HESI EXIT COMPREHENSIVE EXAM 2023-2024 260+
QUESTIONS AND DETAILED ANSWERS WITH RATIONALES
(NIGHTINGALE COLLEGE NURSING) |A+ GRADED|
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
Rationale: 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?
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." ."
Rationale: 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:
B) Ask the answering service to contact the on-call physician
Rationale: The nurse has a duty to protect the client from harm. A nurse who believes that a
physician’s prescription may be in error is responsible for clarifying the prescription before carrying it
out. Therefore the nurse would not administer the medication; instead, the nurse would withhold the
medication until the dose can be clarified. The nurse would not wait until the next morning to obtain
clarification. It is premature to call the nursing supervisor.
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:
, B) Asking the ED physician to check the client
Rationale: PVCs are a result of increased irritability of ventricular cells. Peripheral pulses may be
absent or diminished with the PVCs themselves because the decreased stroke volume of the
premature beats may in turn decrease peripheral perfusion. Because other rhythms also cause
widened QRS complexes, it is essential that the nurse determine whether the premature beats are
resulting in perfusion of the extremities. This is done by palpating the carotid, brachial, or femoral
artery while observing the monitor for widened complexes or by auscultating for apical heart sounds.
In the situation of acute MI, PVCs may be considered warning dysrhythmias, possibly heralding the
onset of ventricular tachycardia or ventricular fibrillation. Therefore the nurse would not tell the client
that the PVCs are expected. Although the nurse will continue to monitor the client and document the
findings, these are not the most appropriate actions of those provided. The most appropriate action
would be to ask the ED physician to check the client.
Test-Taking Strategy: Use the process of elimination. Recalling the significance of PVCs after acute
MI and noting the strategic words "not perfusing" will direct you to the correct option. Review the
significance of PVCs after acute MI if you had difficulty with this question.
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
Rationale: General anesthesia is required for ECT, so NPO status is imposed for 6 to 8 hours before
treatment to help prevent aspiration. Exceptions include clients who routinely receive cardiac
medications, antihypertensive agents, or histamine (H2) blockers, which should be administered
several hours before treatment with a small sip of water. The nurse would not administer a
medication by way of a route that has not been prescribed.
Test-Taking Strategy: Use the process of elimination. Use your knowledge of the principles of
medication administration to help eliminate the option that involves administering the medication by
way of a route other than the prescribed one. Recalling that antihypertensives must be administered
on a regular schedule will assist you in eliminating the options that involve withholding the medication.
Review preprocedure care for the client scheduled for ECT if you had difficulty with this question.
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."
Rationale: When a client expresses feelings of depression, it is extremely important for the nurse to
further explore these feelings with the client
Remember to always focus on the client’s feelings.
,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
Rationale: The FHR is assessed for at least 1 minute when the membranes rupture. The nurse also
checks the quantity, color, and odor of the amniotic fluid. The fluid should be clear (often with bits of
vernix) and have a mild odor. Fluid with a foul or strong odor, cloudy appearance, or yellow
coloration suggests chorioamnionitis and warrants notifying the physician. A large amount of
vernix in the fluid suggests that the fetus is preterm. Greenish, meconium-stained fluid may be seen
in cases of postterm gestation or placental insufficiency. Checking the fluid for protein is not
associated with the data in the question. Although the nurse would continue to monitor the client and
the FHR and would document the findings, contacting the physician is the priority.
Test-Taking Strategy: Focus on the data in the question and note the strategic word "priority." Noting
the words "yellow and has a strong odor" will direct you to the correct option.
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
Rationale: One major complication associated with central venous catheter placement is
pneumothorax, which may result from accidental puncture of the lung. After the catheter has been
placed but before it is used for infusions, its placement must be checked with an x-ray
Test-Taking Strategy: Note the strategic word “immediately.” Use the ABCs — airway, breathing, and
circulation. Recalling that pneumothorax is a complication of the insertion of this type of catheter will
direct you to the correct option
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?
D) "Let's talk about the information that you need to determine your risk of contracting HIV."
