HESI EXIT COMPREHENSIVE REVIEW B
1.Which information is most concerning to the nurse when caring for an older client with bilateral cataracts?
A. States having difficulty with color perception
B. Presents with opacity of the lens upon assessment
C. Complains of seeing a cobweb-type structure in the visual field
D. Reports the need to use a magnifying glass to see small print
Rationale:
Visualization of a cobweb- or hairnet-type structure is a sign of a retinal detachment, which constitutes a medical
emergency. Clients with cataracts are at increased risk for retinal detachment. Distorted color perception, opacity of the
lens, and gradual vision loss are expected signs and symptom of cataracts but do not need immediate attention.
2.When caring for a client hospitalized with Guillain-Barré syndrome, which information is most important for the nurse
to report to the primary health care provider?
A. Ascending numbness from the feet to the knees
B. Decrease in cognitive status of the client
C. Blurred vision and sensation changes
D. Persistent unilateral headache
Rationale:
A decline in cognitive status in a client is indicative of symptoms of hypoxia and a possible need to assist the client with
mechanical ventilation. A primary health care provider will need to be contacted immediately. Options A, C, and D are
findings associated with Guillain-Barré syndrome that should also be reported but are not as critical as the client's hypoxic
status.
3. A client is admitted with a diagnosis of leukemia. Which assessment findings will the nurse include in the client’s plan
of care? (Select all that apply.)
A. Elevated platelets
B. Weight loss
C. Hyperplasia of the gums
D. Elevated white blood count
E. Weakness
Rationale:
Hyperplastic gums, weakness, and elevated white blood count are classic signs of leukemia. Options A, B, and D state
incorrect information for symptoms of leukemia.
4. The nurse enters the examination room of a client who has been told by her health care provider that she has advanced
ovarian cancer. Which response by the nurse is likely to be most supportive for the client?
A. "I know many women who have survived ovarian cancer."
B. "Let's talk about the treatments of ovarian cancer."
C. "In my opinion I would suggest getting a second opinion."
D. "Tell me about what you are feeling right now."
Rationale:
The most therapeutic action for the nurse is to be an active listener and to encourage the client to explore her feelings.
Giving false reassurance or personal are not therapeutic communication for the client.
5. A nurse working in the emergency department admits a client with full-thickness burns to 50% of the body. Assessment
findings indicate high-pitched wheezing, heart rate of 120 beats/min, and disorientation. Which action should the nurse
take first?
A. Insert a large-bore IV for fluid resuscitation.
B. Prepare to assist with maintaining the airway.
C. Cleanse the wounds using sterile technique.
, D. Administer an analgesic for pain.
Rationale:
High-pitched wheezing indicates laryngeal stridor, a sign of laryngeal edema associated with lung injury. Airway
management is the first priority of care. Options A, C, and D are all appropriate interventions in managing the client with a
burn but are not as critical as establishing an airway.
6. The nurse walks into the room and observes the client experiencing a tonic-clonic seizure. Which intervention should
the nurse implement first?
A. Restrain the client to protect from injury.
B. Flex the neck to ensure stabilization.
C. Use a tongue blade to open the airway.
D. Turn client on the side to aid ventilation.
Rationale:
Maintaining the airway during a seizure is the priority for safety. Options A, B, and C are contraindicated during a seizure
and may cause further injury to the client.
7. Which intervention should be included in the plan of care for a client admitted to the hospital with ulcerative colitis?
A. Administer stool softeners.
B. Place the client on fluid restriction.
C. Provide a low-residue diet.
D. Add a milk product to each meal.
Rationale:
A low-residue diet will help decrease symptoms of diarrhea, which are clinical manifestations of ulcerative colitis. Options
A, B, and D are contraindicated and could worsen the condition.
8. A nurse implements an education program to reduce hospital readmissions for clients with heart failure. Which
statement by the client indicates that teaching has been effective?
A. "I will not take my digoxin if my heart rate is higher than 100 beats/min."
B. "I should weigh myself once a week and report any increases."
C. "It is important to increase my fluid intake whenever possible."
D. "I should report an increase of swelling in my feet or ankles."
E. “I will call my health care provider if I have diarrhea for more than a
day.”
Rationale:
An increase in edema indicates worsening right-sided heart failure and should be reported to the primary health care
provider. Digitalis should be held when the heart rate is lower than 60 beats/min. The client with heart failure should
weigh himself or herself daily and report a gain of 2 to 3 lb. An increase in fluid can worsen heart failure.
9. After assessing a 26-year-old client with type 1 diabetes mellitus, which data may indicate that the client is experiencing
chronic complications of diabetes?
A. Blood pressure, 159/98 mm Hg
B. Hemoglobin A1C (HbA1C), 6%
C. Creatinine level, 1.0 mg/dL
D. Chronic sciatica
Rationale:
A blood pressure of 159/98 mm Hg is hypertensive and increases the client's risk for acute coronary syndrome and/or
stroke. Options B and C are within defined parameters, and Option D is not a recognized chronic complication of diabetes.
10. When caring for a client with a tracheostomy, which intervention should the nurse delegate to the unlicensed assistive
personnel (UAP)?
A. Teach the family about signs and symptoms of hypoxia.
B. Take the vital signs and obtain an O2 saturation level 5 minutes before the
procedure.
C. Evaluate the need for tracheal suctioning.
, D. Revise the plan of care to include tracheostomy care.
Rationale:
The nurse may delegate obtaining vital signs and O2 saturation; however, the nurse is responsible for following up on any
reported data. Options A, C, and D are all part of the nursing process and should not be delegated under the nurse's scope
of practice.
11. The charge nurse is making assignments for the upcoming shift. Which client is most appropriate to assign to the
practical nurse (PN)?
A. A client with nausea who needs a nasogastric tube inserted
B. A client in hypertensive crisis who needs titration of IV nitroglycerin
C. A newly admitted client who needs to have a plan of care established
D. A client who is ready for discharge who needs discharge teaching
Rationale:
The client mentioned in option A has a need for a skill that is within the scope of practice for the PN. Titration of an IV
drip, establishing care plans, and discharge teaching are within the scope of practice of a registered nurse (RN) and are not
delegated.
12. A nurse performs an initial admission assessment of a 56-year-old client. Which factor(s) would indicate that the client
is at risk for metabolic syndrome? (Select all that apply.)
A. Abdominal obesity
B. Sedentary lifestyle
C. History of hypoglycemia
D. Hispanic or Asian ethnicity
E. Increased triglycerides
Rationale:
Metabolic syndrome is a name for a group of risk factors that increase the risk for coronary artery disease, type 2 diabetes,
and stroke (A, B, D, and E). Hypoglycemia is not a risk factor for metabolic syndrome (C).
13. Which clinical manifestation in the client with hyperthyroidism is most important to report to the health care provider?
A. Nervousness
B. Increased appetite
C. Apical heart rate of 130 beats/min
D. Insomnia
Rationale:
The apical heart rate of 130 beats/min is a critical finding that could lead to heart failure or other cardiac disorders.
Options A, B, and D are all expected findings that should also be reported but are not as critical.
14. The nurse administers atropine sulfate ophthalmic drops preoperatively to the right eye of a client scheduled for
cataract surgery. Which response by the client indicates that the drug was effective?
A. The pupils become equal and reactive to light.
B. The right pupil constricts within 30 minutes.
C. Bilateral visual accommodation is restored.
D. The right pupil dilates after drop instillation.
Rationale:
Atropine is a mydriatic drug which causes pupil dilation and paralysis in preparation for surgery or examination. Options
A, B, and C do not describe the therapeutic effects of atropine sulfate ophthalmic drops prior to cataract surgery.
15. A client with human immunodeficiency virus (HIV) develops a painful blistering skin rash on the right lateral
abdominal area. Which drug should the nurse expect to administer to treat this condition?
A. Levofloxacin
B. Acyclovir sodium
C. Fluconazole
D. Esomeprazole
1.Which information is most concerning to the nurse when caring for an older client with bilateral cataracts?
A. States having difficulty with color perception
B. Presents with opacity of the lens upon assessment
C. Complains of seeing a cobweb-type structure in the visual field
D. Reports the need to use a magnifying glass to see small print
Rationale:
Visualization of a cobweb- or hairnet-type structure is a sign of a retinal detachment, which constitutes a medical
emergency. Clients with cataracts are at increased risk for retinal detachment. Distorted color perception, opacity of the
lens, and gradual vision loss are expected signs and symptom of cataracts but do not need immediate attention.
2.When caring for a client hospitalized with Guillain-Barré syndrome, which information is most important for the nurse
to report to the primary health care provider?
A. Ascending numbness from the feet to the knees
B. Decrease in cognitive status of the client
C. Blurred vision and sensation changes
D. Persistent unilateral headache
Rationale:
A decline in cognitive status in a client is indicative of symptoms of hypoxia and a possible need to assist the client with
mechanical ventilation. A primary health care provider will need to be contacted immediately. Options A, C, and D are
findings associated with Guillain-Barré syndrome that should also be reported but are not as critical as the client's hypoxic
status.
3. A client is admitted with a diagnosis of leukemia. Which assessment findings will the nurse include in the client’s plan
of care? (Select all that apply.)
A. Elevated platelets
B. Weight loss
C. Hyperplasia of the gums
D. Elevated white blood count
E. Weakness
Rationale:
Hyperplastic gums, weakness, and elevated white blood count are classic signs of leukemia. Options A, B, and D state
incorrect information for symptoms of leukemia.
4. The nurse enters the examination room of a client who has been told by her health care provider that she has advanced
ovarian cancer. Which response by the nurse is likely to be most supportive for the client?
A. "I know many women who have survived ovarian cancer."
B. "Let's talk about the treatments of ovarian cancer."
C. "In my opinion I would suggest getting a second opinion."
D. "Tell me about what you are feeling right now."
Rationale:
The most therapeutic action for the nurse is to be an active listener and to encourage the client to explore her feelings.
Giving false reassurance or personal are not therapeutic communication for the client.
5. A nurse working in the emergency department admits a client with full-thickness burns to 50% of the body. Assessment
findings indicate high-pitched wheezing, heart rate of 120 beats/min, and disorientation. Which action should the nurse
take first?
A. Insert a large-bore IV for fluid resuscitation.
B. Prepare to assist with maintaining the airway.
C. Cleanse the wounds using sterile technique.
, D. Administer an analgesic for pain.
Rationale:
High-pitched wheezing indicates laryngeal stridor, a sign of laryngeal edema associated with lung injury. Airway
management is the first priority of care. Options A, C, and D are all appropriate interventions in managing the client with a
burn but are not as critical as establishing an airway.
6. The nurse walks into the room and observes the client experiencing a tonic-clonic seizure. Which intervention should
the nurse implement first?
A. Restrain the client to protect from injury.
B. Flex the neck to ensure stabilization.
C. Use a tongue blade to open the airway.
D. Turn client on the side to aid ventilation.
Rationale:
Maintaining the airway during a seizure is the priority for safety. Options A, B, and C are contraindicated during a seizure
and may cause further injury to the client.
7. Which intervention should be included in the plan of care for a client admitted to the hospital with ulcerative colitis?
A. Administer stool softeners.
B. Place the client on fluid restriction.
C. Provide a low-residue diet.
D. Add a milk product to each meal.
Rationale:
A low-residue diet will help decrease symptoms of diarrhea, which are clinical manifestations of ulcerative colitis. Options
A, B, and D are contraindicated and could worsen the condition.
8. A nurse implements an education program to reduce hospital readmissions for clients with heart failure. Which
statement by the client indicates that teaching has been effective?
A. "I will not take my digoxin if my heart rate is higher than 100 beats/min."
B. "I should weigh myself once a week and report any increases."
C. "It is important to increase my fluid intake whenever possible."
D. "I should report an increase of swelling in my feet or ankles."
E. “I will call my health care provider if I have diarrhea for more than a
day.”
