student indicates a correct understanding of this precaution?
28. The nurse reviews the comprehensive metabolic panel for a client with an electrolyte imbalance. Which data requires the most immediate intervention by the nurse?
29. A client is admitted to the hospital with the diagnosis of hypokalemia. Which clinical manifestation is most significant?
30. The nurse prepares to administer 3 units of regular insulin and 20 units of NPH insulin subcutaneously to a client with an elevated blood glucose level. Which procedure is correct?
31. The nurse is caring for a client on the medical unit. Which task can be delegated to unlicensed assistive personnel (UAP)?
32. Which disaster management intervention by the nurse is an example of primary prevention?
33. The nurse teaches a class on bioterrorism. Which methods of transmission are possible with the biologic agent Bacillus anthracis(Anthrax)? (Select all that apply.)
34. The nurse assesses a pressure ulcer on a client's heel and notes full-thickness tissue loss, with some visible subcutaneous fat. How should the nurse stage this pressure ulcer?
35. The nurse prepares to administer ophthalmic drops to a client prior to cataract surgery. List the steps in the order that they should be implemented from first step to final step.
36. The nurse is caring for a client who is experiencing severe pain. The expected outcome the nurse writes for the client reads, "The client will state my pain is <2 within 45 minutes after pain medication has been administered." Formulating the expected outcome is an example of which step in the nursing process?
37. When assessing safety for the older adult, which of the following is of highest priority to the nurse?
38. While assessing a client with recurring chest pain, the unit secretary notifies the nurse that the client's health care provider is on the telephone. What action should the nurse instruct the unit secretary to implement?
39. The family of a male adult with schizophrenia does not want the client to be involved in decisions regarding his treatment. The nurse should inform the family that the client has a right to be involved in his treatment planning based on which law?
40. An adult female who presents at the mental clinic trembling and crying becomes distressed when the nurse attempts to conduct an assessment. She complains about the number of questions that are being asked, which she is convinced are going to cause her to have a heart attack. What action should the nurse take?
41. A client in an acute psychiatric setting asks the nurse if their conversations will remain confidential. How should the nurse respond?
42. Which intervention is most important when caring for a client immediately after electroconvulsive therapy (ECT)?
43. A client in the psychiatric setting with an anxiety disorder reports chest pain. Which action should the nurse take first?
44. The nurse is assessing suicide risk for a client recently admitted to the acute psychiatric unit. Which finding is the most significant risk factor?
45. A client who is prescribed chlorpromazine HCl for schizophrenia develops rigidity, a shuffling gait, and tremors. Which action by the nurse is most important?
46. A nurse is interviewing a mother during a well-child visit. Which finding would alert the nurse to continue further assessment of the infant?
47. Which vaccination should the nurse administer to a newborn?
48. Which vital sign in a pediatric client is most important to report to the primary health care provider?
49. The nurse prepares to administer amoxicillin clavulanate potassium (Augmentin) to a child weighing 15 kg. The prescription is for 15 mg/kg every 12 hours by mouth. How many milliliters should the nurse administer when supplied as below?
50. The nurse prepares to administer acetaminophen oral suspension to a child who weighs 66 lb. The prescription reads: Administer 15 mg/kg every 6 hours by mouth. The Tylenol is available 150 mg/5 mL. What is the correct dosage as indicated on the figure.
Click Image to Enlarge
(From Kee JL, Hayes ER, McCuistion LE. Pharmacology: A nursing process approach, ed 7, St. Louis, 2011, Elsevier.)
51. The nurse expects a clinical finding of cyanosis in an infant with which conditions? (Select all that apply.)
52. Which nursing intervention should be implemented postoperatively in an infant with spina bifida after repair of a meningocele?
53. When caring for a hospitalized child with type 1 diabetes mellitus, which intervention can the nurse delegate to the unlicensed assistive personnel (UAP)?
54. The outpatient clinic nurse is reviewing phone messages from last night. Which client should the nurse call back first?
55. Which monitored pattern of fetal heart rate alerts the nurse to seek immediate intervention by the health care provider?
56. When caring for a client in labor, which finding is most important to report to the primary health care provider?
57. Which interventions should be performed by the nurse when caring for a woman in the fourth stage of labor? (Select all that apply.)
58.In caring for a pregnant woman with gestational diabetes, the nurse should be alert to which finding?
59. The nurse anticipates administering Rho(D) immune globulin (RhoGAM) to which individuals? (Select all that apply.)
60. When assessing a normal newborn, which findings should the nurse expect? (Select all that apply.)
61. The nurse is caring for a client with heart failure who develops respiratory distress and coughs up pink frothy sputum. Which action should the nurse take first?
62. When caring for a postsurgical client who has undergone multiple blood transfusions, which serum laboratory finding is of most concern to the nurse?
63. The nurse is caring for a client with respiratory distress whose arterial blood gas (ABG) results are as follows: pH, 7.33; PCO2, 50 mm Hg; PO2, 70 mm Hg; HCO3, 26 mEq/L. How should the nurse interpret these results?
64. The nurse is caring for a client who develops ventricular fibrillation. Which action should the nurse take first?
65. When caring for an 80-year-old client with pneumonia, which finding is of most concern to the nurse?
66. The nurse is caring for a client with a cerebrovascular accident (CVA) who is receiving enteral tube feedings. Which task performed by the UAP requires immediate intervention by the nurse?
67. The nurse is caring for a client with chronic renal failure (CRF) who is receiving dialysis therapy. Which nursing intervention has the greatest priority when planning this client's care?
68. Which finding should be reported to the primary health care provider when caring for a client who has a continuous bladder irrigation after a transurethral resection of the prostate gland (TURP)?
69. Which instructions should the nurse include in the discharge teaching plan of a male client who has had a myocardial infarction and who has a new prescription for nitroglycerin (NTG)? (Select all that apply.)
