HESI MODULE 1 EXAM DEVELOPMENTAL STAGES AND TRANSITIONS
QUESTIONS WITH VERIFIED ANSWER
Correct
Incorrect
1 of 98
Term
A nurse, monitoring a client in the fourth stage of labor, checks the
client's vital signs every 15 minutes. The nurse notes that the client's
pulse rate has increased from 70 to 100 beats per minute. Based on this
finding, which priority action should the nurse take?
A. Checking the client's uterine fundus
B. Notifying the nurse-midwife immediately
C. Documenting the vital signs in the client's medical record
D. Continuing to check the client's vital signs every 15 minutes
Give this one a go later!
1/223
, A. Checking the client's uterine fundus
Rationale: During the fourth stage of labor, the woman's vital signs should be
assessed every 15 minutes during the first hour. An increasing pulse rate is an
early sign of excessive blood loss, because the heart pumps faster to
compensate for reduced blood volume. The blood pressure decreases as the
blood volume diminishes, but this is a later sign of hypovolemia. The most
common reason for excessive postpartum bleeding is that the uterus is not
firmly contracting and compressing open vessels at the placental site.
Therefore the nurse should check the client's uterine fundus for firmness,
height, and positioning. Notifying the nurse-midwife immediately is not
necessary unless the nurse is unable to determine the cause of bleeding and is
unable to correct it. Continuing to check the client's vital signs every 15
minutes will delay necessary intervention. Although the findings will need to
be documented, the priority action is to assess the client for bleeding.
Test-Taking Strategy: Noting the strategic word "priority" and that the pulse
rate has increased and recalling the signs of bleeding and shock will help
direct you to the correct option. Also note that the correct option addresses
assessment of the cause for bleeding.
D. The young adult verbalizes satisfaction with friendships.
E. The young adult has a sense of meaning and direction in life.
Rationale: Most young adults have the physical and emotional resources and
support systems to meet the many challenges, tasks, and responsibilities they face.
Signs of emotional health in the young adult include a sense of meaning and
direction in life, successful negotiation of transitions, absence of feelings of being
cheated or disappointed by life, attainment of several long-term goals, satisfaction
with personal growth and development, reciprocated feelings of love for a partner,
satisfaction with social interactions and friendships, a generally cheerful attitude, no
sensitivity to criticism, and no unrealistic fears.
Test-Taking Strategy: Focus on the subject, a sign of emotional health. Select the
options that use positive words such as "satisfaction" and "meaning and direction."
2/223
, D. The client has been treated for breast cancer.
Rationale: Combination oral contraceptives contain both estrogen and progestin
and are contraindicated during pregnancy and for women who have (or have a
history of) the following disorders: thrombophlebitis, thromboembolic disorders,
cerebrovascular disease, coronary-artery disease, myocardial infarction, known or
suspected breast cancer, known or suspected estrogen-dependent neoplasm,
benign or malignant liver tumors, and undiagnosed abnormal genital bleeding. They
are used with caution in women with diabetes mellitus, women who smoke heavily,
women with risk factors for cardiovascular disease (hypertension, obesity,
hyperlipidemia), and women anticipating elective surgery in which thrombosis might
be expected.
Test-Taking Strategy: Focus on the subject, a contraindication of a combination oral
Ao. n
c Dto
ranccuempetinvtein. g
Retc
haellfiinngditnhgat a combination oral contraceptive contains estrogen
will direct you to the correct option, breast cancer.
Rationale: After delivery, bradycardia (pulse rate 50 to 70 beats per minute) may
occur. The lower pulse rate reflects the large amount of blood returning to the
central circulation after delivery of the placenta. The increase in central circulation
results in increased stroke volume and permits a slower heart rate to provide
adequate maternal circulation. It is not necessary to notify the nurse-midwife or
health care provider immediately, because a pulse rate of 55 beats per minute is a
normal finding. The client should remain on bed rest in the immediate postpartum
period. Although range-of-motion exercises are important for the client on bed
rest, this action is unrelated to the data in the question. Therefore, the most
appropriate nursing action is to document the finding.
Test-Taking Strategy: Note the strategic words "most appropriate." Recalling the
physiological alterations that occur in the woman after delivery will direct you to the
correct option. Remember that after delivery bradycardia may occur and that it is a
normal finding.
Don't know?
2 of 98
Term
3/223
, A nurse performing a neurological assessment of a client in later
adulthood notes that the client has tremors of the hands. Based on this
finding, which action should the nurse take?
A. Document the findings
B. Notify the health care provider immediately
C. Obtain a prescription for a muscle relaxant
D. Ask the health care provider about referring the client to a
neurological specialist
Give this one a go later!
A. Document the findings.
Rationale: Amniotic fluid should be clear and may include bits of vernix, the creamy
white fetal skin lubricant. Therefore the nurse would most appropriately document
the findings. Checking the client's temperature, reporting the findings to the nurse-
midwife, and obtaining a sample of the amniotic fluid for laboratory analysis are not
necessary. Cloudy, yellow, or foul-smelling amniotic fluid suggests infection. Green
fluid indicates that the fetus passed meconium before birth. If abnormalities are
noted, the nurse should notify the nurse-midwife.
Test-Taking Strategy: Focus on the strategic words "most appropriate" indicating that
a priority action is present. Noting the word "clear" in the question will help direct
you to the correct option.
A. Document the findings
Rationale: Senile tremors are occasionally noted in clients in later adulthood.
These benign tremors include intentional tremor of the hands, head-nodding
(as if saying yes), and tongue protrusion. Because this finding is an age-related
occurrence, obtaining a prescription for a muscle relaxant, notifying the health
care provider immediately, and asking about referring the client to a
neurological specialist are unnecessary and incorrect.
