HESI Comprehensive Exam | 100% Verified answers
A 6-year-old child is alert but quiet when brought to the emergency center with
periorbital ecchymosis and ecchymosis behind the ears. The nurse suspects potential
child abuse and continues to assess the child for additional manifestations of a basilar
skull fracture. What assessment finding would be consistent with a basilar skull
fracture?
a. Asymmetry of the face and eye movements.
b. Abnormal position and movement of the arm.
c. Hematemesis and abdominal distention.
d. Rhinorrhoea or otorrhoea with Halo sign -{Correct Answer}- D
A 9-year-old is hospitalized for neutropenia and is placed in reverse isolation. The child
asks the nurse, "Why do you have to wear a gown and mask when you are in my
room?" How should the nurse respond?
a. "There are many forms of bacteria and germs in the hospital."
b. "To protect you because you can get an infection very easily."
c. "After taking medication for 24 hours a gown and mask won't be needed."
d. "Your condition could be spread to staff and other clients in the hospital." -{Correct
Answer}- B
A 16-year-old male client is admitted to the hospital after falling off a bike and sustaining
a fractured bone. The healthcare provider explains the surgery needed to immobilize
the fracture. Which action should be implemented to obtain a valid informed consent?
a. Instruct the client sign the consent before giving medications.
b. Obtain the permission of the custodial parent for the surgery.
c. Obtain the signature of the client's stepfather for the surgery.
d. Notify the non-custodial parent to also sign a consent form. -{Correct Answer}- B
A 56-year-old female client is receiving intracavitary radiation via a radium implant.
Which nurse should be assigned to care for this client?
a. The nurse who is caring for another client receiving intracavitary radiation.
b. A nurse with Marfan's syndrome who is postmenopausal.
c. A nurse with oncology experience who may be pregnant.
d. The nurse who is caring for another client who has Clostridium difficile. -{Correct
Answer}- B
A 63-year-old female client whose husband died one month ago is seen in the
psychiatric clinic. Her daughter tells the nurse that her mother is eating poorly, sleeps
very little at night, and continues to set the table for her deceased husband. What
nursing problem best describes this problem?
a. Confusion related to recent death of loved one.
,b. Delayed grief reaction related to death of husband.
c. Denial related to the loss of a loved one.
d. Unresolved anger related to death of husband. -{Correct Answer}- C
A child is receiving maintainance intravenous (IV) fluids at the rate of 1000 ml for the
first 10 kg of body weight, plus 50 ml/kg per day for each kilogram between 10 and 20.
How many milliliters per hour should the nurse program the infusion pump for a child
who weighs 19.5 kg? (Enter numeric value only. If rounding is required, round to the
nearest whole number.) -{Correct Answer}- 61
A child with bacterial conjunctivitis receives a prescription for erythromycin eye drops.
Which information is most important for the nurse to include in the teaching plan?
a. Apply warm compresses to reduce swelling.
b. Wear sunglasses to protect eyes from sunlight.
c. Take acetaminophen (Tylenol) for any eye discomfort.
d. Avoid sharing towels and washcloths with siblings. -{Correct Answer}- D
A child with Tetrology of Fallot suffers a hypercyanotic episode. Which immediate action
by the nurse can lessen the symptoms of this "TET spell?"
a. Remove child's constrictive clothing.
b. Place child in knee-chest position.
c. Have child stop all current activity.
d. Administer a dose of digoxin stat. -{Correct Answer}- B
A client assigned to a female practical nurse (PN) needs total morning care and sterile
wound packing with a wet-to-dry dressing. The PN tells the nurse that she has never
performed a wound packing. Which intervention should the charge nurse implement?
a. Perform the wound care and have the PN provide the client's morning care.
b. Advise the PN to review the procedure in the procedure manual and then complete
the wound care.
c. Note the PN's learning need to perform a wound packing and contact nursing
education to schedule a time for instruction.
d. Demonstrate the wound care procedure to the PN while the PN assists. -{Correct
Answer}- D
A client is admitted to the hospital for alcohol dependency. What is the priority nursing
intervention during the first 48 hours following admission?
a. Administer thiamine (B1) to prevent Korsakoff's syndrome.
b. Monitor for increased blood pressure and pulse.
c. Administer a PRN benzodiazepine as needed for anxiety.
d. Encourage fluid intake of non-caffeinated beverages. -{Correct Answer}- B
A client is admitted to the hospital with a diagnosis of Type 2 diabetes mellitus and
influenza. Which categories of illness should the nurse develop goals for the client's
plan of care?
