HESI Comprehensive B,
Comprehensive Exam A, 2021 exit
v2
The nrse is caring for a patient with a cerebrovascular accident (CVA) who is
receiving enteral tube feedings. Which task performed by the UAP requires
immediate intervention by the nrse?
A.Suctions oral secretions from mouth
B.Positions head of bed flat when changing sheets
C.Takes temperature using the axillary method
D.Keeps head of bed elevated at 30 degrees Correct answer- B
Rationale:
Positioning the head of the bed flat when enteral feedings are in progress
puts the patient at risk for aspiration (B). The others are all acceptable tasks
performed by the UAP (A, C, and D).
When caring for a postsurgical patient who has undergone multiple blood
transfusions, which serum laboratory finding is of most concern to the nrse?
A.Sodium level, 137 mEq/L
B.Potassium level, 5.5 mEq/L
C.Blood urea nitrogen (BUN) level, 18 mg/dL
D.Calcium level, 10 mEq/L Correct answer- B
Rationale:
Multiple blood transfusions are a risk factor for hyperkalemia. A serum
potassium level higher than 5.0 mEq/L indicates hyperkalemia (B). The
others are normal findings (A, C, and D).
Which vaccination should the nrse administer to a newborn?
A.Hepatitis B
B.Human papilloma virus (HPV)
C.Varicella
D.Meningococcal vaccine Correct answer- A
Rationale:
The hepatitis B vaccination should be given to all newborns before hospital
discharge (A). HPV is not recommended until adolescence (B). Varicella
immunization begins at 12 months (C). Meningococcal vaccine is
administered beginning at 2 years (D).
The nrse is caring for a patient 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.
C.Answer a family member's questions about the patient's plan of care.
D.Teach the patient side effects to report related to the current medication
regimen. Correct answer- B
Rationale:
Obtaining a fingerstick blood glucose level is a simple treatment and is an
appropriate skill for UAP to perform (B). (A, C, and D) are skills that cannot
be delegated to UAP.
The nrse is caring for a patient with an ischemic stroke who has a
prescription for tissue plasminogen activator (t-PA) IV. Which action(s) should
the nrse expect to implement? (Select all that apply.)
A.Administer aspirin with tissue plasminogen activator (t-PA).
B.Complete the National Institute of Health Stroke Scale (NIHSS).
C.Assess the patient for signs of bleeding during and after the infusion.
D.Start t-PA within 6 hours after the onset of stroke symptoms.
E.Initiate multidisciplinary consult for potential rehabilitation. Correct
answer- B,C,E
Rationale:
Neurologic assessment, including the NIHSS, is indicated for the patient
receiving t-PA. This includes close monitoring for bleeding during and after
the infusion; if bleeding or other signs of neurologic impairment occur, the
infusion should be stopped (B, C, and E). Aspirin is contraindicated with t-PA
because it increases the risk for bleeding (A). The administration of t-PA
within 6 hours of symptoms is concurrent with a diagnosis of a myocardial
infarction and within 4.5 hours of symptoms is concurrent for a stroke (D).
When caring for a patient in labor, which finding is most important to report
to the primary health care provider?
A.Maternal heart rate, 90 beats/min.
B.Fetal heart rate, 100 beats/min
C.Maternal blood pressure, 140/86 mm Hg
D.Maternal temperature, 100.0° F Correct answer- B
Rationale:
A fetal heart rate (FHR) of 100 beats/min may indicate fetal distress (B)
because the average FHR at term is 140 beats/min and the normal range is
110 to beats/min 160. The others (A, C, and D) are normal findings for a
woman in labor.
The nrse is caring for a patient with heart failure who develops respiratory
distress and coughs up pink frothy sputum. Which action should the nrse
take first?
A.Draw arterial blood gases.
B.Notify the primary health care provider.
C.Position in a high Fowler's position with the legs down.
D.Obtain a chest X-ray. Correct answer- C
,Rationale:
Positioning the patient in a high Fowler's position with dangling feet will
decrease further venous return to the left ventricle (C). The other actions
should be performed after the change in position (A, B, and D).
