HESI Comprehensive
1. A 2-day postpartum mother who is B. This sensation occurs as breast milk
breastfeeding asks, "Why do I feel moves to the nipple.
this tingling in my breasts after the Rationale:
baby sucks for a few minutes?" When the mother's milk comes in,
Which information should the nurse usually 2 to 3 days after delivery,
provide? women often report they feel a tingling
A. This feeling occurs during feeding sensation in their nipples (B) when let-
with a breast infection. down occurs. (A, C, and D) provide
B. This sensation occurs as breast inaccurate information.
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 A. Check the client's blood pressure.
at 36 weeks' gestation presents to the Rationale:
occupational health clinic The blood pressure (A) should be
complaining of a pounding assessed first. Preeclampsia is a
headache, blurry vision, and swollen multisystem disorder, and women older
ankles. Which intervention should than 35 years and have chronic
the nurse implement first? hypertension are at increased risk.
A. Check the client's blood Classic signs include headache, visual
pressure. changes, edema, recent rapid weight
B. Teach her to elevate her feet gain, and elevated blood pressure. (B,
when sitting. C, and D) can be done if the blood
C. Obtain a 24-hour diet history to pressure is normal.
evaluate for the intake of salty
foods.
D. Assess the fetal heart rate.
3. A 50-year-old man arrives at the C. Ask about scrotal pain or blood in
clinic with complaints of pain on the semen.
ejaculation. Which action should the Rationale:
nurse implement? Orchitis is an acute testicular
A. Teach the client testicular self- inflammation resulting from recurrent
examination (TSE). urinary tract infection, recurrent
B. Assess for the presence of blood sexually transmitted disease (STD), or
, in the urine. an indwelling urethral urinary catheter
C. Ask about scrotal pain or blood causing pain on ejaculation, scrotal
in the semen. pain, blood in the semen, and penile
D. Inquire about a history of kidney discharge, so the nurse should
stones. determine the presence of other
symptoms (C). Although all men
should practice TSE, the client's
symptoms are suggestive of an
inflammatory syndrome rather than
testicular cancer (A). Although
hematuria (B) is associated with renal
disease or calculi (D), the client's pain
is associated with ejaculate, not urine.
4. A 77-year-old female client states C. With age, more fatty tissue
that she has never been so large develops in the abdomen and
around the waist and that she has decreased intestinal movement can
frequent periods of constipation. cause constipation.
Colon disease has been ruled out Rationale:
with a flexible sigmoidoscopy. Which With aging, the abdominal muscles
information should the nurse provide weaken as fatty tissue is deposited
to this client? around the trunk and waist. Slowing
A. As women age, they often become peristalsis also affects the emptying of
rounder in the middle because they the colon, resulting in constipation (C).
do not exercise properly. (A) is not the primary reason for the
B. Further assessment is indicated changes in body structure. (B) is not
because loss of abdominal muscle indicated because loss of muscle tone
tone and constipation do not occur and constipation are age-related
with aging. changes. (D) dismisses the client's
C. With age, more fatty tissue concerns and does not help her
develops in the abdomen and understand the changes that she is
decreased intestinal movement can experiencing.
cause constipation.
D. Because there is no evidence of a
diseased colon, there is no need to
worry about abdominal size.
5. According to Erikson, which client D. A 75-year-old woman who wishes
should the nurse identify as having her friends were still alive so she could
difficulty completing the change some of the choices she made
developmental stage of older adults? over the years
, A. A 60-year-old man who tells the Rationale:
nurse that he is feeling fine and The older woman who wishes she
really does not need any help from could change the choices she has made
anyone in her lifetime is expressing despair
B. A 78-year-old widower who has and is still searching for integrity (D).
come to the mental health clinic for The nurse uses Erikson stages of
counseling after the recent death of development over the life span to
his wife assess an older client's adjustment to
C. An 81-year-old woman who states aging and plans teaching strategies to
that she enjoys having her assist the clients attain integrity versus
grandchildren visit but is usually despair. (A, B, and C) are normal
glad when they go home developmental tasks of older adults.
D. A 75-year-old woman who wishes
her friends were still alive so she
could change some of the choices she
made over the years
6. After administration of an 0730 dose A. Ensure that the client receives
of Humalog 50/50 insulin to a client breakfast within 30 minutes.
with diabetes mellitus, which nursing Rationale:
action has the highest priority? Insulin 50/50 contains 50% regular
A. Ensure that the client receives and 50% NPH insulin. Therefore, the
breakfast within 30 minutes. onset of action is within 30 minutes
B. Remind the client to have a and the nurse's priority action is to
midmorning snack at 1000. ensure that the client receives a
C. Discuss the importance of a breakfast tray to avoid a hypoglycemic
midafternoon snack with the client. reaction (A). (B, C, and D) are also
D. Explain that the client's capillary important nursing actions but are of
glucose will be checked at 1130. less immediacy than (A).
