HESI Comprehensive Exit Exam Answered A+ Solution Guide.
1-Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment
does the nurse perform as a priority before administering the medication?
A. Checking the client's blood pressure
B. Checking the client's peripheral pulses
C. Checking the most recent potassium level
D. Checking the client's intake-and-output record for the last 24 hours Correct
ANS- A. Checking the client's blood pressure
Checking the client's blood pressure
Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor used to treat
hypertension. One common side effect is postural hypotension. Therefore the nurse would
check the client's blood pressure immediately before administering each dose. Checking
the client's peripheral pulses, the results of the most recent potassium level, and the intake
and output for the previous 24 hours are not specifically associated with this mediation.
2-A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse
provides instructions to the client about the test. Which statement by the client indicates a
need for further instruction?
A. "The test will take about 30 minutes."
B. "I need to fast for 8 hours before the test."
C. "I need to drink citrate of magnesia the night before the test and give myself a Fleet
enema on the morning of the test."
D. "I need to take a laxative after the test is completed, because the liquid that I'll have to
drink for the test can be constipating."
Correct ANS- C. "I need to drink citrate of magnesia the night before the test and give
myself a Fleet enema on the morning of the test."
An upper GI series involves visualization of the esophagus, duodenum, and upper jejunum
by means of the use of a contrast medium. It involves swallowing a contrast medium
(usually barium), which is administered in a flavored milkshake. Films are taken at
intervals during the test, which takes about 30 minutes. No special preparation is necessary
before a GI series, except that NPO status must be maintained for 8 hours before the test.
After an upper GI series, the client is prescribed a laxative to hasten elimination of the
barium. Barium that remains in the colon may become hard and difficult to expel, leading to
fecal impaction.
3-A nurse on the evening shift checks a physician's prescriptions and notes that the dose of
a prescribed medication is higher than the normal dose. The nurse calls the physician's
answering service and is told that the physician is off for the night and will be available in
the morning. The nurse should:
,A. Call the nursing supervisor
B. Ask the answering service to contact the on-call physician
C. Withhold the medication until the physician can be reached in the morning
D. Administer the medication but consult the physician when he becomes available
Correct ANS- B. Ask the answering service to contact the on-call physician
4.An emergency department (ED) nurse is monitoring a client with suspected acute
myocardial infarction (MI) who is awaiting transfer to the coronary intensive care unit. The
nurse notes the sudden onset of premature ventricular contractions (PVCs) on the monitor,
checks the client's carotid pulse, and determines that the PVCs are not resulting in
perfusion. The appropriate action by the nurse is:
A. Documenting the findings
B. Asking the ED physician to check the client
C. Continuing to monitor the client's cardiac status
D. Informing the client that PVCs are expected after an MI
Correct ANS- B. Asking the ED physician to check the client
5.NPO status is imposed 8 hours before the procedure on a client scheduled to undergo
electroconvulsive therapy (ECT) at 1 p.m. On the morning of the procedure, the nurse
checks the client's record and notes that the client routinely takes an oral antihypertensive
medication each morning. The nurse should:
A. Administer the antihypertensive with a small sip of water
B. Withhold the antihypertensive and administer it at bedtime
C. Administer the medication by way of the intravenous (IV) route
D. Hold the antihypertensive and resume its administration on the day after the ECT
Correct ANS- A. Administer the antihypertensive with a small sip of water
6 A client who recently underwent coronary artery bypass graft surgery comes to the
physician's office for a follow-up visit. On assessment, the client tells the nurse that he is
feeling depressed. Which response by the nurse is therapeutic?
A. "Tell me more about what you're feeling."
B. "That's a normal response after this type of surgery."
C. "It will take time, but, I promise you, you will get over this depression."
D. "Every client who has this surgery feels the same way for about a month."
Correct ANS- A. "Tell me more about what you're feeling."
7 A client in labor experiences spontaneous rupture of the membranes. The nurse
immediately counts the fetal heart rate (FHR) for 1 full minute and then checks the
amniotic fluid. The nurse notes that the fluid is yellow and has a strong odor. Which of the
following actions should be the nurse's priority?