, a. Two acute illnesses.
b. Two chronic illnesses.
c. One chronic and one acute illness.
d. One acute and one infectious illness. -{Correct Answer}- C
A client is admitted with a medical diagnosis of Addisonian crisis. When completing the
admission assessment, the nurse expects this client to exhibit which clinical
manifestations?
a. Thin, fragile skin, ecchymoses, and complaints of weakness.
b. Headache, diaphoresis, and palpitations.
c. Hypotension, rapid weak pulse, and rapid respiratory rate.
d. Abrupt onset of hyperpyrexia, extreme tachycardia, and delirium. -{Correct Answer}-
C
A client is being admitted to the medical unit from the emergency department after
having a chest tube inserted. What equipment should be brought to this client's room?
a. Crash cart.
b. Endotracheal tube.
c. Rubber-tipped clamps.
d. Partial rebreather oxygen mask. -{Correct Answer}- C
A client is brought into the emergency department following a sudden cardiac arrest. A
full code is started. Five minutes later the family arrives with a durable power of attorney
signed by the client requesting that no extraordinary measures be taken, including
intubation, to save the client's life. What action should the nurse take?
a. Stop the code immediately.
b. Continue the code according to protocol.
c. Ask the legal department if the code should be continued.
d. Assess the family's support for the durable power of attorney. -{Correct Answer}- A
A client is receiving atenolol (Tenormin) 25 mg PO after a myocardial infarction. The
nurse determines the client's apical pulse is 65 beats per minute. What action should
the nurse implement next?
a. Notify the healthcare provider.
b. Measure the blood pressure.
c. Administer the medication.
d. Reassess the apical pulse. -{Correct Answer}- C
A client who has active tuberculosis (TB) is admitted to the medical unit. What action is
most important for the nurse to implement?
a. Place an isolation cart in the hallway.
b. Fit the client with a respirator mask.
c. Don a clean gown for client care.
d. Assign the client to a negative air-flow room. -{Correct Answer}- D
A 6-year-old child is alert but quiet when brought to the emergency center with
periorbital ecchymosis and ecchymosis behind the ears. The nurse suspects potential
child abuse and continues to assess the child for additional manifestations of a basilar
skull fracture. What assessment finding would be consistent with a basilar skull
fracture?
a. Asymmetry of the face and eye movements.
b. Abnormal position and movement of the arm.
c. Hematemesis and abdominal distention.
d. Rhinorrhoea or otorrhoea with Halo sign -{Correct Answer}- D
A 9-year-old is hospitalized for neutropenia and is placed in reverse isolation. The child
asks the nurse, "Why do you have to wear a gown and mask when you are in my
room?" How should the nurse respond?
a. "There are many forms of bacteria and germs in the hospital."
b. "To protect you because you can get an infection very easily."
c. "After taking medication for 24 hours a gown and mask won't be needed."
d. "Your condition could be spread to staff and other clients in the hospital." -{Correct
Answer}- B
A 16-year-old male client is admitted to the hospital after falling off a bike and sustaining
a fractured bone. The healthcare provider explains the surgery needed to immobilize
the fracture. Which action should be implemented to obtain a valid informed consent?
a. Instruct the client sign the consent before giving medications.
b. Obtain the permission of the custodial parent for the surgery.
c. Obtain the signature of the client's stepfather for the surgery.
d. Notify the non-custodial parent to also sign a consent form. -{Correct Answer}- B
A 56-year-old female client is receiving intracavitary radiation via a radium implant.
Which nurse should be assigned to care for this client?
a. The nurse who is caring for another client receiving intracavitary radiation.
b. A nurse with Marfan's syndrome who is postmenopausal.
c. A nurse with oncology experience who may be pregnant.
d. The nurse who is caring for another client who has Clostridium difficile. -{Correct
Answer}- B
A 63-year-old female client whose husband died one month ago is seen in the
psychiatric clinic. Her daughter tells the nurse that her mother is eating poorly, sleeps
very little at night, and continues to set the table for her deceased husband. What
nursing problem best describes this problem?
a. Confusion related to recent death of loved one.
