HESI EXIT COMPREHENSIVE REVIEW A QUESTIONS & ANSWERS
(Detail Solutions and Resource for the test)
1. The nurse is correct in withholding an older adult client's dose
of nifedipine if which assessment finding is obtained?
A. Blood pressure of 90/56 mm Hg
B. Apical pulse rate of 68 beats/min
C. Potassium level of 3.3 mEq/L
D. Urine output of 200 mL in 4 hours
Rationale:
Nifedipine is a calcium channel blocker that causes a decrease in
blood pressure. It should be withheld if the blood pressure is lowered,
and 90/56 mm Hg is a low blood pressure for an adult male. A pulse
rate <60 beats/min is an indication to withhold the drug. A potassium
level of 3.3 mEq/L is low (normal, 3.5 to 5.0 mEq/L), but this finding
does not affect the administration of Procardia. Urine output of more
than 30 mL/hr, or 120 mL in 4 hours, is normal. Although a 200-mL
output in 4 hours is slightly less than normal and warrants follow-up,
it is not an indication to withhold a nifedipine (Procardia) dose.
2. Until the census on the obstetrics (OB) unit increases, an
unlicensed assistive personnel (UAP) who usually works in
labor and delivery and the newborn nursery is assigned to work
on the postoperative unit. Which client would be best for the
charge nurse to assign to this UAP?
A. An adolescent who was readmitted to the
hospital because of a postoperative
infection
B. A woman with a new colostomy who
requires discharge teaching
C. A woman who had a hip replacement and
may be transferred to the home care unit
, D. A man who had a cholecystectomy and
currently has a nasogastric tube set to
intermittent suction
Rationale:
A hip replacement is considered a clean case, and transferring the
client to another unit is likely to involve physically moving the client
and her belongings. The charge nurse will be responsible for
providing a report to the home care unit if the transfer occurs. The
adolescent client is infected, and an employee who works on an OB
unit should be assigned to clean cases in case the employee is
required to return to the OB unit. This requires the skills of a
registered nurse (RN) to do discharge teaching and provide emotional
support. This may require skills beyond the level of this UAP.
3. A very busy hospital unit has had several discharges and the
census is unusually low. What is the best way for the charge
nurse to use the time of the nursing staff?
A. Encourage staff to participate in online in-
service education.
B. Assign staff to make sure that all
equipment is thoroughly cleaned.
C. Ask which staff members would like to go
home for the remainder of the day.
D. Notify the supervisor that the staff needs
additional assignments.
Rationale:
Online educational programs are available
around the clock, so staff can engage in
continuing education programs when the
opportunity arises, such as during periods
of low census. Option B is not the
responsibility of the nursing staff. Option
C is not the best use of staff and does not
use the extra time provided by the low
census. The charge nurse should use the
(Detail Solutions and Resource for the test)
1. The nurse is correct in withholding an older adult client's dose
of nifedipine if which assessment finding is obtained?
A. Blood pressure of 90/56 mm Hg
B. Apical pulse rate of 68 beats/min
C. Potassium level of 3.3 mEq/L
D. Urine output of 200 mL in 4 hours
Rationale:
Nifedipine is a calcium channel blocker that causes a decrease in
blood pressure. It should be withheld if the blood pressure is lowered,
and 90/56 mm Hg is a low blood pressure for an adult male. A pulse
rate <60 beats/min is an indication to withhold the drug. A potassium
level of 3.3 mEq/L is low (normal, 3.5 to 5.0 mEq/L), but this finding
does not affect the administration of Procardia. Urine output of more
than 30 mL/hr, or 120 mL in 4 hours, is normal. Although a 200-mL
output in 4 hours is slightly less than normal and warrants follow-up,
it is not an indication to withhold a nifedipine (Procardia) dose.
2. Until the census on the obstetrics (OB) unit increases, an
unlicensed assistive personnel (UAP) who usually works in
labor and delivery and the newborn nursery is assigned to work
on the postoperative unit. Which client would be best for the
charge nurse to assign to this UAP?
A. An adolescent who was readmitted to the
hospital because of a postoperative
infection
B. A woman with a new colostomy who
requires discharge teaching
C. A woman who had a hip replacement and
may be transferred to the home care unit
, D. A man who had a cholecystectomy and
currently has a nasogastric tube set to
intermittent suction
Rationale:
A hip replacement is considered a clean case, and transferring the
client to another unit is likely to involve physically moving the client
and her belongings. The charge nurse will be responsible for
providing a report to the home care unit if the transfer occurs. The
adolescent client is infected, and an employee who works on an OB
unit should be assigned to clean cases in case the employee is
required to return to the OB unit. This requires the skills of a
registered nurse (RN) to do discharge teaching and provide emotional
support. This may require skills beyond the level of this UAP.
3. A very busy hospital unit has had several discharges and the
census is unusually low. What is the best way for the charge
nurse to use the time of the nursing staff?
A. Encourage staff to participate in online in-
service education.
B. Assign staff to make sure that all
equipment is thoroughly cleaned.
C. Ask which staff members would like to go
home for the remainder of the day.
D. Notify the supervisor that the staff needs
additional assignments.
Rationale:
Online educational programs are available
around the clock, so staff can engage in
continuing education programs when the
opportunity arises, such as during periods
of low census. Option B is not the
responsibility of the nursing staff. Option
C is not the best use of staff and does not
use the extra time provided by the low
census. The charge nurse should use the
