HESI Comprehensive Exam B
66. The nurse is caring for a client with a cerebrovascular accident (CVA) who is
receiving enteral tube feedings. Which task performed by the UAP requires
immediate intervention by the nurse?
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
(ANS - B
Rationale:
Positioning the head of the bed flat when enteral feedings are in progress puts the
client at risk for aspiration (B). The others are all acceptable tasks performed by
the UAP (A, C, and D).
62. When caring for a postsurgical client who has undergone multiple blood
transfusions, which serum laboratory finding is of most concern to the nurse?
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
(ANS - 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).
47. Which vaccination should the nurse administer to a newborn?
A.Hepatitis B
B.Human papilloma virus (HPV)
C.Varicella
,D.Meningococcal vaccine
(ANS - 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).
31. 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 finger stick blood glucose level.
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.
(ANS - 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.
20. The nurse is caring for a client with an ischemic stroke who has a prescription
for tissue plasminogen activator (t-PA) IV. Which action(s) 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.
(ANS - B,C,E
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 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).
56. When caring for a client 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
(ANS - 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.
61. The nurse is caring for a client with heart failure who develops respiratory
distress and coughs up pink frothy sputum. Which action should the nurse 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.
(ANS - 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).
45. A client who is prescribed chlorpromazine HCl (Thorazine) for schizophrenia
develops rigidity, a shuffling gait, and tremors. Which action by the nurse is most
important?
, A. Administer a dose of benztropine mesylate (Cogentin) PRN.
B. Determine if the client has increased photosensitivity.
C. Provide comfort measures for sore muscles.
D. Assess the client for visual and auditory hallucinations.
(ANS - 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 nurse 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).
46. A nurse is interviewing a mother during a well-child visit. Which finding
would alert the nurse 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
(ANS - 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).
7. Which intervention should be included in the plan of care for a client admitted to
the hospital with ulcerative colitis?
A.Administer stool softeners.
B.Place the client on fluid restriction.
C.Provide a low-residue diet.
D.Add a milk product to each meal.
(ANS - C
66. The nurse is caring for a client with a cerebrovascular accident (CVA) who is
receiving enteral tube feedings. Which task performed by the UAP requires
immediate intervention by the nurse?
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
(ANS - B
Rationale:
Positioning the head of the bed flat when enteral feedings are in progress puts the
client at risk for aspiration (B). The others are all acceptable tasks performed by
the UAP (A, C, and D).
62. When caring for a postsurgical client who has undergone multiple blood
transfusions, which serum laboratory finding is of most concern to the nurse?
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
(ANS - 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).
47. Which vaccination should the nurse administer to a newborn?
A.Hepatitis B
B.Human papilloma virus (HPV)
C.Varicella
,D.Meningococcal vaccine
(ANS - 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).
31. 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 finger stick blood glucose level.
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.
(ANS - 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.
20. The nurse is caring for a client with an ischemic stroke who has a prescription
for tissue plasminogen activator (t-PA) IV. Which action(s) 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.
(ANS - B,C,E
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 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).
56. When caring for a client 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
(ANS - 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.
61. The nurse is caring for a client with heart failure who develops respiratory
distress and coughs up pink frothy sputum. Which action should the nurse 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.
(ANS - 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).
45. A client who is prescribed chlorpromazine HCl (Thorazine) for schizophrenia
develops rigidity, a shuffling gait, and tremors. Which action by the nurse is most
important?
, A. Administer a dose of benztropine mesylate (Cogentin) PRN.
B. Determine if the client has increased photosensitivity.
C. Provide comfort measures for sore muscles.
D. Assess the client for visual and auditory hallucinations.
(ANS - 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 nurse 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).
46. A nurse is interviewing a mother during a well-child visit. Which finding
would alert the nurse 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
(ANS - 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).
7. Which intervention should be included in the plan of care for a client admitted to
the hospital with ulcerative colitis?
A.Administer stool softeners.
B.Place the client on fluid restriction.
C.Provide a low-residue diet.
D.Add a milk product to each meal.
(ANS - C