7. The antigout medication allopurinol A. "I take aspirin for my pain."
(Zyloprim) is prescribed for a client newly Rationale:
diagnosed with gout. Which comment by The client should be taught to
the client warrants intervention by the avoid aspirin (A) because the
nurse? ingestion of aspirin or diuretics
A. "I take aspirin for my pain." can precipitate an attack of
B. "I frequently eat fruit and drink fruit gout. (B, C, and D) are all
juices." appropriate for the treatment of
C. "I drink a great deal of water, so I have gout. The client's urinary pH
to get up at night to urinate." can be increased by the intake
D. "I observe my skin daily to see if I have of alkaline ash foods, such as
, an allergic rash to the medication." citrus fruits and juices, which
will help reduce stone
formation (B). Increasing fluids
helps prevent urinary calculi
(stone) formation and should
be encouraged, even if the
client must get up at night to
urinate (C). Allopurinol has a
rare but potentially fatal
hypersensitivity syndrome,
which is characterized by a
rash and fever. The medication
should be discontinued
immediately if this occurs (D).
8. Because of census overload, the charge A. A stage 3 sacral pressure
nurse of an acute care medical unit must ulcer, with colonized
select a client who can be transferred back methicillin-resistant
to a residential facility. The client with Staphylococcus aureus
which symptomology is the most stable? (MRSA)
A. A stage 3 sacral pressure ulcer, with Rationale:
colonized methicillin-resistant The client with colonized
Staphylococcus aureus (MRSA) MRSA (A) is the most stable
B. Pneumonia, with a sputum culture of client, because colonization
gram-negative bacteria does not cause symptomatic
C. Urinary tract infection, with positive disease. The gram-negative
blood cultures organisms causing pneumonia
D. Culture of a diabetic foot ulcer shows are typically resistant to drug
gram-positive cocci therapy (B), which makes
recovery very difficult. Positive
blood cultures (C) indicate a
systemic infection. Poor
circulation places the diabetic
with an infected ulcer (D) at
high risk for poor healing and
bone infection.
9. The charge nurse of a 16-bed medical unit is B. Assign the UAPs to take
making 0700 to 1900 shift assignments. The vital signs and obtain daily
team consists of two RNs, two PNs, and two weights.
UAP. Which assignment is the most Rationale:
1. A 2-day postpartum mother who is B. This sensation occurs as breast milk
breastfeeding asks, "Why do I feel moves to the nipple.
this tingling in my breasts after the Rationale:
baby sucks for a few minutes?" When the mother's milk comes in,
Which information should the nurse usually 2 to 3 days after delivery,
provide? women often report they feel a tingling
A. This feeling occurs during feeding sensation in their nipples (B) when let-
with a breast infection. down occurs. (A, C, and D) provide
B. This sensation occurs as breast inaccurate information.
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 A. Check the client's blood pressure.
at 36 weeks' gestation presents to the Rationale:
occupational health clinic The blood pressure (A) should be
complaining of a pounding assessed first. Preeclampsia is a
headache, blurry vision, and swollen multisystem disorder, and women older
ankles. Which intervention should than 35 years and have chronic
the nurse implement first? hypertension are at increased risk.
A. Check the client's blood Classic signs include headache, visual
pressure. changes, edema, recent rapid weight
B. Teach her to elevate her feet gain, and elevated blood pressure. (B,
when sitting. C, and D) can be done if the blood
C. Obtain a 24-hour diet history to pressure is normal.
evaluate for the intake of salty
foods.
D. Assess the fetal heart rate.
3. A 50-year-old man arrives at the C. Ask about scrotal pain or blood in
clinic with complaints of pain on the semen.
ejaculation. Which action should the Rationale:
nurse implement? Orchitis is an acute testicular
A. Teach the client testicular self- inflammation resulting from recurrent
examination (TSE). urinary tract infection, recurrent
B. Assess for the presence of blood sexually transmitted disease (STD), or
, in the urine. an indwelling urethral urinary catheter
C. Ask about scrotal pain or blood causing pain on ejaculation, scrotal
in the semen. pain, blood in the semen, and penile
D. Inquire about a history of kidney discharge, so the nurse should
stones. determine the presence of other
symptoms (C). Although all men
should practice TSE, the client's
symptoms are suggestive of an
inflammatory syndrome rather than
testicular cancer (A). Although
hematuria (B) is associated with renal
disease or calculi (D), the client's pain
is associated with ejaculate, not urine.
4. A 77-year-old female client states C. With age, more fatty tissue
that she has never been so large develops in the abdomen and
around the waist and that she has decreased intestinal movement can
frequent periods of constipation. cause constipation.
