(SOLVED)Evolve Comprehensive Exam: HESI (Answered+ Rationale) Updated Spring 2022/2023.

Evolve Comprehensive Exam (Hesi) A client with asthma receives a prescription for high blood pressure during a clinic visit. Which prescription should the nurse anticipate the client to receive that is at least likely to exacerbate asthma? ans: Metoprolol Tartrate( Lopressor) The best antihypertensive agent for clients with asthma is metoprolol (Lopressor) (C), a beta2 blocking agent which is also cardioselective and less likely to cause bronchoconstriction. Pindolol (A) is a beta2 blocker that can cause bronchoconstriction and increase asthmatic symptoms. Although carteolol (B) is a beta blocking agent and an effective antihypertensive agent used in managing angina, it can increase a client's risk for bronchoconstriction due to its nonselective beta blocker action. Propranolol (D) also blocks the beta2 receptors in the lungs, causing bronchoconstriction, and is not indicated in clients with asthma and other obstructive pulmonary disorders. A male client who has been taking propranolol ( inderal) for 18 months tells the nurse the healthcare provider discontinued the medication because his blood pressure has been normal for the past three months. Which instruction should the use provide? ans: Ask the health care provider about tapering the drug dose over the next week. Although the healthcare provider discontinued the propranolol, measures to prevent rebound cardiac excitation, such as progressively reducing the dose over one to two weeks (C), should be recommended to prevent rebound tachycardia, hypertension, and ventricular dysrhythmias. Abrupt cessation (A and B) of the beta-blocking agent may precipitate tachycardia and rebound hypertension, so gradual weaning should be recommended. A client who is taking clonidine ( Catapres, Duraclon) reports drowsiness. Which additional assessment should the nurse make? ans: How long has the client been taking the medication Drowsiness can occur in the early weeks of treatment with clonidine and with continued use becomes less intense, so the length of time the client has been on the medication (A) provides information to direct additional instruction. (B, C, and D) are not relevant. The nurse is preparing to admister atropine, an anticholinergic, to a client who is scheduled for a cholecystectomy. The client asks the nurse to explain th reason for the prescribed medication. What response is best for the nurse to provide? ans: Decrease the risk of bradycardia during surgery Atropine may be prescribed preoperatively to increase the automaticity of the sinoatrial node and prevent a dangerous reduction in heart rate (B) during surgical anesthesia. (A, C and D) do not address the therapeutic action of atropine use perioperatively. An 80 year old client is given morphine sulphate for postoperative pain. Which concomitant medication should the nurse question that poses a potential development of urniary retention in this geriatric client. ? ans: Tricyclic antidepressants Drugs with anticholinergic properties, such as tricyclic antidepressants (C), can exacerbate urinary retention associated with opioids in the older client. Although tricyclic antidepressants and antihistamines with opioids can exacerbate urinary retention, the concurrent use of (A and B) with opioids do not. Nonsteroidal antiinflammatory agents (D) can increase the risk for bleeding, but do not increase urinary retention with opioids (D). The nurse obtains a heart rate of 92 and a blood pressure of 110/76 prior to administering a scheduled dose of verapamil (Calan) for a client with atrial flutter Which action should the nurse implement? ans: Admister the dose as prescribed Verapamil slows sinoatrial (SA) nodal automaticity, delays atrioventricular (AV) nodal conduction, which slows the ventricular rate, and is used to treat atrial flutter, so (A) should be implemented, based on the client's heart rate and blood pressure. (B and C) are not indicated. (D) delays the administration of the scheduled dose. following an emergency Cesarean delivery the nurse encourages the new mother to breastfed her newborn . the client asks why she should breastfeed now. Which info should the nurse provide? ans: Stimulate contraction of the uterus When the infant suckles at the breast, oxytocin is released by the posterior pituitary to stimulates the "letdown" reflex, which causes the release of colostrum, and contracts the uterus (C) to prevent uterine hemorrhage. (A and B) do not support the client's need in the immediate period after the emergency delivery. Although maternal-newborn bonding (D) is facilitated by early breastfeeding, the priority is uterine contraction stimulation. The nurse identifies a clients needs and formulates th nursing problem of " Imbalancee nutrition: Less than body requirements, related to mental impairment and decreased intkae, as evidence by increasing confusion and weight loss of more than 30 pounds over the last 6 months. " which short-term goal is best for this client? ans: Eat 50% of six small meals each day by the end of the week Short-term goals should be realistic and attainable and should have a timeline of 7 to 10 days before discharge. (A) meets those criteria. (B) is nurse-oriented. (C) may be beyond the capabilities of a confused client. (D) is a long-term goal. the nursie is caring for a client who is unable to void. The plan of care establishes an objective for the client to ingest at least 1000 mL of fluid between 7:00 am and 3:30pm. Which client response should the