HESI Comprehensive B, Comprehensive Exam A,
2026 exit v 2 Exam || Most Recent Exam 2026-2027
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The nurse formulates a nursing diagnosis of pain related to
muscle spasms for a client with extreme lower back pain
associated with acute lumbosacral strain.
Which is the best intervention for the nurse to implement?
A. Perform range-of-motion exercises on the lower extremities
every 4 hours. B. Place a small firm pillow under the upper back
to flex the lumbar spine gently.
C. Rest in bed with the head of the bed elevated 20 degrees and
flex the knees. D. Position in reverse Trendelenburg with the
feet firmly against the foot of the bed. - ANSWER-C. Rest in bed
with the head of the bed elevated 20 degrees and flex the
knees.
Rationale:
Resting in bed with the head of the bed elevated 20 degrees
and flexing the knees reduces stress on the lower back
muscles (C). Range-of-motion exercises can result in
paravertebral muscle spasms and increased pain (A). Bending
the knees, rather than (B), reduces stress on the lower back. (D)
places stress on the lower back and increases the client's pain.
,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 k
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. -
ANSWER-A. Spea
privately with the
nurse.
Rationale:
The nurse-manager should speak privately with the nurse (A)
to assess the
nurse's motives and to discuss allowing other team members
the opportunity to
be on call for the day shift. (B) might become confrontational.
(C) is irrelevant.
,(D) is not
warranted.
Which nursing intervention(s) should be implemented when
caring for a client with bipolar disorder in the manic phase?
(Select all that apply.)
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. -
ANSWER-A. Report lithium level of 2.0 mEq/L to the primary
health care provider.
D. Maintain consistent salt levels in the diet when client is
taking lithium.
E. Assess the client's nutritional and 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).
A registered nurse (RN) delivers telehealth services to clients
via electronic communication. Which nursing action creates the
greatest risk for professional liability and has the potential for a
malpractice lawsuit?
A. Participating in telephone consultations with clients
B. Identifying oneself by name and title to clients in telehealth
communications
C. Sending medical records to health care providers via the
Internet
D. Answering a client-initiated health question via electronic
mail - ANSWER-C. Sending medical records to health care
providers via the Internet Rationale:
Sending medical records over the Internet, even with the latest
security protection, creates the greatest risk for liability
because of the high potential of breaching client confidentiality
and the amount of information being transferred (C). Client
confidentiality is protected by federal wiretapping laws making
telephone consultation (A) a private and protected form of
communication. By stating one's name and credentials in
telehealth communication (B), one is taking responsibility for
the encounter. E-mail initiated by the client (D) poses less risk
than sending records via the Internet.
Which assessment finding indicates that nystatin
(Mycostatin) swish and
2026 exit v 2 Exam || Most Recent Exam 2026-2027
Actual Complete Real Exam Questions And Correct
Answers (Verified Answers) Already Graded A+ |
Guaranteed Success!! Newest Exam || Just
Released!!
The nurse formulates a nursing diagnosis of pain related to
muscle spasms for a client with extreme lower back pain
associated with acute lumbosacral strain.
Which is the best intervention for the nurse to implement?
A. Perform range-of-motion exercises on the lower extremities
every 4 hours. B. Place a small firm pillow under the upper back
to flex the lumbar spine gently.
C. Rest in bed with the head of the bed elevated 20 degrees and
flex the knees. D. Position in reverse Trendelenburg with the
feet firmly against the foot of the bed. - ANSWER-C. Rest in bed
with the head of the bed elevated 20 degrees and flex the
knees.
Rationale:
Resting in bed with the head of the bed elevated 20 degrees
and flexing the knees reduces stress on the lower back
muscles (C). Range-of-motion exercises can result in
paravertebral muscle spasms and increased pain (A). Bending
the knees, rather than (B), reduces stress on the lower back. (D)
places stress on the lower back and increases the client's pain.
,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 k
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. -
ANSWER-A. Spea
privately with the
nurse.
Rationale:
The nurse-manager should speak privately with the nurse (A)
to assess the
nurse's motives and to discuss allowing other team members
the opportunity to
be on call for the day shift. (B) might become confrontational.
(C) is irrelevant.
,(D) is not
warranted.
Which nursing intervention(s) should be implemented when
caring for a client with bipolar disorder in the manic phase?
(Select all that apply.)
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. -
ANSWER-A. Report lithium level of 2.0 mEq/L to the primary
health care provider.
D. Maintain consistent salt levels in the diet when client is
taking lithium.
E. Assess the client's nutritional and 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).
A registered nurse (RN) delivers telehealth services to clients
via electronic communication. Which nursing action creates the
greatest risk for professional liability and has the potential for a
malpractice lawsuit?
A. Participating in telephone consultations with clients
B. Identifying oneself by name and title to clients in telehealth
communications
C. Sending medical records to health care providers via the
Internet
D. Answering a client-initiated health question via electronic
mail - ANSWER-C. Sending medical records to health care
providers via the Internet Rationale:
Sending medical records over the Internet, even with the latest
security protection, creates the greatest risk for liability
because of the high potential of breaching client confidentiality
and the amount of information being transferred (C). Client
confidentiality is protected by federal wiretapping laws making
telephone consultation (A) a private and protected form of
communication. By stating one's name and credentials in
telehealth communication (B), one is taking responsibility for
the encounter. E-mail initiated by the client (D) poses less risk
than sending records via the Internet.
Which assessment finding indicates that nystatin
(Mycostatin) swish and