4/223
QUESTIONS WITH VERIFIED ANSWER
Correct
Incorrect
1 of 98
Term
A nurse, monitoring a client in the fourth stage of labor, checks the
client's vital signs every 15 minutes. The nurse notes that the client's
pulse rate has increased from 70 to 100 beats per minute. Based on this
finding, which priority action should the nurse take?
A. Checking the client's uterine fundus
B. Notifying the nurse-midwife immediately
C. Documenting the vital signs in the client's medical record
D. Continuing to check the client's vital signs every 15 minutes
Give this one a go later!
1/223
, A. Checking the client's uterine fundus
Rationale: During the fourth stage of labor, the woman's vital signs should be
assessed every 15 minutes during the first hour. An increasing pulse rate is an
early sign of excessive blood loss, because the heart pumps faster to
compensate for reduced blood volume. The blood pressure decreases as the
blood volume diminishes, but this is a later sign of hypovolemia. The most
common reason for excessive postpartum bleeding is that the uterus is not
firmly contracting and compressing open vessels at the placental site.
Therefore the nurse should check the client's uterine fundus for firmness,
height, and positioning. Notifying the nurse-midwife immediately is not
necessary unless the nurse is unable to determine the cause of bleeding and is
unable to correct it. Continuing to check the client's vital signs every 15
minutes will delay necessary intervention. Although the findings will need to
be documented, the priority action is to assess the client for bleeding.
Test-Taking Strategy: Noting the strategic word "priority" and that the pulse
rate has increased and recalling the signs of bleeding and shock will help
direct you to the correct option. Also note that the correct option addresses
assessment of the cause for bleeding.
D. The young adult verbalizes satisfaction with friendships.
E. The young adult has a sense of meaning and direction in life.
Rationale: Most young adults have the physical and emotional resources and
support systems to meet the many challenges, tasks, and responsibilities they face.
Signs of emotional health in the young adult include a sense of meaning and
direction in life, successful negotiation of transitions, absence of feelings of being
cheated or disappointed by life, attainment of several long-term goals, satisfaction
with personal growth and development, reciprocated feelings of love for a partner,
satisfaction with social interactions and friendships, a generally cheerful attitude, no
sensitivity to criticism, and no unrealistic fears.
Test-Taking Strategy: Focus on the subject, a sign of emotional health. Select the
options that use positive words such as "satisfaction" and "meaning and direction."
2/223
, D. The client has been treated for breast cancer.
Rationale: Combination oral contraceptives contain both estrogen and progestin
and are contraindicated during pregnancy and for women who have (or have a
history of) the following disorders: thrombophlebitis, thromboembolic disorders,
cerebrovascular disease, coronary-artery disease, myocardial infarction, known or
suspected breast cancer, known or suspected estrogen-dependent neoplasm,
benign or malignant liver tumors, and undiagnosed abnormal genital bleeding. They
are used with caution in women with diabetes mellitus, women who smoke heavily,
women with risk factors for cardiovascular disease (hypertension, obesity,
hyperlipidemia), and women anticipating elective surgery in which thrombosis might
be expected.
Test-Taking Strategy: Focus on the subject, a contraindication of a combination oral
Ao. n
c Dto
ranccuempetinvtein. g
Retc
haellfiinngditnhgat a combination oral contraceptive contains estrogen
will direct you to the correct option, breast cancer.
Rationale: After delivery, bradycardia (pulse rate 50 to 70 beats per minute) may
occur. The lower pulse rate reflects the large amount of blood returning to the
central circulation after delivery of the placenta. The increase in central circulation
results in increased stroke volume and permits a slower heart rate to provide
adequate maternal circulation. It is not necessary to notify the nurse-midwife or
health care provider immediately, because a pulse rate of 55 beats per minute is a
normal finding. The client should remain on bed rest in the immediate postpartum
period. Although range-of-motion exercises are important for the client on bed
rest, this action is unrelated to the data in the question. Therefore, the most
appropriate nursing action is to document the finding.
Test-Taking Strategy: Note the strategic words "most appropriate." Recalling the
physiological alterations that occur in the woman after delivery will direct you to the
correct option. Remember that after delivery bradycardia may occur and that it is a
normal finding.
Don't know?
2 of 98
Term
3/223
, A nurse performing a neurological assessment of a client in later
adulthood notes that the client has tremors of the hands. Based on this
finding, which action should the nurse take?
A. Document the findings
B. Notify the health care provider immediately
C. Obtain a prescription for a muscle relaxant
D. Ask the health care provider about referring the client to a
neurological specialist
Give this one a go later!
A. Document the findings.
Rationale: Amniotic fluid should be clear and may include bits of vernix, the creamy
white fetal skin lubricant. Therefore the nurse would most appropriately document
the findings. Checking the client's temperature, reporting the findings to the nurse-
midwife, and obtaining a sample of the amniotic fluid for laboratory analysis are not
necessary. Cloudy, yellow, or foul-smelling amniotic fluid suggests infection. Green
fluid indicates that the fetus passed meconium before birth. If abnormalities are
noted, the nurse should notify the nurse-midwife.
Test-Taking Strategy: Focus on the strategic words "most appropriate" indicating that
a priority action is present. Noting the word "clear" in the question will help direct
you to the correct option.
A. Document the findings
Rationale: Senile tremors are occasionally noted in clients in later adulthood.
These benign tremors include intentional tremor of the hands, head-nodding
(as if saying yes), and tongue protrusion. Because this finding is an age-related
occurrence, obtaining a prescription for a muscle relaxant, notifying the health
care provider immediately, and asking about referring the client to a
neurological specialist are unnecessary and incorrect.
4/223