nurse document that indicates a successful outcome? ans: Drinks 240 mL of fluid five times during the shift. The nurse should evaluate the client's outcome by observing the client's performance of each expected behavior, so drinking 240 mL of fluid five or six times during the shift (D) indicates a fluid intake of 1200 to 1440 mL, which meets the objective of at least 1000 mL during the designated period. (A) uses the term "adequate," which is not quantified. (B) is not the objective, which establishes an intake of at least 1000 mL. (C) is not an evaluation of the specific fluid intake. a client who has active tuberculosis ( TB) is admitted to the medical unit. What action is most important for the nurse to implement? ans: Assign the client to a negative air-flow room Active tuberculosis requires implementation of airborne precautions, so the client should be assigned to a negative pressure air-flow room (D). Although (A and C) should be implemented for clients in isolation with contact precautions, it is most important that air flow from the room is minimized when the client has TB. (B) should be implemented when the client leaves the isolation environment. A client is receiving atonal (tenormin) 25 mg PO after a myocardial infraction. The nurse determines the clinents apical pulse is 65 beats per minute. What action should the nurse implement next? ans: Administer the medication Atenolol, a beta-blocker, blocks the beta receptors of the sinoatrial node to reduce the heart rate, so the medication should be administered (C) because the client's apical pulse is greater than 60. (A, B, and D) are not indicated at this time. A 6 year old child is alert but quiet when brought to the emergency center with periobital ecchymosis and ecchymosis behind the ears. The nurse suspects potential child abuse and continues to assess the child for additional manifestations of a basilar skull fracture. What assessment finding would be consistent with the basilar skull fracture? ans: Rhinorrhoea or otorrhoea with halo sign Raccoon eyes (periorbital ecchymosis) and Battle's sign (ecchymosis behind the ear over the mastoid process) are both signs of a basilar skull fracture, so the nurse should assess for possible meningeal tears that manifest as a Halo sign with CSF leakage from the ears or nose (D). (A) is consistent with orbital fractures. (B) occurs with wrenching traumas of the shoulder or arm fractures. (C) occurs with blunt abdominal injuries. The nurse is assessing a client who complains of weight loss, racing heart rate and difficulty sleeping. The nurse determines the client has moist skin with fine hair, prominent eyes, lid retrace, and a staring expression. These findings are consistent with which disorder? ans: Graves disease This client is exhibiting symptoms associated with hyperthyroidism or Grave's disease (A), which is an autoimmune condition affecting the thyroid. (B, C, and D) are not associated with these symptoms. The nurse is assessing an older adult client and determines that the client's left upper eyelid droops, covering more of the iris than the right eyelid. Which description should the nurse use to document this finding? ans: Ptosis on the left eyelid Ptosis is the term to describe an eyelid droop that covers a large portion of the iris (A), which may result from oculomotor nerve or eyelid muscle disorder. (B) is characterized by rapid, rhythmic movement of both eyes. (C) is a distortion of the lens of the eye, causing decreased visual acuity. (D) is a term used to describe a protrusion of the eyeballs that occurs with hyperthyroidism. The nurse obtains the pluse rate of 89 beats/min for an infant before administering digoxin (Lanoxin) which action should the nurse take? ans: Withhold the medication and contact the healthcare provider Bradycardia is an early sign of digoxin toxicity, so if the infant's pulse rate is less than 100 beats/minute, digoxin should be withheld and the healthcare provider should be notified (D). Assessing the respiratory rate (A) is not indicated before administering Lanoxin. (B and C) place the infant at further risk for digoxin toxicity. The nurse is developing a teaching plan for an adolescent with a milwaukee brace. Which instruction should the nurse include? ans: Wear the brace over a T-shirt 23 hours a day. Idiopathic scoliosis is an abnormal lateral curvature of the spine in adolescent females. Early treatment uses a Milwaukee brace that places pressure against the lateral spinal curvature, under the neck, and against the iliac crest, so it should be worn for 23 hours per day over a T-shirt (D) which reduces friction and chafing of the skin. (A, B, and C) reduce the effectiveness of the brace. A 9 year old is hospitalized for the neutropenia and is placed in reverse isolation. The child asks the nurse " why do you have to wear a gown and mask when you are in my room?" How should the nurse respond? ans: " To protect you because you can get an infection very easily Reverse isolation precaution implement measures to protect the client from exposure to microorganisms from others (B). Although microbes are prevalent in all environments, (A) does not adequately answer the child's question. Reverse isolation should be implemented until the client's white blood cell increases (C). Neutropenia in this child does not place others (D) at risk for infection. A male client who had abdominal surgery has a nasogastric tube to suction, oxygen per nasal cannula, and complains of dry mouth. Which action should the nurse implement? ans: Apply a water soluble