HESI 101 HESI EXIT COMPREHENSIVE REVIEW
B Questions And Answers With Rationales New Update
2023/2024
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 Rationales New Update
2023/2024
,HESI 101 HESI EXIT COMPREHENSIVE REVIEW
B Questions And Answers With Rationales New Update
2023/2024
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 Rationales New Update
2023/2024
,HESI 101 HESI EXIT COMPREHENSIVE REVIEW
B Questions And Answers With Rationales New Update
2023/2024
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 nurse assesses a pressure ulcer on a client's heel and notes full-
thickness tissue loss, with some visible subcutaneous fat. How should the nurse
stage this pressure ulcer?
HESI 101 HESI EXIT COMPREHENSIVE REVIEW
B Questions And Answers With Rationales New Update
2023/2024
, HESI 101 HESI EXIT COMPREHENSIVE REVIEW
B Questions And Answers With Rationales New Update
2023/2024
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
Rationale:
The statement above describes a stage III ulcer, which is defined as full-thickness
tissue loss in which subcutaneous fat may be exposed but without exposure of
bone, tendon, or muscle. A stage I ulcer includes intact skin with nonblanchable
redness of a localized area. A stage II ulcer is described by partial-thickness loss
of dermis, including a shallow open ulcer with a pinkish red wound bed. Full-
thickness tissue loss with exposed bone, tendon, or muscle and slough or eschar is
indicative of a stage IV ulcer.
The nurse prepares to administer ophthalmic drops to a client prior to cataract
surgery. List the steps in the order that they should be implemented from first
step to final step.
1. Drop prescribed number of drops into conjunctival sac.
2. Wash hands and apply clean gloves.
3. Place dominant hand on the client’s forehead.
4. Ask the client to close the eye gently.
HESI 101 HESI EXIT COMPREHENSIVE REVIEW
B Questions And Answers With Rationales New Update
2023/2024
B Questions And Answers With Rationales New Update
2023/2024
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 Rationales New Update
2023/2024
,HESI 101 HESI EXIT COMPREHENSIVE REVIEW
B Questions And Answers With Rationales New Update
2023/2024
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 Rationales New Update
2023/2024
,HESI 101 HESI EXIT COMPREHENSIVE REVIEW
B Questions And Answers With Rationales New Update
2023/2024
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 nurse assesses a pressure ulcer on a client's heel and notes full-
thickness tissue loss, with some visible subcutaneous fat. How should the nurse
stage this pressure ulcer?
HESI 101 HESI EXIT COMPREHENSIVE REVIEW
B Questions And Answers With Rationales New Update
2023/2024
, HESI 101 HESI EXIT COMPREHENSIVE REVIEW
B Questions And Answers With Rationales New Update
2023/2024
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
Rationale:
The statement above describes a stage III ulcer, which is defined as full-thickness
tissue loss in which subcutaneous fat may be exposed but without exposure of
bone, tendon, or muscle. A stage I ulcer includes intact skin with nonblanchable
redness of a localized area. A stage II ulcer is described by partial-thickness loss
of dermis, including a shallow open ulcer with a pinkish red wound bed. Full-
thickness tissue loss with exposed bone, tendon, or muscle and slough or eschar is
indicative of a stage IV ulcer.
The nurse prepares to administer ophthalmic drops to a client prior to cataract
surgery. List the steps in the order that they should be implemented from first
step to final step.
1. Drop prescribed number of drops into conjunctival sac.
2. Wash hands and apply clean gloves.
3. Place dominant hand on the client’s forehead.
4. Ask the client to close the eye gently.
HESI 101 HESI EXIT COMPREHENSIVE REVIEW
B Questions And Answers With Rationales New Update
2023/2024
