HESI COMPREHENSIVE EXAM
260 COMPLETE QUESTIONS
AND ANSWERS
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.
A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse provides
instructions to the client about the test. Which statement by the client indicates a need for
further instruction?
"The test will take about 30 minutes."
"I need to fast for 8 hours before the test."
,"I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on
the morning of the test."
"I need to take a laxative after the test is completed, because the liquid that I'll have to drink for
the test can be constipating." - answer- "I need to drink citrate of magnesia the night
before the test and give myself a Fleet enema on the morning of the test."
Rationale: No special preparation is necessary before a GI series, except that NPO (nothing by
mouth) status must be maintained for 8 hours before the test. An upper GI series involves
visualization of the esophagus, duodenum, and upper jejunum by means of the use of a
contrast medium. It involves swallowing a contrast medium (usually barium), which is
administered in a flavored milkshake. Films are taken at intervals during the test, which takes
about 30 minutes. After an upper GI series, the client is prescribed a laxative to hasten
elimination of the barium. Barium that remains in the colon may become hard and difficult to
expel, leading to fecal impaction.
A nurse on the evening shift checks a primary health care provider's prescriptions and notes
that the dose of a prescribed medication is higher than the normal dose. The nurse calls the
primary health care provider's answering service and is told that the primary health care
provider is off for the night and will be available in the morning. What should the nurse do
next?
Call the nursing supervisor
Ask the answering service to contact the on-call primary health care provider
Withhold the medication until the primary health care provider can be reached in the morning
Administer the medication but consult the primary health care provider when he becomes
available - answer- Ask the answering service to contact the on-call primary health care
provider
Rationale: The nurse has a duty to protect the client from harm. A nurse who believes that a
primary health care provider's prescription may be in error is responsible for clarifying the
prescription before carrying it out. Therefore the nurse would not administer the medication;
instead, the nurse would withhold the medication until the dose can be clarified. The nurse
,would not wait until the next morning to obtain clarification. It is premature to call the nursing
supervisor.
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?
A.Suctions oral secretions from mouth
B.Positions head of bed flat when changing sheets
C.Takes temperature using the axillary method
D.Keeps head of bed elevated at 30 degrees - answer- B
Rationale:
Positioning the head of the bed flat when enteral feedings are in progress puts the client at risk
for aspiration (B). The others are all acceptable tasks performed by the UAP (A, C, and D).
When caring for a postsurgical client who has undergone multiple blood transfusions, which
serum laboratory finding is of most concern to the nurse?
A.Sodium level, 137 mEq/L
B.Potassium level, 5.5 mEq/L
C.Blood urea nitrogen (BUN) level, 18 mg/dL
D.Calcium level, 10 mEq/L - answer- B
Rationale:
Multiple blood transfusions are a risk factor for hyperkalemia. A serum potassium level higher
than 5.0 mEq/L indicates hyperkalemia (B). The others are normal findings (A, C, and D).
Which vaccination should the nurse administer to a newborn?
A.Hepatitis B
B.Human papilloma virus (HPV)
, C.Varicella
D.Meningococcal vaccine - answer- A
Rationale:
The hepatitis B vaccination should be given to all newborns before hospital discharge (A). HPV is
not recommended until adolescence (B). Varicella immunization begins at 12 months (C).
Meningococcal vaccine is administered beginning at 2 years (D).
The nurse is caring for a client on the medical unit. Which task can be delegated to unlicensed
assistive personnel (UAP)?
A.Assess the need to change a central line dressing.
B.Obtain a fingerstick blood glucose level.
C.Answer a family member's questions about the client's plan of care.
D.Teach the client side effects to report related to the current medication regimen. - answer-
B
Rationale:
Obtaining a fingerstick blood glucose level is a simple treatment and is an appropriate skill for
UAP to perform (B). (A, C, and D) are skills that cannot be delegated to UAP.
The nurse is caring for a client with an ischemic stroke who has a prescription for tissue
plasminogen activator (t-PA) IV. Which action(s) should the nurse expect to implement? (Select
all that apply.)
A.Administer aspirin with tissue plasminogen activator (t-PA).
B.Complete the National Institute of Health Stroke Scale (NIHSS).
C.Assess the client for signs of bleeding during and after the infusion.
D.Start t-PA within 6 hours after the onset of stroke symptoms.
