HESI 101 HESI EXIT COMPREHENSIVE REVIEW
B Questions And Answers With Rationales New Update
2022
The nurse is caring for a client with an ischemic stroke who has a
prescription for tissue plasminogen activator (t-PA) IV. Which actions should the
nurse 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 client 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.
Rationale:
Neurologic assessment, including the NIHSS, is indicated for the client 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 contrain-dicated 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).
HESI 101 HESI EXIT COMPREHENSIVE REVIEW
B Questions And Answers With Explanations New
Update 2022
,HESI 101 HESI EXIT COMPREHENSIVE REVIEW
B Questions And Answers With Rationales New Update
2022
Which action by the nurse is consistent with culturally competent care?
A. Treating each client the same regardless of race
or religion
B. Ensuring that all Native American clients
have access to a shaman
C. Understanding one's own world view in addition
to the client's
HESI 101 HESI EXIT COMPREHENSIVE REVIEW
B Questions And Answers With Explanations New
Update 2022
,HESI 101 HESI EXIT COMPREHENSIVE REVIEW
B Questions And Answers With Rationales New Update
2022
D. Including the family in the plan of care for older
clients
Rationale:
The nurse should understand his or her own values and views to prevent those
values from being imparted to others, in addition to understanding the client's
cultural views. Treating every client the same or assuming that all clients share the
same values does not exhibit cultural competence or sensitivity.
The charge nurse reviews the charting of a graduate nurse. Which indicates
a need for further education on documentation?
A. Uses descriptive words such as "gurgling"
to describe breath sounds.
B. Records temperature 30 minutes before and
after giving acetaminophen.
C. Charts some actions in advance of performing
them.
D. Includes the client's response to an intervention.
Rationale:
Charting actions prior to implementing them is an example of fraudulent charting,
and the graduate nurse should receive further education. Options A, B, and D are
appropriate charting examples.
Which data obtained during a respiratory assessment for a 78-year-old client
HESI 101 HESI EXIT COMPREHENSIVE REVIEW
B Questions And Answers With Explanations New
Update 2022
, HESI 101 HESI EXIT COMPREHENSIVE REVIEW
B Questions And Answers With Rationales New Update
2022
is most important to report to the primary health care provider?
A. Auscultation of vesicular breath sounds
B. Pulse oximetry reading of 89%
C. Arterial PaO2 of 86%
D. Resonance on percussion of the lungs
Rationale:
An oxygen saturation lower than 90% indicates hypoxia. Options A, C, and D are
all normal findings.
The nurse hears a series of long-duration, discontinuous, low-pitched sounds
on auscultation of a client's lower lung fields. Which documentation of this finding
is correct?
HESI 101 HESI EXIT COMPREHENSIVE REVIEW
B Questions And Answers With Explanations New
Update 2022
B Questions And Answers With Rationales New Update
2022
The nurse is caring for a client with an ischemic stroke who has a
prescription for tissue plasminogen activator (t-PA) IV. Which actions should the
nurse 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 client 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.
Rationale:
Neurologic assessment, including the NIHSS, is indicated for the client 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 contrain-dicated 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).
HESI 101 HESI EXIT COMPREHENSIVE REVIEW
B Questions And Answers With Explanations New
Update 2022
,HESI 101 HESI EXIT COMPREHENSIVE REVIEW
B Questions And Answers With Rationales New Update
2022
Which action by the nurse is consistent with culturally competent care?
A. Treating each client the same regardless of race
or religion
B. Ensuring that all Native American clients
have access to a shaman
C. Understanding one's own world view in addition
to the client's
HESI 101 HESI EXIT COMPREHENSIVE REVIEW
B Questions And Answers With Explanations New
Update 2022
,HESI 101 HESI EXIT COMPREHENSIVE REVIEW
B Questions And Answers With Rationales New Update
2022
D. Including the family in the plan of care for older
clients
Rationale:
The nurse should understand his or her own values and views to prevent those
values from being imparted to others, in addition to understanding the client's
cultural views. Treating every client the same or assuming that all clients share the
same values does not exhibit cultural competence or sensitivity.
The charge nurse reviews the charting of a graduate nurse. Which indicates
a need for further education on documentation?
A. Uses descriptive words such as "gurgling"
to describe breath sounds.
B. Records temperature 30 minutes before and
after giving acetaminophen.
C. Charts some actions in advance of performing
them.
D. Includes the client's response to an intervention.
Rationale:
Charting actions prior to implementing them is an example of fraudulent charting,
and the graduate nurse should receive further education. Options A, B, and D are
appropriate charting examples.
Which data obtained during a respiratory assessment for a 78-year-old client
HESI 101 HESI EXIT COMPREHENSIVE REVIEW
B Questions And Answers With Explanations New
Update 2022
, HESI 101 HESI EXIT COMPREHENSIVE REVIEW
B Questions And Answers With Rationales New Update
2022
is most important to report to the primary health care provider?
A. Auscultation of vesicular breath sounds
B. Pulse oximetry reading of 89%
C. Arterial PaO2 of 86%
D. Resonance on percussion of the lungs
Rationale:
An oxygen saturation lower than 90% indicates hypoxia. Options A, C, and D are
all normal findings.
The nurse hears a series of long-duration, discontinuous, low-pitched sounds
on auscultation of a client's lower lung fields. Which documentation of this finding
is correct?
HESI 101 HESI EXIT COMPREHENSIVE REVIEW
B Questions And Answers With Explanations New
Update 2022
