HESI Comprehensive B Practice
1 An 8-year-old child is receiving A
. digoxin (Lanoxin) for congestive heart Rationale:
failure (CHF). In assessing the child, Nausea and vomiting are early signs
the nurse finds that her apical heart of digoxin toxicity. However, the
rate is 80 beats/min, she complains of normal resting heart rate for a child
being slightly nauseated, and her 8 to 10 years of age is 70 to 110
serum digoxin level is 1.2 ng/mL. beats/min and the therapeutic range
What action should the nurse take? of serum digoxin levels is 0.5 to 2
A. Because the child's heart rate and ng/mL. Based on the objective data,
digoxin level are within normal range, (A) is the best of the choices
assess for the cause of the nausea. provided because the serum digoxin
B. Hold the next dose of digoxin until level is within normal levels. (B) is
the health care provider can be not warranted by the data presented.
notified because the serum digoxin The digoxin level is within the
level is elevated. therapeutic range and the child is not
C. Administer the next dose of digoxin showing signs of toxicity (C). The
and notify the health care provider child's pulse rate is within normal
that the child is showing signs of range for her age group (D).
toxicity.
D. Notify the health care provider that
the child's pulse rate is below normal
for her age group.
2 A 12-year-old boy complains to the C
. nurse that he is "short" (4'5" [53 Rationale:
inches]). His twin sister is 5 inches Girls experience a growth spurt at
taller than he is (4'10" [58 inches]). 9.5 to 14.5 years of age and boys at
Based on these findings, what 10.5 to 16 years of age (C). There
conclusion should the nurse reach? are insufficient data to support (A);
A.The boy is not growing as normally growth trends must be assessed to
expected. reach such a conclusion. (B) is not
B. The girl is experiencing a period of unexpected. The fact that the
unexpected growth. children are twins has less to do
C.A normal growth spurt occurs in with their growth than the fact that
girls 1 to 2 years earlier than boys. they are male and female (D).
D.Male-female twins are not identical;
therefore, their growth cannot be
, compared.
3 A 45-year-old female client is admitted C
. to the psychiatric unit for evaluation. Rationale:
Her husband states that she has been Agoraphobia (C) is the fear of
reluctant to leave home for the last 6 crowds or of being in an open
months. The client has not gone to place. (A) is the fear of being in
work for a month, has been terminated closed places. (B) is the fear of high
from her job, and has not left the places. (D) is an abnormal fear of
house since that time. This client is death or bodies after death. A
displaying symptoms of which phobia is an unrealistic fear
disorder? associated with severe anxiety.
A.Claustrophobia
B.Acrophobia
C.Agoraphobia
D.Necrophobia
4 An adult client with a medical C
. diagnosis of substance abuse and Rationale:
schizophrenia was recently switched Alcohol enhances the side effects of
from oral fluphenazine HCl (Prolixin) Prolixin. The half-life of Prolixin
to IM fluphenazine decanoate (Prolixin PO is 8 hours, whereas the half-life
Decanoate) because of medication of the Prolixin Decanoate IM is 2 to
noncompliance. What should the nurse 4 weeks. Therefore, the side effects
teach the client and family about this of drinking alcohol are far more
change in medication regimen? severe when the client drinks
A.Long-acting medication is more alcohol after taking the long-acting
effective than daily medication. Prolixin Decanoate IM (C). (A, B,
B.A client with substance abuse must and D) provide incorrect
not take any oral medications. information.
C.There will continue to be a risk of
alcohol and drug interaction.
D.Support groups are only helpful for
substance abuse treatment.
5 An adult female who presents at the D
. mental clinic trembling and crying Rationale:
becomes distressed when the nurse The client is exhibiting signs of
attempts to conduct an assessment. moderate anxiety, which include
She complains about the number of voice tremors, shakiness, somatic
questions that are being asked, which complaints, and selective inattention.
, she is convinced are going to cause (D) is the best method for addressing
her to have a heart attack. What this client's level of anxiety by
action should the nurse take? creating a shared understanding of
A. Take the client's blood pressure the client's concerns. Although
and reassure her that questioning assessment of her blood pressure (A)
will not cause a heart attack. might be a worthwhile intervention,
B. Explain that treatment is based on reassuring her that questioning will
information obtained in the not cause a heart attack (A) is
assessment. argumentative. (B) suggests that
C. Encourage the client to relax so treatment cannot be provided without
that she can provide the information the information, which is
requested. manipulative. Asking the client to
D. Empower the client to share her relax (C) is likely to increase her
story of why she is here at the mental anxiety.
health clinic.
6 After assessing a 26-year-old client A
. with type 1 diabetes mellitus, which Rationale:
data may indicate that the client is A blood pressure of 159/98 mm Hg is
experiencing chronic complications hypertensive and increases the
of diabetes? client's risk for acute coronary
A. Blood pressure, 159/98 mm Hg syndrome and/or stroke (A). (B and
B.Hemoglobin A1c (HbA1c), 6% C) are within defined parameters, and
C.Creatinine level, 1.0 mg/dL (D) is not a recognized chronic
D.Chronic sciatica complication of diabetes.