E.Initiate multidisciplinary consult for potential rehabilitation. - answer- B,C,E
Rationale:
260 COMPLETE QUESTIONS
AND ANSWERS
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.
A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse provides
instructions to the client about the test. Which statement by the client indicates a need for
further instruction?
"The test will take about 30 minutes."
"I need to fast for 8 hours before the test."
,"I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on
the morning of the test."
"I need to take a laxative after the test is completed, because the liquid that I'll have to drink for
the test can be constipating." - answer- "I need to drink citrate of magnesia the night
before the test and give myself a Fleet enema on the morning of the test."
Rationale: No special preparation is necessary before a GI series, except that NPO (nothing by
mouth) status must be maintained for 8 hours before the test. An upper GI series involves
visualization of the esophagus, duodenum, and upper jejunum by means of the use of a
contrast medium. It involves swallowing a contrast medium (usually barium), which is
administered in a flavored milkshake. Films are taken at intervals during the test, which takes
about 30 minutes. After an upper GI series, the client is prescribed a laxative to hasten
elimination of the barium. Barium that remains in the colon may become hard and difficult to
expel, leading to fecal impaction.
A nurse on the evening shift checks a primary health care provider's prescriptions and notes
that the dose of a prescribed medication is higher than the normal dose. The nurse calls the
primary health care provider's answering service and is told that the primary health care
provider is off for the night and will be available in the morning. What should the nurse do
next?
Call the nursing supervisor
Ask the answering service to contact the on-call primary health care provider
Withhold the medication until the primary health care provider can be reached in the morning
Administer the medication but consult the primary health care provider when he becomes
available - answer- Ask the answering service to contact the on-call primary health care
provider
Rationale: The nurse has a duty to protect the client from harm. A nurse who believes that a
primary health care provider's prescription may be in error is responsible for clarifying the
prescription before carrying it out. Therefore the nurse would not administer the medication;
instead, the nurse would withhold the medication until the dose can be clarified. The nurse
,would not wait until the next morning to obtain clarification. It is premature to call the nursing
supervisor.
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?
A.Suctions oral secretions from mouth
B.Positions head of bed flat when changing sheets
C.Takes temperature using the axillary method
D.Keeps head of bed elevated at 30 degrees - answer- B
Rationale:
Positioning the head of the bed flat when enteral feedings are in progress puts the client at risk
for aspiration (B). The others are all acceptable tasks performed by the UAP (A, C, and D).
When caring for a postsurgical client who has undergone multiple blood transfusions, which
serum laboratory finding is of most concern to the nurse?
A.Sodium level, 137 mEq/L
B.Potassium level, 5.5 mEq/L
C.Blood urea nitrogen (BUN) level, 18 mg/dL
D.Calcium level, 10 mEq/L - answer- B
Rationale:
Multiple blood transfusions are a risk factor for hyperkalemia. A serum potassium level higher
than 5.0 mEq/L indicates hyperkalemia (B). The others are normal findings (A, C, and D).
Which vaccination should the nurse administer to a newborn?
A.Hepatitis B
B.Human papilloma virus (HPV)
, C.Varicella
D.Meningococcal vaccine - answer- A
Rationale:
The hepatitis B vaccination should be given to all newborns before hospital discharge (A). HPV is
not recommended until adolescence (B). Varicella immunization begins at 12 months (C).
Meningococcal vaccine is administered beginning at 2 years (D).
The nurse is caring for a client on the medical unit. Which task can be delegated to unlicensed
assistive personnel (UAP)?
A.Assess the need to change a central line dressing.
B.Obtain a fingerstick blood glucose level.
C.Answer a family member's questions about the client's plan of care.
D.Teach the client side effects to report related to the current medication regimen. - answer-
B
Rationale:
Obtaining a fingerstick blood glucose level is a simple treatment and is an appropriate skill for
UAP to perform (B). (A, C, and D) are skills that cannot be delegated to UAP.
The nurse is caring for a client with an ischemic stroke who has a prescription for tissue
plasminogen activator (t-PA) IV. Which action(s) should the nurse expect to implement? (Select
all that apply.)
A.Administer aspirin with tissue plasminogen activator (t-PA).
B.Complete the National Institute of Health Stroke Scale (NIHSS).
C.Assess the client for signs of bleeding during and after the infusion.
D.Start t-PA within 6 hours after the onset of stroke symptoms.
E.Initiate multidisciplinary consult for potential rehabilitation. - answer- B,C,E
Rationale:
