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HESI EXIT COMPREHENSIVE REVIEW B
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.
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
HESI 101HESI EXIT COMPREHENSIVE REVIEW B
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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.
HESI 101HESI EXIT COMPREHENSIVE REVIEW B
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,HESI 101HESI EXIT COMPREHENSIVE REVIEW B
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A client is admitted with a diagnosis of leukemia. This condition is manifested
by which of the following?
A. Fever, elevated white blood count,
elevated platelets
B. Fatigue, weight loss and anorexia, elevated
red blood cells
C. Hyperplasia of the gums, elevated white blood
count, weakness
D. Hypocellular bone marrow aspirate,
fever, decreased hemoglobin level
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.
The nurse is caring for a client on the medical unit. Which task can
be delegated to unlicensed assistive personnel (UAP)?
A. Assess the need to change a central line dressing.
B. Obtain a fingerstick blood glucose level.
HESI 101HESI EXIT COMPREHENSIVE REVIEW B
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C. Answer a family member's questions about the
client's plan of care.
D. Teach the client side effects to report related
to the current medication regimen.
Rationale:
Obtaining a fingerstick blood glucose level is a simple treatment and is an
appropriate skill for UAP to perform. Options A, C, and D are skills that cannot be
delegated to UAP.
Which disaster management intervention by the nurse is an example of
primary prevention?
A. Emergency department triage
B. Follow-up care for psychological problems
C. Education of rescue workers in first aid
D. Treatment of clients who are injured
Rationale:
Primary prevention is aimed at preventing disease or injury. Training rescue
workers prior to a disaster is an example of minimizing or preventing
injury. Option A is an example of secondary prevention. Option B is an
example of tertiary prevention. Option D is an example of secondary
prevention.
The nurse teaches a class on bioterrorism. Which methods of transmission
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