7 The charge nurse is making A
. assignments for the upcoming shift. Rationale:
Which client is most appropriate to This client has a need for a skill that
assign to the licensed practical nurse is within the scope of practice for the
(LPN)? LPN (A). Titration of an IV drip,
A.A client with nausea who needs a establishing care plans, and discharge
nasogastric tube inserted teaching are within the scope of
B.A client in hypertensive crisis who practice of a registered nurse (RN)
needs titration of IV nitroglycerin and are not delegated (B, C, and D).
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
, 8 The charge nurse observes a student B
. nurse enter the room of a client who Rationale:
is prescribed airborne precautions. The use of personal protective
The application of which personal equipment (PPE) for airborne
protective equipment by the student precautions includes a properly
indicates a correct understanding of prefitted N95 respirator or mask (B).
this precaution? (A, C and D) do not provide the
A. Surgical mask, clean gloves, and appropriate respiratory equipment for
gown airborne precautions. A surgical mask
B. Properly fitted N95 respirator or is used for preventing transmission of
mask droplet precautions.
C. Sterile gloves and gown
D. Goggles, clean gloves, and gown
9 The charge nurse reviews the C
. charting of a graduate nurse. Which Rationale:
indicates a need for further Charting actions prior to
education on documentation? implementing them is an example of
A. Uses descriptive words such as fraudulent charting and the graduate
"gurgling" to describe breath sounds nurse should receive further
B.Records temperature 30 minutes education (C). (A, B, and D) are
before and after giving appropriate charting examples.
acetaminophen
C.Charts some actions in advance of
performing them
D.Includes the client's response to an
intervention
10 A client at 32 weeks of gestation is B
. hospitalized with preeclampsia, Rationale:
and magnesium sulfate is Magnesium sulfate, a central nervous
prescribed to control the system (CNS) depressant, helps
symptoms. Before the next dose of prevent seizures, so (A) is a positive
MgSO4 is given, which assessment sign that the medication is having a
finding indicates that the patient is desired effect. The minimum urine
at risk for toxicity? output expected for a repeat dose of
A. Deep tendon reflexes—decrease magnesium sulfate is 30 mL/hr, so 100
to 2+ mL of urine in 4 hours can lead to poor
B.100 mL of urine output in 4 excretion of magnesium, with a
hours possible cumulative effect (B). A
C. Respiratory rate decreases to 16 decreased respiratory rate (C) indicates
1 An 8-year-old child is receiving A
. digoxin (Lanoxin) for congestive heart Rationale:
failure (CHF). In assessing the child, Nausea and vomiting are early signs
the nurse finds that her apical heart of digoxin toxicity. However, the
rate is 80 beats/min, she complains of normal resting heart rate for a child
being slightly nauseated, and her 8 to 10 years of age is 70 to 110
serum digoxin level is 1.2 ng/mL. beats/min and the therapeutic range
What action should the nurse take? of serum digoxin levels is 0.5 to 2
A. Because the child's heart rate and ng/mL. Based on the objective data,
digoxin level are within normal range, (A) is the best of the choices
assess for the cause of the nausea. provided because the serum digoxin
B. Hold the next dose of digoxin until level is within normal levels. (B) is
the health care provider can be not warranted by the data presented.
notified because the serum digoxin The digoxin level is within the
level is elevated. therapeutic range and the child is not
C. Administer the next dose of digoxin showing signs of toxicity (C). The
and notify the health care provider child's pulse rate is within normal
that the child is showing signs of range for her age group (D).
toxicity.
D. Notify the health care provider that
the child's pulse rate is below normal
for her age group.
2 A 12-year-old boy complains to the C
. nurse that he is "short" (4'5" [53 Rationale:
inches]). His twin sister is 5 inches Girls experience a growth spurt at
taller than he is (4'10" [58 inches]). 9.5 to 14.5 years of age and boys at
Based on these findings, what 10.5 to 16 years of age (C). There
conclusion should the nurse reach? are insufficient data to support (A);
A.The boy is not growing as normally growth trends must be assessed to
expected. reach such a conclusion. (B) is not
B. The girl is experiencing a period of unexpected. The fact that the
unexpected growth. children are twins has less to do
C.A normal growth spurt occurs in with their growth than the fact that
girls 1 to 2 years earlier than boys. they are male and female (D).
D.Male-female twins are not identical;
therefore, their growth cannot be
, compared.
3 A 45-year-old female client is admitted C
. to the psychiatric unit for evaluation. Rationale:
Her husband states that she has been Agoraphobia (C) is the fear of
reluctant to leave home for the last 6 crowds or of being in an open
months. The client has not gone to place. (A) is the fear of being in
work for a month, has been terminated closed places. (B) is the fear of high
from her job, and has not left the places. (D) is an abnormal fear of
house since that time. This client is death or bodies after death. A
displaying symptoms of which phobia is an unrealistic fear
disorder? associated with severe anxiety.