Feedback: CORRECT
Rationale: HIV is a concern of rape victims. Such concern should always be addressed, and the
victim should be given the information needed to evaluate his or her risk. Pregnancy may occur as a
result of rape, and pregnancy prophylaxis can be offered in the emergency department or during
follow-up, once the results of a pregnancy test have been obtained..
Test-Taking Strategy: Use your knowledge of therapeutic communication
, 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:
C) Take the medication with food
Rationale: Ibuprofen is a nonsteroidal antiinflammatory medication. Side effects include nausea (with
or without vomiting) and dyspepsia (heartburn, indigestion, or epigastric pain). If gastrointestinal
distress occurs, the client should be instructed to take the medication with milk or 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: _1670 mL
Rationale: The client’s 24-hour total oral intake is 1570 mL, and the IV intake totals 100 mL (50 mL of
normal saline solution every 12 hours). Therefore the 24-hour intake total is 1670 mL.
Test-Taking Strategy: Focus on the subject, the client’s total intake in a 24-hour period. Add the oral
intake and then note that every 12 hours the client is receiving an IV antibiotic that is diluted in 50 mL
of normal saline solution. Therefore the total IV intake is 100 mL in 24 hours. Review calculation of
intake and output if you had difficulty with this question.
12.
Lorazepam (Ativan) 1 mg by way of intravenous (IV) injection (IV push) is prescribed for a
client for the management of anxiety. The nurse prepares the medication as prescribed and
administers the medication over a period of:
A) 3 minutes
Rationale: Lorazepam is a benzodiazepine. When administered by IV injection, each 2 mg or fraction
thereof is administered over a period of 1 to 5 minutes.
13.
A nurse, conducting an assessment of a client being seen in the clinic for symptoms of a
sinus infection, asks the client about medications that he is taking. The client tells the nurse
that he is taking nefazodone hydrochloride (Serzone). On the basis of this information, the
nurse determines that the client most likely has a history of: A) Depression
14.
Phenelzine sulfate (Nardil) is prescribed for a client with depression. The nurse provides
information to the client about the adverse effects of the medication and tells the client to
contact the physician immediately if she experiences:
D) Neck stiffness or soreness
QUESTIONS AND DETAILED ANSWERS WITH RATIONALES
(NIGHTINGALE COLLEGE NURSING) |A+ GRADED|
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
Rationale: 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?
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." ."
Rationale: 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:
B) Ask the answering service to contact the on-call physician
Rationale: The nurse has a duty to protect the client from harm. A nurse who believes that a
physician’s prescription may be in error is responsible for clarifying the prescription before carrying it
out. Therefore the nurse would not administer the medication; instead, the nurse would withhold the
medication until the dose can be clarified. The nurse would not wait until the next morning to obtain
clarification. It is premature to call the nursing supervisor.
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:
, B) Asking the ED physician to check the client
Rationale: PVCs are a result of increased irritability of ventricular cells. Peripheral pulses may be
absent or diminished with the PVCs themselves because the decreased stroke volume of the
premature beats may in turn decrease peripheral perfusion. Because other rhythms also cause
widened QRS complexes, it is essential that the nurse determine whether the premature beats are
resulting in perfusion of the extremities. This is done by palpating the carotid, brachial, or femoral
artery while observing the monitor for widened complexes or by auscultating for apical heart sounds.
In the situation of acute MI, PVCs may be considered warning dysrhythmias, possibly heralding the
onset of ventricular tachycardia or ventricular fibrillation. Therefore the nurse would not tell the client
that the PVCs are expected. Although the nurse will continue to monitor the client and document the
findings, these are not the most appropriate actions of those provided. The most appropriate action
would be to ask the ED physician to check the client.
Test-Taking Strategy: Use the process of elimination. Recalling the significance of PVCs after acute
MI and noting the strategic words "not perfusing" will direct you to the correct option. Review the
significance of PVCs after acute MI if you had difficulty with this question.
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
Rationale: General anesthesia is required for ECT, so NPO status is imposed for 6 to 8 hours before
treatment to help prevent aspiration. Exceptions include clients who routinely receive cardiac
medications, antihypertensive agents, or histamine (H2) blockers, which should be administered
several hours before treatment with a small sip of water. The nurse would not administer a
medication by way of a route that has not been prescribed.
