HESI Comprehensive Exit Exam 1 Questions With
Complete Solutions (And Rationale)
The clinic nurse identifies an elevation in the results of the triple
marker screening test for a client who is in the first trimester of
pregnancy. Which action should the nurse prepare the client for?
a. Repeating the triple marker test.
b. Preparing for other diagnostic testing.
c. Counseling about possible fetal defects.
d. Securing permission for pregnancy termination.
B
(The triple marker screen measures maternal serum levels for
alpha-fetoprotein (AFP), human chorionic gonadotropin (HCG),
and estriol, which screens for indications of possible fetal
defects. An elevated result may be a false indicator, so other
tests are indicated. Repeating the triple marker screening is not
necessary or helpful. Elevated results warrant further testing
with ultrasound or amniocentesis before initiating counseling for
birth defects or discussing termination of pregnancy.)
The nurse is caring for critically ill clients. Which client should
be monitored for the development of neurogenic shock?
a. Heart failure.
b. Gastrointestinal hemorrhage.
c. Spinal cord injury.
d. Diabetes insipidus.
,C
(Spinal cord injuries place the client at high risk for the
development of neurogenic distributive shock. The development
to watch for in clients with heart failure is cardiogenic shock, in
GI bleeding is hemorrhagic shock, and in diabetes insipidus is
hypovolemic shock.)
Following major abdominal surgery, a male client's arterial
blood gas analysis reveals Pa0 2 95 mmHg and PaC0 2 50
mmHg. He is receiving oxygen by nasal cannula at 4
liters/minute and is reluctant to move in bed or deep breathe.
Based on this information, what action should the nurse
implement at this time?
a. Increase the oxygen flow to 6 liters/minute.
b. Encourage the use of an incentive spirometer.
c. Notify the healthcare provider of the crisis blood gas values.
d. Encourage the client to breathe slower.
B
(The blood gas reveals adequate oxygenation (Pa02 95) and
hypoventilation (PaC02 > 45). The client needs to be
encouraged in activities that increase the depth of breathing (e.
g., use of the incentive spirometer). Increasing oxygen rate will
only increase an already adequate Pa02. These are not crisis
blood gas findings so no need to call healthcare provider.
Asking client to breathe slower will only worsen the
hypoventilation.)
,Clinical portfolios are being introduced into the performance
appraisal process for staff nurses employed at a hospital. What
should the nurse-manager request that each staff nurse include in
the portfolio?
a. Evaluations by past nursing faculty and employers to
document ongoing competence.
b. Copies of any articles the nurse has read that relate to client
care on the nursing unit.
c. Letters of support from family members and friends who are
healthcare professionals.
d. A self-evaluation that identifies how the nurse has met
professional objectives and goals.
D
(A clinical portfolio should include pertinent information that
assists in providing a comprehensive view of the employee's
performance. A self-evaluation provides an important
assessment of the nurse's strengths, weaknesses, and progress
toward the achievement of professional goals. Past evaluations
not pertinent nor useful evaluative data regarding current
performance. While documentation of continuing education and
any certifications achieved are important to include in a clinical
portfolio, copies of articles read is not necessary. Letters of
support are not a significant component of a clinical portfolio.)
An 80-year-old client is given morphine sulphate for
postoperative pain. Which concomitant medication should the
nurse question that poses a potential development of urinary
retention in this geriatric client?
, a. Insulin.
b. Antacids.
c. Tricyclic antidepressants.
d. Nonsteroidal antiinflammatory agents.
C
(Drugs with anticholinergic properties, such as tricyclic
antidepressants, can exacerbate urinary retention associated with
opioids in the older client. Although tricyclic antidepressants
and antihistamines with opioids can exacerbate urinary
retention, the concurrent use of insulin or antacids with opioids
do not. Nonsteroidal antiinflammatory agents can increase the
risk for bleeding, but do not increase urinary retention with
opioids.)
The nurse is teaching staff in a long-term facility home the
principles of caring for clients with essential hypertension.
Which comment should the nurse include in the inservice
presentation about the care of clients with hypertension?
a. "Clients with an elevated blood pressure often exhibit a stiff
neck and are diaphoretic."
b. "As long as clients receive daily antihypertensive
medications, no further interventions are needed."
c. "Caregivers should only conduct blood pressure checks under
a registered nurse's direct supervision."
d. "Frequent blood pressure checks, including readings taken by
automated machines, are recommended."