A.Claustrophobia
B.Acrophobia
C.Agoraphobia
D.Necrophobia
4 An adult client with a medical C
. diagnosis of substance abuse and Rationale:
schizophrenia was recently switched Alcohol enhances the side effects of
from oral fluphenazine HCl (Prolixin) Prolixin. The half-life of Prolixin
to IM fluphenazine decanoate (Prolixin PO is 8 hours, whereas the half-life
Decanoate) because of medication of the Prolixin Decanoate IM is 2 to
noncompliance. What should the nurse 4 weeks. Therefore, the side effects
teach the client and family about this of drinking alcohol are far more
change in medication regimen? severe when the client drinks
A.Long-acting medication is more alcohol after taking the long-acting
effective than daily medication. Prolixin Decanoate IM (C). (A, B,
B.A client with substance abuse must and D) provide incorrect
not take any oral medications. information.
C.There will continue to be a risk of
alcohol and drug interaction.
D.Support groups are only helpful for
substance abuse treatment.
5 An adult female who presents at the D
. mental clinic trembling and crying Rationale:
becomes distressed when the nurse The client is exhibiting signs of
attempts to conduct an assessment. moderate anxiety, which include
She complains about the number of voice tremors, shakiness, somatic
questions that are being asked, which complaints, and selective inattention.
, she is convinced are going to cause (D) is the best method for addressing
her to have a heart attack. What this client's level of anxiety by
action should the nurse take? creating a shared understanding of
A. Take the client's blood pressure the client's concerns. Although
and reassure her that questioning assessment of her blood pressure (A)
will not cause a heart attack. might be a worthwhile intervention,
B. Explain that treatment is based on reassuring her that questioning will
information obtained in the not cause a heart attack (A) is
assessment. argumentative. (B) suggests that
C. Encourage the client to relax so treatment cannot be provided without
that she can provide the information the information, which is
requested. manipulative. Asking the client to
D. Empower the client to share her relax (C) is likely to increase her
story of why she is here at the mental anxiety.
health clinic.
6 After assessing a 26-year-old client A
. with type 1 diabetes mellitus, which Rationale:
data may indicate that the client is A blood pressure of 159/98 mm Hg is
experiencing chronic complications hypertensive and increases the
of diabetes? client's risk for acute coronary
A. Blood pressure, 159/98 mm Hg syndrome and/or stroke (A). (B and
B.Hemoglobin A1c (HbA1c), 6% C) are within defined parameters, and
C.Creatinine level, 1.0 mg/dL (D) is not a recognized chronic
D.Chronic sciatica complication of diabetes.
7 The charge nurse is making A
. assignments for the upcoming shift. Rationale:
Which client is most appropriate to This client has a need for a skill that
assign to the licensed practical nurse is within the scope of practice for the
(LPN)? LPN (A). Titration of an IV drip,
A.A client with nausea who needs a establishing care plans, and discharge
nasogastric tube inserted teaching are within the scope of
B.A client in hypertensive crisis who practice of a registered nurse (RN)
needs titration of IV nitroglycerin and are not delegated (B, C, and D).
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
, 8 The charge nurse observes a student B
. nurse enter the room of a client who Rationale:
is prescribed airborne precautions. The use of personal protective
The application of which personal equipment (PPE) for airborne
protective equipment by the student precautions includes a properly
indicates a correct understanding of prefitted N95 respirator or mask (B).
this precaution? (A, C and D) do not provide the
A. Surgical mask, clean gloves, and appropriate respiratory equipment for
gown airborne precautions. A surgical mask
B. Properly fitted N95 respirator or is used for preventing transmission of
mask droplet precautions.
C. Sterile gloves and gown
D. Goggles, clean gloves, and gown
9 The charge nurse reviews the C
. charting of a graduate nurse. Which Rationale:
indicates a need for further Charting actions prior to
education on documentation? implementing them is an example of
A. Uses descriptive words such as fraudulent charting and the graduate
"gurgling" to describe breath sounds nurse should receive further
B.Records temperature 30 minutes education (C). (A, B, and D) are
before and after giving appropriate charting examples.
acetaminophen
C.Charts some actions in advance of
performing them
D.Includes the client's response to an
intervention
10 A client at 32 weeks of gestation is B
. hospitalized with preeclampsia, Rationale:
and magnesium sulfate is Magnesium sulfate, a central nervous
prescribed to control the system (CNS) depressant, helps
symptoms. Before the next dose of prevent seizures, so (A) is a positive
MgSO4 is given, which assessment sign that the medication is having a
finding indicates that the patient is desired effect. The minimum urine
at risk for toxicity? output expected for a repeat dose of
A. Deep tendon reflexes—decrease magnesium sulfate is 30 mL/hr, so 100
to 2+ mL of urine in 4 hours can lead to poor
B.100 mL of urine output in 4 excretion of magnesium, with a
hours possible cumulative effect (B). A
C. Respiratory rate decreases to 16 decreased respiratory rate (C) indicates