70. Which of the following cardiac rhythms is represented in the image?
(From Lewis SL, Dirksen SR, Heitkemper MM, et al. Medical-surgical nursing, ed 8, St. Louis, 2011, Mosby.)
71. The nurse prepares to administer digoxin, 0.125 mg PO, to an adult client with heart failure and notes that the digoxin serum level in the laboratory report is 1 ng/mL. Which action should the nurse take?
72. The nurse prepares to administer digoxin, 0.125 mg IV, to an adult client with atrial fibrillation. Which client datum requires the nurse to withhold the medication?
73. The nurse in the emergency department is caring for a client with type 1 diabetes mellitus in diabetic ketoacidosis (DKA). Which action should the nurse take first?
74. The nurse administers regular insulin (human), 8 units subcutaneously, to a client at 8:00 am, 30 minutes before breakfast. At what time is the client most at risk for a hypoglycemic reaction?
75. The nurse assesses a client who is taking indomethacin (Indocin) for arthritic pain. Which of the following is most important to report to the primary health care provider?
76. The nurse is caring for a client with deep vein thrombosis who is on a continuous IV heparin infusion. The activated partial prothrombin time (aPTT) is 120 seconds. Which action should the nurse take?
77. The nurse is caring for a hospitalized client with myasthenia gravis. Which finding requires the most immediate action by the nurse?
78.The nurse is planning the care for a client who is admitted with syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which interventions should the nurse include in this client's plan of care? (Select all that apply.)
79. A client with type 2 diabetes has a plantar foot ulcer. When developing a teaching plan regarding foot care, what information should the nurse obtain first from the client?
80. A nurse working in a community health setting is performing primary health screenings. Which individual is at highest risk for contracting an HIV infection?
81. A client at 32 weeks of gestation is hospitalized with preeclampsia, and magnesium sulfate is prescribed to control the symptoms. Before the next dose of MgSO4 is given, which assessment finding indicates that the client is at risk for toxicity?
82. A client comes to the obstetric clinic for her first prenatal visit and complains of feeling nauseated every morning. The client tells the nurse, "I'm having second thoughts about wanting to have this baby." Which response is best for the nurse to make?
83. A primipara presents to the perinatal unit describing rupture of the membranes (ROM), which occurred 12 hours prior to coming to the hospital. An oxytocin infusion is begun, and 8 hours later the client's contractions are irregular and mild. What vital sign should the nurse monitor with greater frequency than the typical unit protocol?
84. An adult client with a medical diagnosis of substance abuse and schizophrenia was recently switched from oral fluphenazineHCl to IM fluphenazinedecanoate because of medication noncompliance. What should the nurse teach the client and family about this change in medication regimen?
85. A 45-year-old female client is admitted to the psychiatric unit for evaluation. Her husband states that she has been reluctant to leave home for the last 6 months. The client has not gone to work for a month, has been terminated from her job, and has not left the house since that time. This client is displaying symptoms of which disorder?
86. A 12-year-old boy complains to the nurse that he is "short" (4′5″ [53 inches]). His twin sister is 5 inches taller than he is (4′10″ [58 inches]). Based on these findings, what conclusion should the nurse reach?
87. When administering an intramuscular injection, which factor is most important to ensure the best medication absorption?
88. An older client calls the clinic and complains of feeling very weak and dizzy. Further assessment by the nurse indicates that the client self-administered an enema of 3 L of tap water because of constipation. What is the most likely cause of the client's symptoms?
89. The nurse plans to teach blood glucose self-monitoring to a client who is newly diagnosed with diabetes mellitus type 1, and the health care provider has given the client a schedule for testing. In addition to the prescribed schedule, the nurse should also instruct the client to check the blood glucose level in which circumstance?
90. An 8-year-old child is receiving digoxin for congestive heart failure (CHF). In assessing the child, the nurse finds that her apical heart rate is 80 beats/min, she complains of being slightly nauseated, and her serum digoxin level is 1.2 ng/mL. What action should the nurse take?
91. A client who is first day postoperative after a mastectomy becomes increasingly restless and agitated. Vital signs are temperature, 100° F; pulse, 98 beats/min; respirations, 24 breaths/min; and blood pressure, 120/80 mm Hg. Which intervention should the nurse implement first?
92. A client is receiving propylthiouracil (PTU) prior to thyroid surgery. Which diagnostic test results indicate that the medication is producing the desired effect?
93. A client exhibits symptoms of alcohol intoxication. The blood alcohol level is 200 mg (0.2%). Which measurement tool is best for the nurse to use during the initial assessment of this client?
94. A client with bipolar disorder is seen in the mental health clinic for evaluation of a new medication regimen that includes risperidone. The nurse notes that the client has gained 30 lb in the past 3 months. Which assessment is most important for the nurse to obtain?
95. A client is admitted to a mental health unit because of mild depression. When asked, he denies suicidal ideation, but the nurse reads in the psychosocial assessment that there were attempts to overdose on aspirin 5 years earlier. Which intervention is most important for the nurse to implement?
96. A couple expresses concern and fear prior to having an amniocentesis to determine fetal lung maturity. To assist them in coping with this situation, which intervention is best for the nurse to implement?
97. A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care?
98. The nurse is assessing a client at 20 weeks' gestation. Which measurement should be compared with the client's current weight to obtain the most accurate data about her weight gain during pregnancy?
99. Which intervention(s) should the nurse implement when administering a new prescription of amitriptyline HCl to a client with a depressive disorder? (Select all that apply.)
100. The nurse assesses a woman in the emergency room who is in her third trimester of pregnancy. Which finding(s) is(are) indicative of abruptio placentae? (Select all that apply.) [Show Less]