A patient who is prescribed chlorpromazine HCl (Thorazine) for schizophrenia
develops rigidity, a shuffling gait, and tremors. Which action by the nrse is
most important?A.Administer a dose of benztropine mesylate (Cogentin)
PRN.
B.Determine if the patient has increased photosensitivity.
C.Provide comfort measures for sore muscles.
D.Assess the patient for visual and auditory hallucinations. Correct answer- A
Rationale:
Rigidity, shuffling gait, pill-rolling hand movements, tremors, dyskinesia, and
masklike face are extrapyramidal side effects associated with Thorazine. It is
most important for the nrse to administer an anticholinergic such as
Cogentin to reverse these effects (A). The others (B, C, D) may be
appropriate interventions but are not as urgent as (A).
A nrse is interviewing a mother during a well-child visit. Which finding would
alert the nrse to continue further assessment of the infant?
A.Two-month-old who is unable to roll from back to abdomen
B.Ten-month-old who cannot sit without support
C.Nine-month-old who cries when his mother leaves the room
D.Eight-month-old who has not yet begun to speak words Correct answer- B
Rationale:
As a developmental milestone, infants should sit unsupported by 8 months
(B). The milestone of rolling over is achieved at 5 to 6 months for most
infants (A). Stranger anxiety is common from 7 to 9 months (C). Speaking a
few words is expected at about 12 months (D).
Which intervention should be included in the plan of care for a patient
admitted to the hospital with ulcerative colitis?
A.Administer stool softeners.
B.Place the patient on fluid restriction.
C.Provide a low-residue diet.
D.Add a milk product to each meal. Correct answer- C
Rationale:
A low-residue diet (C) will help decrease symptoms of diarrhea, which are
clinical manifestations of ulcerative colitis. (A, B, and D) are contraindicated
and could worsen the condition.
The nrse is caring for a patient with deep vein thrombosis who is on a
continuous IV heparin infusion. The activated partial prothrombin time (aPTT)
is 120 seconds. Which action should the nrse take?
A.Increase the rate of the heparin infusion using a nomogram.
, B.Decrease the heparin infusion rate and give vitamin K IM.
C.Continue the heparin infusion at the current prescribed rate.
D.Stop the heparin drip and prepare to administer protamine sulfate. Correct
answer- D
Rationale:
An aPTT more than 100 seconds is a critically high value; therefore, the
heparin should be stopped. The antidote for heparin is protamine sulfate (D).
Increasing the rate would increase the risk for hemorrhage (A). The infusion
should be stopped, and vitamin K is the antidote for warfarin (Coumadin) (B).
Keeping the infusion at the current rate would increase the risk for
hemorrhage (C).
While assessing a patient with recurring chest pain, the unit secretary
notifies the nrse that the patient's health care provider is on the telephone.
What action should the nrse instruct the unit secretary to implement?
A.Transfer the call into the room of the patient.
B.Instruct the secretary to explain reason for the call.
C.Ask another nrse to take the phone call.
D.Ask the health care provider to see the patient on the unit. Correct answer-
C
Rationale:
Another nrse should be asked to take the phone call (C), which allows the
nrse to stay at the bedside to complete the assessment of the patient's chest
pain. (A and B) should not be done during an acute change in the patient's
condition. Requesting the health care provider (D) to come to the unit is
premature until the nrse completes assessment of the patient's status.
Which instruction(s) should the nrse include in the discharge teaching plan of
a male patient who has had a myocardial infarction and who has a new
prescription for nitroglycerin (NTG)? (Select all that apply.)
A.Keep the medication in your pocket so that it can be accessed quickly.
B.Call 911 if chest pain is not relieved after one nitroglycerin.
C.Store the medication in its original container and protect it from light.
D.Activate the emergency medical system after three doses of medication.
E.Do not use within 1 hour of taking sildenafil citrate (Viagra). Correct
answer- B,C
Rationale:
Emergency action should be taken if chest pain is not relieved after one
nitroglycerin tablet (B). The medication should be kept in the original
container to protect from light (C). Keeping the medication in the shirt pocket
provides an environment that is too warm (A). The newest guidelines
recommend calling 911 after one nitroglycerin tablet if chest pain is not
relieved (D). Nitroglycerin and other nitrates should never be taken with
Viagra (E).