,b. Delayed grief reaction related to death of husband.
c. Denial related to the loss of a loved one.
d. Unresolved anger related to death of husband. -{Correct Answer}- C
A child is receiving maintainance intravenous (IV) fluids at the rate of 1000 ml for the
first 10 kg of body weight, plus 50 ml/kg per day for each kilogram between 10 and 20.
How many milliliters per hour should the nurse program the infusion pump for a child
who weighs 19.5 kg? (Enter numeric value only. If rounding is required, round to the
nearest whole number.) -{Correct Answer}- 61
A child with bacterial conjunctivitis receives a prescription for erythromycin eye drops.
Which information is most important for the nurse to include in the teaching plan?
a. Apply warm compresses to reduce swelling.
b. Wear sunglasses to protect eyes from sunlight.
c. Take acetaminophen (Tylenol) for any eye discomfort.
d. Avoid sharing towels and washcloths with siblings. -{Correct Answer}- D
A child with Tetrology of Fallot suffers a hypercyanotic episode. Which immediate action
by the nurse can lessen the symptoms of this "TET spell?"
a. Remove child's constrictive clothing.
b. Place child in knee-chest position.
c. Have child stop all current activity.
d. Administer a dose of digoxin stat. -{Correct Answer}- B
A client assigned to a female practical nurse (PN) needs total morning care and sterile
wound packing with a wet-to-dry dressing. The PN tells the nurse that she has never
performed a wound packing. Which intervention should the charge nurse implement?
a. Perform the wound care and have the PN provide the client's morning care.
b. Advise the PN to review the procedure in the procedure manual and then complete
the wound care.
c. Note the PN's learning need to perform a wound packing and contact nursing
education to schedule a time for instruction.
d. Demonstrate the wound care procedure to the PN while the PN assists. -{Correct
Answer}- D
A client is admitted to the hospital for alcohol dependency. What is the priority nursing
intervention during the first 48 hours following admission?
a. Administer thiamine (B1) to prevent Korsakoff's syndrome.
b. Monitor for increased blood pressure and pulse.
c. Administer a PRN benzodiazepine as needed for anxiety.
d. Encourage fluid intake of non-caffeinated beverages. -{Correct Answer}- B
A client is admitted to the hospital with a diagnosis of Type 2 diabetes mellitus and
influenza. Which categories of illness should the nurse develop goals for the client's
plan of care?
, a. Two acute illnesses.
b. Two chronic illnesses.
c. One chronic and one acute illness.
d. One acute and one infectious illness. -{Correct Answer}- C
A client is admitted with a medical diagnosis of Addisonian crisis. When completing the
admission assessment, the nurse expects this client to exhibit which clinical
manifestations?
a. Thin, fragile skin, ecchymoses, and complaints of weakness.
b. Headache, diaphoresis, and palpitations.
c. Hypotension, rapid weak pulse, and rapid respiratory rate.
d. Abrupt onset of hyperpyrexia, extreme tachycardia, and delirium. -{Correct Answer}-
C
A client is being admitted to the medical unit from the emergency department after
having a chest tube inserted. What equipment should be brought to this client's room?
a. Crash cart.
b. Endotracheal tube.
c. Rubber-tipped clamps.
d. Partial rebreather oxygen mask. -{Correct Answer}- C
A client is brought into the emergency department following a sudden cardiac arrest. A
full code is started. Five minutes later the family arrives with a durable power of attorney
signed by the client requesting that no extraordinary measures be taken, including
intubation, to save the client's life. What action should the nurse take?
a. Stop the code immediately.
b. Continue the code according to protocol.
c. Ask the legal department if the code should be continued.
d. Assess the family's support for the durable power of attorney. -{Correct Answer}- A
A client is receiving atenolol (Tenormin) 25 mg PO after a myocardial infarction. The
nurse determines the client's apical pulse is 65 beats per minute. What action should
the nurse implement next?
a. Notify the healthcare provider.
b. Measure the blood pressure.
c. Administer the medication.
d. Reassess the apical pulse. -{Correct Answer}- C
A client who has active tuberculosis (TB) is admitted to the medical unit. What action is
most important for the nurse to implement?
a. Place an isolation cart in the hallway.
b. Fit the client with a respirator mask.
c. Don a clean gown for client care.
d. Assign the client to a negative air-flow room. -{Correct Answer}- D
