HESI Comprehensive Exam A Practice 2021 (LATEST UPDATE) Top Grade

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? A. This feeling occurs during feeding with a breast infection. B. This sensation occurs as breast milk moves to the nipple. C. The baby does not have good latch-on. D. The infant is not positioned correctly. 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? A. Check the client's blood pressure. B. Teach her to elevate her feet when sitting. C. Obtain a 24-hour diet history to evaluate for the intake of salty foods. D. Assess the fetal heart rate. 3 A 50-year-old man arrives at the . clinic with complaints of pain on ejaculation. Which action should the nurse implement? A. Teach the client testicular self- examination (TSE). B. Assess for the presence of blood in the urine. C. Ask about scrotal pain or blood in the semen. D. Inquire about a history of kidney stones. After administration of an 0730 dose . of Humalog 50/50 insulin to a client with diabetes mellitus, which nursing action has the highest priority? A. Ensure that the client receives breakfast within 30 minutes. B. Remind the client to have a midmorning snack at 1000. C. Discuss the importance of a midafternoon snack with the client. D. Explain that the client's capillary glucose will be checked at 1130. 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. A stage 3 sacral pressure ulcer, with colonized methicillin-resistant Staphylococcus aureus (MRSA) B. Pneumonia, with a sputum culture of gram-negative bacteria C. Urinary tract infection, with positive blood cultures D. Culture of a diabetic foot ulcer shows gram-positive cocci A client has been on a mechanical ventilator for several days. What should the nurse use to document and record this client's respirations? A. The respiratory settings on the ventilator B. Only the client's spontaneous respirations C. The ventilator-assisted respirations minus the client's independent breaths D. The ventilator setting for respiratory rate and the client- initiated respirations 18 A client is admitted to the mental . health unit with a chief complaint of crying, depressed mood, and sleeping difficulties. While talking about the death of a friend, the client states, "I can't believe this happened." Which statement by the nurse is most therapeutic? A. "It sounds like you're feeling very sad." B. "Tell me more about how you're feeling." C. "How often do you have crying spells?" D. "Do you want to talk about these feelings?" 19 A client reports experiencing . dysuria and urinary frequency. Which client teaching should the nurse provide? A. Save the next urine sample. B. Restrict oral fluid intake. C. Strain all voided urine. D. Reduce physical activity A client has been receiving levofloxacin (Levaquin), 500 mg IV piggyback q24h for 7 days. The UAP reports to the nurse that the client has had three loose foul-smelling stools this morning. Which intervention is most important for the nurse to implement? A. Perform a digital evaluation for fecal impaction. B. Administer a PRN dose of psyllium (Metamucil). C. Obtain a stool specimen for culture and sensitivity. D. Instruct the UAP to obtain The nurse plans to evaluate the effectiveness of a bronchodilator. Which assessment datum indicates that the desired effect of a bronchodilator has been achieved? A. Increased oxygen saturation B. Increased urinary output C. Decreased apical pulse rate D. Decreased blood pressure The nurse recognizes which behavior(s) in a client as warning sign(s) of an impending suicide attempt? (Select all that apply.) A. Reports feelings of sadness B. Mood changes from depressed to happy C. Begins giving away possessions D. Becomes compliant with medication regimen E. Independently joins a support group The nurse should encourage a laboring client to begin pushing at which point? A. When the cervix is completely effaced B. When the client describes the need to have a bowel movement C. When the cervix is completely dilated D. When the anterior or posterior lip of the cervix is palpable A nurse who has recently completed . orientation is beginning work in the labor and delivery unit for the first time. When making assignments, which client should the charge nurse assign to this new nurse? A. A primigravida who is 8 cm dilated after 14 hours of labor B. A client scheduled for a repeat cesarean birth at 38 weeks' gestation C. A client being induced for fetal demise at 20 weeks' gestation D. A multiparous client who is dilated 5 cm and 50% effaced The nurse would be correct in . withholding a dose of digoxin in a client with congestive heart failure without specific instruction from the health care provider if which finding was documented? A. Serum digoxin level is 1.5 ng/mL B. Blood pressure is 104/68 mm Hg C. Serum potassium level is 2.5 mEq/L D. Apical pulse is 68/min When the nurse-manager posts a . schedule for volunteers to be on call, one staff member immediately signs up for all available 7-to-3 day shifts. Other staff members complain to the charge nurse that they were not permitted the opportunity to be on call for the day shift. What action should the nurse-manager implement? A. Speak privately with the nurse. B. Hold a staff meeting to discuss this issue. C. Review the nurse's current salary. D. Nominate the nurse for employee of the month. Which assessment finding for a client . with peritoneal dialysis requires immediate intervention by the nurse? A. The color of the dialysate outflow is opaque yellow. A. Report lithium level of 2.0 mEq/L to the primary health care provider. B. Encourage competitive physical activities as part of the client's therapy. C. Provide an environment with increased stimuli to engage the client. D. Maintain consistent salt levels in the diet when client is taking lithium. E. Assess the client's nutritional and hydration status. 97 Which pathophysiologic response . supports the contraindication for opioids, such as morphine, in clients with increased intracranial pressure (ICP)? A. Sedation produced by opioids is a result of a prolonged half-life when the ICP is elevated. B. Higher doses of opioids are required when cerebral blood flow is reduced by an elevated ICP. C. Dysphoria from opioids contributes to altered levels of consciousness with an elevated ICP. D. Opioids suppress respirations, which increases Pco2 and contributes to an elevated ICP. hydration status. Rationale: A therapeutic level for serum lithium is 0.5 to 1.5 mEq/L, and the client with 2.0 mEq/L is experiencing toxicity (A). Consistent salt levels are important when taking lithium to maintain a therapeutic level (D). Because of the client's manic state, the client is at risk for impaired nutrition and dehydration; therefore, they should be assessed (E). Noncompetitive physical activities should be encouraged because of the risk for agitation (B), and decreased environmental stimuli is therapeutic for the manic phase (C). D. Opioids suppress respirations, which increases Pco2 and contributes to an elevated ICP. Rationale: The greatest risk associated with opioids such as morphine (D) is respiratory depression that causes an increase in Pco2, which increases ICP and masks the early signs of intracranial bleeding in head injury. (A, B, and C) do not support the risks associated with opioid use in a client with increased ICP. 98. Which physiologic finding in an older adult contributes to an adverse drug reaction? A. Reduced renal excretion A. Reduced renal excretion Rationale: During the aging process, reduced renal function (A) is common and contributes to drug accumulation that contributes to B. Reduced gastrointestinal motility C. Increased hepatic metabolism D. Increased risk of autoimmune disorders Which question is most relevant to ask the parents when obtaining the history of a 2-year-old child recently diagnosed with osteomyelitis? A. "Has your child had an ear infection recently?" B. "Does your child seem resistant to toilet training?" C. "Is your child a picky eater?" D. "Do you have a family history of bone disorders?"