Comprehensive Exam A, 2021 exit
v2
The nrse is caring for a patient with a cerebrovascular accident (CVA) who is
receiving enteral tube feedings. Which task performed by the UAP requires
immediate intervention by the nrse?
A.Suctions oral secretions from mouth
B.Positions head of bed flat when changing sheets
C.Takes temperature using the axillary method
D.Keeps head of bed elevated at 30 degrees Correct answer- B
Rationale:
Positioning the head of the bed flat when enteral feedings are in progress
puts the patient at risk for aspiration (B). The others are all acceptable tasks
performed by the UAP (A, C, and D).
When caring for a postsurgical patient who has undergone multiple blood
transfusions, which serum laboratory finding is of most concern to the nrse?
A.Sodium level, 137 mEq/L
B.Potassium level, 5.5 mEq/L
C.Blood urea nitrogen (BUN) level, 18 mg/dL
D.Calcium level, 10 mEq/L Correct answer- B
Rationale:
Multiple blood transfusions are a risk factor for hyperkalemia. A serum
potassium level higher than 5.0 mEq/L indicates hyperkalemia (B). The
others are normal findings (A, C, and D).
Which vaccination should the nrse administer to a newborn?
A.Hepatitis B
B.Human papilloma virus (HPV)
C.Varicella
D.Meningococcal vaccine Correct answer- A
Rationale:
The hepatitis B vaccination should be given to all newborns before hospital
discharge (A). HPV is not recommended until adolescence (B). Varicella
immunization begins at 12 months (C). Meningococcal vaccine is
administered beginning at 2 years (D).
The nrse is caring for a patient 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.
C.Answer a family member's questions about the patient's plan of care.
D.Teach the patient side effects to report related to the current medication
regimen. Correct answer- B
Rationale:
Obtaining a fingerstick blood glucose level is a simple treatment and is an
appropriate skill for UAP to perform (B). (A, C, and D) are skills that cannot
be delegated to UAP.
The nrse is caring for a patient with an ischemic stroke who has a
prescription for tissue plasminogen activator (t-PA) IV. Which action(s) should
the nrse expect to implement? (Select all that apply.)
A.Administer aspirin with tissue plasminogen activator (t-PA).
B.Complete the National Institute of Health Stroke Scale (NIHSS).
C.Assess the patient for signs of bleeding during and after the infusion.
D.Start t-PA within 6 hours after the onset of stroke symptoms.
E.Initiate multidisciplinary consult for potential rehabilitation. Correct
answer- B,C,E
Rationale:
Neurologic assessment, including the NIHSS, is indicated for the patient
receiving t-PA. This includes close monitoring for bleeding during and after
the infusion; if bleeding or other signs of neurologic impairment occur, the
infusion should be stopped (B, C, and E). Aspirin is contraindicated with t-PA
because it increases the risk for bleeding (A). The administration of t-PA
within 6 hours of symptoms is concurrent with a diagnosis of a myocardial
infarction and within 4.5 hours of symptoms is concurrent for a stroke (D).
When caring for a patient in labor, which finding is most important to report
to the primary health care provider?
A.Maternal heart rate, 90 beats/min.
B.Fetal heart rate, 100 beats/min
C.Maternal blood pressure, 140/86 mm Hg
D.Maternal temperature, 100.0° F Correct answer- B
Rationale:
A fetal heart rate (FHR) of 100 beats/min may indicate fetal distress (B)
because the average FHR at term is 140 beats/min and the normal range is
110 to beats/min 160. The others (A, C, and D) are normal findings for a
woman in labor.
The nrse is caring for a patient with heart failure who develops respiratory
distress and coughs up pink frothy sputum. Which action should the nrse
take first?
A.Draw arterial blood gases.
B.Notify the primary health care provider.
C.Position in a high Fowler's position with the legs down.
D.Obtain a chest X-ray. Correct answer- C
,Rationale:
Positioning the patient in a high Fowler's position with dangling feet will
decrease further venous return to the left ventricle (C). The other actions
should be performed after the change in position (A, B, and D).