A. Contacting the physician
B. Documenting the findings
, C. Checking the fluid for protein
D. Continuing to monitor the client and the FHR
Correct ANS- A. Contacting the physician Correct
8 A nurse has assisted a physician in inserting a central venous access device into a client
with a diagnosis of severe malnutrition who will be receiving parenteral nutrition (PN).
After insertion of the catheter, the nurse immediately plans to:
A. Call the radiography department to obtain a chest x-ray
B. Check the client's blood glucose level to serve as a baseline measurement
C. Hang the prescribed bag of PN and start the infusion at the prescribed rate
D. Infuse normal saline solution through the catheter at a rate of 100 mL/hr to maintain
patency
Correct ANS- A. Call the radiography department to obtain a chest x-ray
9 A rape victim being treated in the emergency department says to the nurse, "I'm really
worried that I've got HIV now." What is the appropriate response by the nurse?
A. "HIV is rarely an issue in rape victims."
B. "Every rape victim is concerned about HIV."
C. "You're more likely to get pregnant than to contract HIV."
D. "Let's talk about the information that you need to determine your risk of contracting
HIV."
Correct ANS- D. "Let's talk about the information that you need to determine your risk of
contracting HIV."
10 A client is taking prescribed ibuprofen (Motrin), 300 mg orally four times daily, to
relieve joint pain resulting from rheumatoid arthritis. The client tells the nurse that the
medication is causing nausea and indigestion. The nurse should tell the client to:
A. Contact the physician
B. Stop taking the medication
C. Take the medication with food
D. Take the medication twice a day instead of four times
Correct ANS- C. Take the medication with food
11 A client's oral intake of liquids includes 120 mL on the night shift, 800 mL on the day
shift, and 650 mL on the evening shift. The client is receiving an intravenous (IV) antibiotic
every 12 hours, diluted in 50 mL of normal saline solution. The nurse empties 700 mL of
urine from the client's Foley catheter at the end of the day shift. Thereafter, 500 mL of urine
is emptied at the end of the evening shift and 325 mL at the end of the night shift.
Nasogastric tube drainage totals 155 mL for the 24-hour period, and the total drainage
from the Jackson-Pratt device is 175 mL. What is the client's total intake during the 24-hour
period? Type your answer in the space provided.
Answer: ________mL
1-Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment
does the nurse perform as a priority before administering the medication?
A. Checking the client's blood pressure
B. Checking the client's peripheral pulses
C. Checking the most recent potassium level
D. Checking the client's intake-and-output record for the last 24 hours Correct
ANS- A. Checking the client's blood pressure
Checking the client's blood pressure
Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor used to treat
hypertension. One common side effect is postural hypotension. Therefore the nurse would
check the client's blood pressure immediately before administering each dose. Checking
the client's peripheral pulses, the results of the most recent potassium level, and the intake
and output for the previous 24 hours are not specifically associated with this mediation.
2-A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse
provides instructions to the client about the test. Which statement by the client indicates a
need for further instruction?
A. "The test will take about 30 minutes."
B. "I need to fast for 8 hours before the test."
C. "I need to drink citrate of magnesia the night before the test and give myself a Fleet
enema on the morning of the test."
D. "I need to take a laxative after the test is completed, because the liquid that I'll have to
drink for the test can be constipating."
Correct ANS- C. "I need to drink citrate of magnesia the night before the test and give
myself a Fleet enema on the morning of the test."
An upper GI series involves visualization of the esophagus, duodenum, and upper jejunum
by means of the use of a contrast medium. It involves swallowing a contrast medium
(usually barium), which is administered in a flavored milkshake. Films are taken at
intervals during the test, which takes about 30 minutes. No special preparation is necessary
before a GI series, except that NPO status must be maintained for 8 hours before the test.
After an upper GI series, the client is prescribed a laxative to hasten elimination of the
barium. Barium that remains in the colon may become hard and difficult to expel, leading to
fecal impaction.