Complete Solutions (And Rationale)
The clinic nurse identifies an elevation in the results of the triple
marker screening test for a client who is in the first trimester of
pregnancy. Which action should the nurse prepare the client for?
a. Repeating the triple marker test.
b. Preparing for other diagnostic testing.
c. Counseling about possible fetal defects.
d. Securing permission for pregnancy termination.
B
(The triple marker screen measures maternal serum levels for
alpha-fetoprotein (AFP), human chorionic gonadotropin (HCG),
and estriol, which screens for indications of possible fetal
defects. An elevated result may be a false indicator, so other
tests are indicated. Repeating the triple marker screening is not
necessary or helpful. Elevated results warrant further testing
with ultrasound or amniocentesis before initiating counseling for
birth defects or discussing termination of pregnancy.)
The nurse is caring for critically ill clients. Which client should
be monitored for the development of neurogenic shock?
a. Heart failure.
b. Gastrointestinal hemorrhage.
c. Spinal cord injury.
d. Diabetes insipidus.
,C
(Spinal cord injuries place the client at high risk for the
development of neurogenic distributive shock. The development
to watch for in clients with heart failure is cardiogenic shock, in
GI bleeding is hemorrhagic shock, and in diabetes insipidus is
hypovolemic shock.)
Following major abdominal surgery, a male client's arterial
blood gas analysis reveals Pa0 2 95 mmHg and PaC0 2 50
mmHg. He is receiving oxygen by nasal cannula at 4
liters/minute and is reluctant to move in bed or deep breathe.
Based on this information, what action should the nurse
implement at this time?
a. Increase the oxygen flow to 6 liters/minute.
b. Encourage the use of an incentive spirometer.
c. Notify the healthcare provider of the crisis blood gas values.
d. Encourage the client to breathe slower.
B
(The blood gas reveals adequate oxygenation (Pa02 95) and
hypoventilation (PaC02 > 45). The client needs to be
encouraged in activities that increase the depth of breathing (e.
g., use of the incentive spirometer). Increasing oxygen rate will
only increase an already adequate Pa02. These are not crisis
blood gas findings so no need to call healthcare provider.
Asking client to breathe slower will only worsen the
hypoventilation.)
,Clinical portfolios are being introduced into the performance
appraisal process for staff nurses employed at a hospital. What
should the nurse-manager request that each staff nurse include in
the portfolio?
a. Evaluations by past nursing faculty and employers to
document ongoing competence.
b. Copies of any articles the nurse has read that relate to client
care on the nursing unit.
c. Letters of support from family members and friends who are
healthcare professionals.
d. A self-evaluation that identifies how the nurse has met
professional objectives and goals.
D
(A clinical portfolio should include pertinent information that
assists in providing a comprehensive view of the employee's
performance. A self-evaluation provides an important
assessment of the nurse's strengths, weaknesses, and progress
toward the achievement of professional goals. Past evaluations
not pertinent nor useful evaluative data regarding current
performance. While documentation of continuing education and
any certifications achieved are important to include in a clinical
portfolio, copies of articles read is not necessary. Letters of
support are not a significant component of a clinical portfolio.)
An 80-year-old client is given morphine sulphate for
postoperative pain. Which concomitant medication should the
nurse question that poses a potential development of urinary
retention in this geriatric client?
, a. Insulin.
b. Antacids.
c. Tricyclic antidepressants.
d. Nonsteroidal antiinflammatory agents.
C
(Drugs with anticholinergic properties, such as tricyclic
antidepressants, can exacerbate urinary retention associated with
opioids in the older client. Although tricyclic antidepressants
and antihistamines with opioids can exacerbate urinary
retention, the concurrent use of insulin or antacids with opioids
do not. Nonsteroidal antiinflammatory agents can increase the
risk for bleeding, but do not increase urinary retention with
opioids.)
The nurse is teaching staff in a long-term facility home the
principles of caring for clients with essential hypertension.
Which comment should the nurse include in the inservice
presentation about the care of clients with hypertension?
a. "Clients with an elevated blood pressure often exhibit a stiff
neck and are diaphoretic."
b. "As long as clients receive daily antihypertensive
medications, no further interventions are needed."
c. "Caregivers should only conduct blood pressure checks under
a registered nurse's direct supervision."
d. "Frequent blood pressure checks, including readings taken by
automated machines, are recommended."