A patient who is prescribed chlorpromazine HCl (Thorazine) for schizophrenia
develops rigidity, a shuffling gait, and tremors. Which action by the nrse is
most important?A.Administer a dose of benztropine mesylate (Cogentin)
PRN.
B.Determine if the patient has increased photosensitivity.
C.Provide comfort measures for sore muscles.
D.Assess the patient for visual and auditory hallucinations. Correct answer- A
Rationale:
Rigidity, shuffling gait, pill-rolling hand movements, tremors, dyskinesia, and
masklike face are extrapyramidal side effects associated with Thorazine. It is
most important for the nrse to administer an anticholinergic such as
Cogentin to reverse these effects (A). The others (B, C, D) may be
appropriate interventions but are not as urgent as (A).
A nrse is interviewing a mother during a well-child visit. Which finding would
alert the nrse to continue further assessment of the infant?
A.Two-month-old who is unable to roll from back to abdomen
B.Ten-month-old who cannot sit without support
C.Nine-month-old who cries when his mother leaves the room
D.Eight-month-old who has not yet begun to speak words Correct answer- B
Rationale:
As a developmental milestone, infants should sit unsupported by 8 months
(B). The milestone of rolling over is achieved at 5 to 6 months for most
infants (A). Stranger anxiety is common from 7 to 9 months (C). Speaking a
few words is expected at about 12 months (D).
Which intervention should be included in the plan of care for a patient
admitted to the hospital with ulcerative colitis?
A.Administer stool softeners.
B.Place the patient on fluid restriction.
C.Provide a low-residue diet.
D.Add a milk product to each meal. Correct answer- C
Rationale:
A low-residue diet (C) will help decrease symptoms of diarrhea, which are
clinical manifestations of ulcerative colitis. (A, B, and D) are contraindicated
and could worsen the condition.
The nrse is caring for a patient with deep vein thrombosis who is on a
continuous IV heparin infusion. The activated partial prothrombin time (aPTT)
is 120 seconds. Which action should the nrse take?
A.Increase the rate of the heparin infusion using a nomogram.
, B.Decrease the heparin infusion rate and give vitamin K IM.
C.Continue the heparin infusion at the current prescribed rate.
D.Stop the heparin drip and prepare to administer protamine sulfate. Correct
answer- D
Rationale:
An aPTT more than 100 seconds is a critically high value; therefore, the
heparin should be stopped. The antidote for heparin is protamine sulfate (D).
Increasing the rate would increase the risk for hemorrhage (A). The infusion
should be stopped, and vitamin K is the antidote for warfarin (Coumadin) (B).
Keeping the infusion at the current rate would increase the risk for
hemorrhage (C).
While assessing a patient with recurring chest pain, the unit secretary
notifies the nrse that the patient's health care provider is on the telephone.
What action should the nrse instruct the unit secretary to implement?
A.Transfer the call into the room of the patient.
B.Instruct the secretary to explain reason for the call.
C.Ask another nrse to take the phone call.
D.Ask the health care provider to see the patient on the unit. Correct answer-
C
Rationale:
Another nrse should be asked to take the phone call (C), which allows the
nrse to stay at the bedside to complete the assessment of the patient's chest
pain. (A and B) should not be done during an acute change in the patient's
condition. Requesting the health care provider (D) to come to the unit is
premature until the nrse completes assessment of the patient's status.
Which instruction(s) should the nrse include in the discharge teaching plan of
a male patient who has had a myocardial infarction and who has a new
prescription for nitroglycerin (NTG)? (Select all that apply.)
A.Keep the medication in your pocket so that it can be accessed quickly.
B.Call 911 if chest pain is not relieved after one nitroglycerin.
C.Store the medication in its original container and protect it from light.
D.Activate the emergency medical system after three doses of medication.
E.Do not use within 1 hour of taking sildenafil citrate (Viagra). Correct
answer- B,C
Rationale:
Emergency action should be taken if chest pain is not relieved after one
nitroglycerin tablet (B). The medication should be kept in the original
container to protect from light (C). Keeping the medication in the shirt pocket
provides an environment that is too warm (A). The newest guidelines
recommend calling 911 after one nitroglycerin tablet if chest pain is not
relieved (D). Nitroglycerin and other nitrates should never be taken with
Viagra (E).