3-A nurse on the evening shift checks a physician's prescriptions and notes that the dose of
a prescribed medication is higher than the normal dose. The nurse calls the physician's
answering service and is told that the physician is off for the night and will be available in
the morning. The nurse should:
,A. Call the nursing supervisor
B. Ask the answering service to contact the on-call physician
C. Withhold the medication until the physician can be reached in the morning
D. Administer the medication but consult the physician when he becomes available
Correct ANS- B. Ask the answering service to contact the on-call physician
4.An emergency department (ED) nurse is monitoring a client with suspected acute
myocardial infarction (MI) who is awaiting transfer to the coronary intensive care unit. The
nurse notes the sudden onset of premature ventricular contractions (PVCs) on the monitor,
checks the client's carotid pulse, and determines that the PVCs are not resulting in
perfusion. The appropriate action by the nurse is:
A. Documenting the findings
B. Asking the ED physician to check the client
C. Continuing to monitor the client's cardiac status
D. Informing the client that PVCs are expected after an MI
Correct ANS- B. Asking the ED physician to check the client
5.NPO status is imposed 8 hours before the procedure on a client scheduled to undergo
electroconvulsive therapy (ECT) at 1 p.m. On the morning of the procedure, the nurse
checks the client's record and notes that the client routinely takes an oral antihypertensive
medication each morning. The nurse should:
A. Administer the antihypertensive with a small sip of water
B. Withhold the antihypertensive and administer it at bedtime
C. Administer the medication by way of the intravenous (IV) route
D. Hold the antihypertensive and resume its administration on the day after the ECT
Correct ANS- A. Administer the antihypertensive with a small sip of water
6 A client who recently underwent coronary artery bypass graft surgery comes to the
physician's office for a follow-up visit. On assessment, the client tells the nurse that he is
feeling depressed. Which response by the nurse is therapeutic?
A. "Tell me more about what you're feeling."
B. "That's a normal response after this type of surgery."
C. "It will take time, but, I promise you, you will get over this depression."
D. "Every client who has this surgery feels the same way for about a month."
Correct ANS- A. "Tell me more about what you're feeling."
7 A client in labor experiences spontaneous rupture of the membranes. The nurse
immediately counts the fetal heart rate (FHR) for 1 full minute and then checks the
amniotic fluid. The nurse notes that the fluid is yellow and has a strong odor. Which of the
following actions should be the nurse's priority?
A. Contacting the physician
B. Documenting the findings
, C. Checking the fluid for protein
D. Continuing to monitor the client and the FHR
Correct ANS- A. Contacting the physician Correct
8 A nurse has assisted a physician in inserting a central venous access device into a client
with a diagnosis of severe malnutrition who will be receiving parenteral nutrition (PN).
After insertion of the catheter, the nurse immediately plans to:
A. Call the radiography department to obtain a chest x-ray
B. Check the client's blood glucose level to serve as a baseline measurement
C. Hang the prescribed bag of PN and start the infusion at the prescribed rate
D. Infuse normal saline solution through the catheter at a rate of 100 mL/hr to maintain
patency
Correct ANS- A. Call the radiography department to obtain a chest x-ray
9 A rape victim being treated in the emergency department says to the nurse, "I'm really
worried that I've got HIV now." What is the appropriate response by the nurse?
A. "HIV is rarely an issue in rape victims."
B. "Every rape victim is concerned about HIV."
C. "You're more likely to get pregnant than to contract HIV."
D. "Let's talk about the information that you need to determine your risk of contracting
HIV."
Correct ANS- D. "Let's talk about the information that you need to determine your risk of
contracting HIV."
10 A client is taking prescribed ibuprofen (Motrin), 300 mg orally four times daily, to
relieve joint pain resulting from rheumatoid arthritis. The client tells the nurse that the
medication is causing nausea and indigestion. The nurse should tell the client to:
A. Contact the physician
B. Stop taking the medication
C. Take the medication with food
D. Take the medication twice a day instead of four times
Correct ANS- C. Take the medication with food
11 A client's oral intake of liquids includes 120 mL on the night shift, 800 mL on the day
shift, and 650 mL on the evening shift. The client is receiving an intravenous (IV) antibiotic
every 12 hours, diluted in 50 mL of normal saline solution. The nurse empties 700 mL of
urine from the client's Foley catheter at the end of the day shift. Thereafter, 500 mL of urine
is emptied at the end of the evening shift and 325 mL at the end of the night shift.
Nasogastric tube drainage totals 155 mL for the 24-hour period, and the total drainage
from the Jackson-Pratt device is 175 mL. What is the client's total intake during the 24-hour
period? Type your answer in the space provided.
Answer: ________mL