Test-Taking Strategy: Use the process of elimination. Use your knowledge of the principles of
medication administration to help eliminate the option that involves administering the medication by
way of a route other than the prescribed one. Recalling that antihypertensives must be administered
on a regular schedule will assist you in eliminating the options that involve withholding the medication.
Review preprocedure care for the client scheduled for ECT if you had difficulty with this question.
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."
Rationale: When a client expresses feelings of depression, it is extremely important for the nurse to
further explore these feelings with the client
Remember to always focus on the client’s feelings.
,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
Rationale: The FHR is assessed for at least 1 minute when the membranes rupture. The nurse also
checks the quantity, color, and odor of the amniotic fluid. The fluid should be clear (often with bits of
vernix) and have a mild odor. Fluid with a foul or strong odor, cloudy appearance, or yellow
coloration suggests chorioamnionitis and warrants notifying the physician. A large amount of
vernix in the fluid suggests that the fetus is preterm. Greenish, meconium-stained fluid may be seen
in cases of postterm gestation or placental insufficiency. Checking the fluid for protein is not
associated with the data in the question. Although the nurse would continue to monitor the client and
the FHR and would document the findings, contacting the physician is the priority.
Test-Taking Strategy: Focus on the data in the question and note the strategic word "priority." Noting
the words "yellow and has a strong odor" will direct you to the correct option.
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
Rationale: One major complication associated with central venous catheter placement is
pneumothorax, which may result from accidental puncture of the lung. After the catheter has been
placed but before it is used for infusions, its placement must be checked with an x-ray
Test-Taking Strategy: Note the strategic word “immediately.” Use the ABCs — airway, breathing, and
circulation. Recalling that pneumothorax is a complication of the insertion of this type of catheter will
direct you to the correct option
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?
D) "Let's talk about the information that you need to determine your risk of contracting HIV."
Feedback: CORRECT
Rationale: HIV is a concern of rape victims. Such concern should always be addressed, and the
victim should be given the information needed to evaluate his or her risk. Pregnancy may occur as a
result of rape, and pregnancy prophylaxis can be offered in the emergency department or during
follow-up, once the results of a pregnancy test have been obtained..
Test-Taking Strategy: Use your knowledge of therapeutic communication
, 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:
C) Take the medication with food
Rationale: Ibuprofen is a nonsteroidal antiinflammatory medication. Side effects include nausea (with
or without vomiting) and dyspepsia (heartburn, indigestion, or epigastric pain). If gastrointestinal
distress occurs, the client should be instructed to take the medication with milk or 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: _1670 mL
Rationale: The client’s 24-hour total oral intake is 1570 mL, and the IV intake totals 100 mL (50 mL of
normal saline solution every 12 hours). Therefore the 24-hour intake total is 1670 mL.
Test-Taking Strategy: Focus on the subject, the client’s total intake in a 24-hour period. Add the oral
intake and then note that every 12 hours the client is receiving an IV antibiotic that is diluted in 50 mL
of normal saline solution. Therefore the total IV intake is 100 mL in 24 hours. Review calculation of
intake and output if you had difficulty with this question.
12.
Lorazepam (Ativan) 1 mg by way of intravenous (IV) injection (IV push) is prescribed for a
client for the management of anxiety. The nurse prepares the medication as prescribed and
administers the medication over a period of:
A) 3 minutes
Rationale: Lorazepam is a benzodiazepine. When administered by IV injection, each 2 mg or fraction
thereof is administered over a period of 1 to 5 minutes.
13.
A nurse, conducting an assessment of a client being seen in the clinic for symptoms of a
sinus infection, asks the client about medications that he is taking. The client tells the nurse
that he is taking nefazodone hydrochloride (Serzone). On the basis of this information, the
nurse determines that the client most likely has a history of: A) Depression
14.
Phenelzine sulfate (Nardil) is prescribed for a client with depression. The nurse provides
information to the client about the adverse effects of the medication and tells the client to
contact the physician immediately if she experiences:
D) Neck stiffness or soreness