Colon disease has been ruled out Rationale:
with a flexible sigmoidoscopy. Which With aging, the abdominal muscles
information should the nurse provide weaken as fatty tissue is deposited
to this client? around the trunk and waist. Slowing
A. As women age, they often become peristalsis also affects the emptying of
rounder in the middle because they the colon, resulting in constipation (C).
do not exercise properly. (A) is not the primary reason for the
B. Further assessment is indicated changes in body structure. (B) is not
because loss of abdominal muscle indicated because loss of muscle tone
tone and constipation do not occur and constipation are age-related
with aging. changes. (D) dismisses the client's
C. With age, more fatty tissue concerns and does not help her
develops in the abdomen and understand the changes that she is
decreased intestinal movement can experiencing.
cause constipation.
D. Because there is no evidence of a
diseased colon, there is no need to
worry about abdominal size.
5. According to Erikson, which client D. A 75-year-old woman who wishes
should the nurse identify as having her friends were still alive so she could
difficulty completing the change some of the choices she made
developmental stage of older adults? over the years
, A. A 60-year-old man who tells the Rationale:
nurse that he is feeling fine and The older woman who wishes she
really does not need any help from could change the choices she has made
anyone in her lifetime is expressing despair
B. A 78-year-old widower who has and is still searching for integrity (D).
come to the mental health clinic for The nurse uses Erikson stages of
counseling after the recent death of development over the life span to
his wife assess an older client's adjustment to
C. An 81-year-old woman who states aging and plans teaching strategies to
that she enjoys having her assist the clients attain integrity versus
grandchildren visit but is usually despair. (A, B, and C) are normal
glad when they go home developmental tasks of older adults.
D. A 75-year-old woman who wishes
her friends were still alive so she
could change some of the choices she
made over the years
6. After administration of an 0730 dose A. Ensure that the client receives
of Humalog 50/50 insulin to a client breakfast within 30 minutes.
with diabetes mellitus, which nursing Rationale:
action has the highest priority? Insulin 50/50 contains 50% regular
A. Ensure that the client receives and 50% NPH insulin. Therefore, the
breakfast within 30 minutes. onset of action is within 30 minutes
B. Remind the client to have a and the nurse's priority action is to
midmorning snack at 1000. ensure that the client receives a
C. Discuss the importance of a breakfast tray to avoid a hypoglycemic
midafternoon snack with the client. reaction (A). (B, C, and D) are also
D. Explain that the client's capillary important nursing actions but are of
glucose will be checked at 1130. less immediacy than (A).
7. The antigout medication allopurinol A. "I take aspirin for my pain."
(Zyloprim) is prescribed for a client newly Rationale:
diagnosed with gout. Which comment by The client should be taught to
the client warrants intervention by the avoid aspirin (A) because the
nurse? ingestion of aspirin or diuretics
A. "I take aspirin for my pain." can precipitate an attack of
B. "I frequently eat fruit and drink fruit gout. (B, C, and D) are all
juices." appropriate for the treatment of
C. "I drink a great deal of water, so I have gout. The client's urinary pH
to get up at night to urinate." can be increased by the intake
D. "I observe my skin daily to see if I have of alkaline ash foods, such as
, an allergic rash to the medication." citrus fruits and juices, which
will help reduce stone
formation (B). Increasing fluids
helps prevent urinary calculi
(stone) formation and should
be encouraged, even if the
client must get up at night to
urinate (C). Allopurinol has a
rare but potentially fatal
hypersensitivity syndrome,
which is characterized by a
rash and fever. The medication
should be discontinued
immediately if this occurs (D).
8. Because of census overload, the charge A. A stage 3 sacral pressure
nurse of an acute care medical unit must ulcer, with colonized
select a client who can be transferred back methicillin-resistant
to a residential facility. The client with Staphylococcus aureus
which symptomology is the most stable? (MRSA)
A. A stage 3 sacral pressure ulcer, with Rationale:
colonized methicillin-resistant The client with colonized
Staphylococcus aureus (MRSA) MRSA (A) is the most stable
B. Pneumonia, with a sputum culture of client, because colonization
gram-negative bacteria does not cause symptomatic
C. Urinary tract infection, with positive disease. The gram-negative
blood cultures organisms causing pneumonia
D. Culture of a diabetic foot ulcer shows are typically resistant to drug
gram-positive cocci therapy (B), which makes
recovery very difficult. Positive
blood cultures (C) indicate a
systemic infection. Poor
circulation places the diabetic
with an infected ulcer (D) at
high risk for poor healing and
bone infection.
9. The charge nurse of a 16-bed medical unit is B. Assign the UAPs to take
making 0700 to 1900 shift assignments. The vital signs and obtain daily
team consists of two RNs, two PNs, and two weights.
UAP. Which assignment is the most Rationale:
