HESI PN COMPREHENSIVE EXAM 3
QUESTION AND ANSWERS 2024/2025
UPDATED
A 38-year-old female client is admitted to the mental health unit after a recent
manic episode of spending large amounts of money on new furniture, making
excessive long-distance phone calls, and not sleeping for three days. During the
admission process, the client is wearing a green bathing suit. What intervention
should the nurse implement?
Assess the client's needs for food, liquids, and rest.
During a group therapy session, a client with hypomania threatens to strike
another client. What intervention is best for the nurse to implement?
Firmly inform the client that acting out anger is not acceptable.
A client who is a laboratory technician and has a history of allergic rhinitis,
asthma, and multiple food allergies is scheduled for surgery. Which action should
the nurse implement?
Document a possible Type I latex allergy.
In reviewing the medical record, the nurse notes that a client's last eye
examination revealed an IOP of 28 mmHg. What information should the nurse ask
the client?
Use of prescribed eye drops since last exam by ophthalmologist.
Which action should the nurse implement to assess for JVD in a client with HF?
Observe the vertical distention of the veins as the client is gradually elevated to an
upright position.
The nurse identifies a client's laboratory results and identifies an elevated serum
ammonia level. Which pathophysiological process contributes to this finding?
Failure of the liver to convert ammonia absorbed from the bowel to urea.
A client with GERD is unconscious and unresponsive to stimuli. The nurse places
the client in a side-lying position. The nurse should monitor for the risk of which
complication?
Aspiration pneumonia.
A client returns to the unit after abdominal Nissen fundoplication for treatment of
GERD. After 4 hours, the nurse determines the client has no drainage from the
NGT and has absent bowel sounds. What action should the nurse implement?
Irrigate the NGT with normal saline.
A male client who is admitted with a bleeding peptic ulcer develops sudden,
severe upper abdominal pain. The client becomes diaphoretic and draws his
knees over his abdomen. Which finding should the nurse report to the healthcare
provider?
A rigid, boardlike abdomen.
A client returns to the postoperative unit after a gastroduodenostomy (Billroth I)
for treatment of a perforated ulcer. The healthcare provider's prescriptions
, include morphine with a patient-controlled analgesia (PCA), nasogastric tube
(NGT) to low intermittent nasogastric suction, and IV fluids and antibiotics. The
client complains of increasing abdominal pain 12 hours after returning to the
surgical unit. The nurse determines the client has no bowel sounds, and 200 ml of
bright red nasogastric drainage is in the suction canister in the past hour. What is
the priority action the nurse should implement?
Notify the healthcare provider.
A patient returns from surgery following an abdominal-perineal resection with a
sigmoid colostomy and abdominal and perineal incisions. The colostomy is
dressed with petroleum jelly gauze and dry gauze dressings. The perineal
incision is partially closed and has two drains attached to Jackson-Pratt suction.
On the first postoperative day, the nurse gives the highest priority to
a. teaching about a low-residue diet.
b. monitoring drainage from the stoma.
c. assessing the perineal drainage and incision.
d. encouraging acceptance of the colostomy site.
Maintain dry perineal dressings
C Assessing the perineal drainage and incision
What information in a client's history indicates the highest risk factor for hepatitis
C?
Intravenous drug abuse
A client with advanced cirrhosis and hepatic encephalopathy is manifesting....
Apply a pressure-relieving mattress under the client.
A female client arrives at the clinic because her boyfriend....
Gonorrhea is often asymptomatic in women because the infection is not visible.
A patient with comminuted fractures of the tibia and fibula is treated with open
reduction and application of an external fixator. The next day, the patient
complains of severe pain in the leg, which is unrelieved by ordered analgesics.
The patient's toes are pink, but the patient complains of numbness and tingling.
The most appropriate action by the nurse is to
a. notify the patient's health care provider.
b. check the patient's blood pressure.
c. assess the external fixator pins for redness or drainage.
d. elevate the extremity and apply ice over the wound site.
Notify the HCP
On the secound day after admission, a client with a fractures pelvis develops
chest pain, tachypnea, and tachycardia. Which additional finding should the
nurse identify that is most likely related to a fat embolism?
Petechiae of the anterior chest wall
A client is comatose upon arrival to the emergency room department after falling
from the roof. The client flexes with painful stimuli, and the nurse determines the
client"s Glasgow Coma Scale is 6. Which intervention should the nurse prepare
to implement to maintain the client"s airway?
A nasopharyngeal tube
QUESTION AND ANSWERS 2024/2025
UPDATED
A 38-year-old female client is admitted to the mental health unit after a recent
manic episode of spending large amounts of money on new furniture, making
excessive long-distance phone calls, and not sleeping for three days. During the
admission process, the client is wearing a green bathing suit. What intervention
should the nurse implement?
Assess the client's needs for food, liquids, and rest.
During a group therapy session, a client with hypomania threatens to strike
another client. What intervention is best for the nurse to implement?
Firmly inform the client that acting out anger is not acceptable.
A client who is a laboratory technician and has a history of allergic rhinitis,
asthma, and multiple food allergies is scheduled for surgery. Which action should
the nurse implement?
Document a possible Type I latex allergy.
In reviewing the medical record, the nurse notes that a client's last eye
examination revealed an IOP of 28 mmHg. What information should the nurse ask
the client?
Use of prescribed eye drops since last exam by ophthalmologist.
Which action should the nurse implement to assess for JVD in a client with HF?
Observe the vertical distention of the veins as the client is gradually elevated to an
upright position.
The nurse identifies a client's laboratory results and identifies an elevated serum
ammonia level. Which pathophysiological process contributes to this finding?
Failure of the liver to convert ammonia absorbed from the bowel to urea.
A client with GERD is unconscious and unresponsive to stimuli. The nurse places
the client in a side-lying position. The nurse should monitor for the risk of which
complication?
Aspiration pneumonia.
A client returns to the unit after abdominal Nissen fundoplication for treatment of
GERD. After 4 hours, the nurse determines the client has no drainage from the
NGT and has absent bowel sounds. What action should the nurse implement?
Irrigate the NGT with normal saline.
A male client who is admitted with a bleeding peptic ulcer develops sudden,
severe upper abdominal pain. The client becomes diaphoretic and draws his
knees over his abdomen. Which finding should the nurse report to the healthcare
provider?
A rigid, boardlike abdomen.
A client returns to the postoperative unit after a gastroduodenostomy (Billroth I)
for treatment of a perforated ulcer. The healthcare provider's prescriptions
, include morphine with a patient-controlled analgesia (PCA), nasogastric tube
(NGT) to low intermittent nasogastric suction, and IV fluids and antibiotics. The
client complains of increasing abdominal pain 12 hours after returning to the
surgical unit. The nurse determines the client has no bowel sounds, and 200 ml of
bright red nasogastric drainage is in the suction canister in the past hour. What is
the priority action the nurse should implement?
Notify the healthcare provider.
A patient returns from surgery following an abdominal-perineal resection with a
sigmoid colostomy and abdominal and perineal incisions. The colostomy is
dressed with petroleum jelly gauze and dry gauze dressings. The perineal
incision is partially closed and has two drains attached to Jackson-Pratt suction.
On the first postoperative day, the nurse gives the highest priority to
a. teaching about a low-residue diet.
b. monitoring drainage from the stoma.
c. assessing the perineal drainage and incision.
d. encouraging acceptance of the colostomy site.
Maintain dry perineal dressings
C Assessing the perineal drainage and incision
What information in a client's history indicates the highest risk factor for hepatitis
C?
Intravenous drug abuse
A client with advanced cirrhosis and hepatic encephalopathy is manifesting....
Apply a pressure-relieving mattress under the client.
A female client arrives at the clinic because her boyfriend....
Gonorrhea is often asymptomatic in women because the infection is not visible.
A patient with comminuted fractures of the tibia and fibula is treated with open
reduction and application of an external fixator. The next day, the patient
complains of severe pain in the leg, which is unrelieved by ordered analgesics.
The patient's toes are pink, but the patient complains of numbness and tingling.
The most appropriate action by the nurse is to
a. notify the patient's health care provider.
b. check the patient's blood pressure.
c. assess the external fixator pins for redness or drainage.
d. elevate the extremity and apply ice over the wound site.
Notify the HCP
On the secound day after admission, a client with a fractures pelvis develops
chest pain, tachypnea, and tachycardia. Which additional finding should the
nurse identify that is most likely related to a fat embolism?
Petechiae of the anterior chest wall
A client is comatose upon arrival to the emergency room department after falling
from the roof. The client flexes with painful stimuli, and the nurse determines the
client"s Glasgow Coma Scale is 6. Which intervention should the nurse prepare
to implement to maintain the client"s airway?
A nasopharyngeal tube