Rationale:
An increase in edema indicates worsening right-sided heart failure and should be reported to the primary health care
provider. Digitalis should be held when the heart rate is lower than 60 beats/min. The client with heart failure should
weigh himself or herself daily and report a gain of 2 to 3 lb. An increase in fluid can worsen heart failure.
9. After assessing a 26-year-old client with type 1 diabetes mellitus, which data may indicate that the client is experiencing
chronic complications of diabetes?
A. Blood pressure, 159/98 mm Hg
B. Hemoglobin A1C (HbA1C), 6%
C. Creatinine level, 1.0 mg/dL
D. Chronic sciatica
Rationale:
A blood pressure of 159/98 mm Hg is hypertensive and increases the client's risk for acute coronary syndrome and/or
stroke. Options B and C are within defined parameters, and Option D is not a recognized chronic complication of diabetes.
10. When caring for a client with a tracheostomy, which intervention should the nurse delegate to the unlicensed assistive
personnel (UAP)?
A. Teach the family about signs and symptoms of hypoxia.
B. Take the vital signs and obtain an O2 saturation level 5 minutes before the
procedure.
C. Evaluate the need for tracheal suctioning.
, D. Revise the plan of care to include tracheostomy care.
Rationale:
The nurse may delegate obtaining vital signs and O2 saturation; however, the nurse is responsible for following up on any
reported data. Options A, C, and D are all part of the nursing process and should not be delegated under the nurse's scope
of practice.
11. The charge nurse is making assignments for the upcoming shift. Which client is most appropriate to assign to the
practical nurse (PN)?
A. A client with nausea who needs a nasogastric tube inserted
B. A client in hypertensive crisis who needs titration of IV nitroglycerin
C. A newly admitted client who needs to have a plan of care established
D. A client who is ready for discharge who needs discharge teaching
Rationale:
The client mentioned in option A has a need for a skill that is within the scope of practice for the PN. Titration of an IV
drip, establishing care plans, and discharge teaching are within the scope of practice of a registered nurse (RN) and are not
delegated.
12. A nurse performs an initial admission assessment of a 56-year-old client. Which factor(s) would indicate that the client
is at risk for metabolic syndrome? (Select all that apply.)
A. Abdominal obesity
B. Sedentary lifestyle
C. History of hypoglycemia
D. Hispanic or Asian ethnicity
E. Increased triglycerides
Rationale:
Metabolic syndrome is a name for a group of risk factors that increase the risk for coronary artery disease, type 2 diabetes,
and stroke (A, B, D, and E). Hypoglycemia is not a risk factor for metabolic syndrome (C).
13. Which clinical manifestation in the client with hyperthyroidism is most important to report to the health care provider?
A. Nervousness
B. Increased appetite
C. Apical heart rate of 130 beats/min
D. Insomnia
Rationale:
The apical heart rate of 130 beats/min is a critical finding that could lead to heart failure or other cardiac disorders.
Options A, B, and D are all expected findings that should also be reported but are not as critical.
14. The nurse administers atropine sulfate ophthalmic drops preoperatively to the right eye of a client scheduled for
cataract surgery. Which response by the client indicates that the drug was effective?
A. The pupils become equal and reactive to light.
B. The right pupil constricts within 30 minutes.
C. Bilateral visual accommodation is restored.
D. The right pupil dilates after drop instillation.
Rationale:
Atropine is a mydriatic drug which causes pupil dilation and paralysis in preparation for surgery or examination. Options
A, B, and C do not describe the therapeutic effects of atropine sulfate ophthalmic drops prior to cataract surgery.
15. A client with human immunodeficiency virus (HIV) develops a painful blistering skin rash on the right lateral
abdominal area. Which drug should the nurse expect to administer to treat this condition?
A. Levofloxacin
B. Acyclovir sodium
C. Fluconazole
D. Esomeprazole