lubricant to the lips, oral mucosa and nares. To ease the client's discomfort, a water soluble lubricant to the lips and nares assists to keep the mucous membranes moist (D). (A) is a petroleum-based product and should not be used because it is flammable. (B and C) should not be given to the client with a nasogastric tube to suction because it can cause further distension and interfere with fluid and electrolyte balance. The nurse is assessing the laboratory results for a client who is admitted with renal failure and osteodystrophy. Which findings are consistent with this client's clincail picture ? ans: Serum potassium of 5.5 mEq and total calcium of 6 mg/dl. In renal failure, normal serum electrolyte balance is altered because the kidneys fail to activate vitamin D, calcium absorption is impaired, and serum calcium decreases, which stimulates the release of PTH causing resorption of calcium and phosphate from the bone. A decreased tubular excretion and a decreased glomerular filtration rate results in hypocalcemia, hyperphosphatemia, and hyperkalemia (C). (A) is reflective of a non-renal cause, such as dehydration or liver pathology. (B) is more indicative of infection. Renal failure causes anemia and hyperphosphatemia, not (D). A 56 year old female client is receiving intracavitary radiation via a radium implant. Which nurse should be assigned to care for this client? ans: A nurse with marfran's syndrome who is postmenopausal. A client receiving intracavity radiation poses a radiation hazard as long as the intracavity radiation source is in place. A nurse's ability to care of this client is not affected by Marfan's syndrome (B), which is a hereditary disorder of connective tissues, bones, muscles, ligaments and skeletal structures. The goal is to limit any one staff member's exposure to the calculated time span based on the half-life of radium, such as the number of minutes at the bedside per day, so (A) should not be assigned. (C) should not be exposed to the radiation due to the possible effect on the fetus. A radiation exposure decreases the immune response in the client who should not be exposed to the potential inadvertent transmission of an infectious organism (D). Which info should the nurse provide a client who has undergone cryrosyrgery for stage 1A cerviacl cancer? ans: Use a sanitary napkin instead of a tampon. Clients should avoid the use of tampons for 3 to 6 weeks (D) after the procedure to reduce the risk of infection. A heavy, watery vaginal discharge is expected during this time, so (A) is unnecessary. Sexual intercourse should be avoided for up to 6 weeks, so (B) is inaccurate. (C) is not a side effect of the procedure but may indicate human papillomavirus or a cancerous lesion and should be reported. the nurse is preparing a client for schedules surgical procedure. What client statement should the nurse report to the healthcare provider.? ans: Recalls drinking a glass of juice after midnight. Because there is a risk of aspiration while under general anesthesia The risk of aspiration while under general anesthesia is increased when the stomach is not empty prior to a surgical procedure, so the client's intake of juice (B) after midnight should be reported the healthcare provider. Preoperative fear and anxiety (A) are common and should be further explored by the nurse. (C) should be communicated using allergy identification tags on the client's records and bracelets on the client's wrist. (D) is a common and expected side effect of perioperative medications. The nurse determines that a clients body weight is 105A% above the standardized height-weight scale. Which related factor should the nurse include in the nursing problem, " Imbalanced nutrition: More than body requirements ? " ans: Inadequate lifesyle changes in diet and exercise Obesity is a body weight that is 20% above desirable weight for a person's age, sex, height, body build, and calculated body mass index (BMI). (C) best identifies factors that contribute to the formulation of the nursing diagnosis. (A and B) are medical classifications for a client's weight. Although the client is at an increased risk for several chronic illnesses (D), such as heart disease, diabetes mellitus, hypertension, coronary artery disease and hyperlipidemia, this is not a contributing cause or related factor that supports the nursing diagnosis. The nurse is inspecting the external eye structures for a client. Which finding is a normal racial variation? ans: An African-American Client may have slightly yellow sclerae. Recognizing normal variations that are common in different racial groups helps the nurse differentiate an early sign of pathology, such as yellow sclerae. A slightly yellow color of the sclera for (C) is a normal racial variation found in the African-American population. (A, B, and D) are findings not related to one racial group. During the physical assessment, which finding should the nurse recognize as a normal finding? ans: Regular pulsation at the epigastric area when the client is supine. Recognizing normal findings in the physical exam is a necessity. The regular and recurrent expansion and contraction of an artery produced by waves of pressure caused by the ejection of blood from the left ventricle as it contracts is a normal finding (A). (B, C, and D) are abnormal findings that require further assessment. When documenting assessment data, which statement should the nurse record in the narrative nursing notes? ans: S1 Murmur auscultated in supine position. Documentation of subjective and objective data