HESI COMPREHENSIVE EXIT EXAM 2024 / HESI
COMPREHENSIVE EXIT EXAM ACTUAL EXAM 180
QUESTIONS AND CORRECT DETAILED ANSWERS
(VERIFIED ANSWERS) WITH RATIONALES |ALREADY
GRADED A+||BRAND NEW!!
A client is receiving parenteral nutrition (PN). The nurse monitors the client for complications of the
therapy and should assess the client for which manifestations of hyperglycemia?
1.Fever, weak pulse, and thirst
2.Nausea, vomiting, and oliguria
3.Sweating, chills, and abdominal pain
4.Weakness, thirst, and increased urine output - answer-4.
Weakness, thirst, and increased urine output
A client has been discharged to home on parenteral nutrition (PN). With each visit, the home care nurse
should assess which parameter most closely in monitoring this therapy?
1.Pulse and weight
2.Temperature and weight
3.Pulse and blood pressure
4.Temperature and blood pressure - answer-2.
Temperature and weight
The nurse is caring for a group of adult clients on an acute care medical-surgical nursing unit. The nurse
understands that which client would be the least likely candidate for parenteral nutrition (PN)?
1.A 66-year-old client with extensive burns
2.A 42-year-old client who has had an open cholecystectomy
3.A 27-year-old client with severe exacerbation of Crohn's disease
4.A 35-year-old client with persistent nausea and vomiting from chemotherapy - answer-2.
A 42-year-old client who has had an open cholecystectomy
Rationale:
,Parenteral nutrition is indicated in clients whose gastrointestinal tracts are not functional or must be
rested, cannot take in a diet enterally for extended periods, or have increased metabolic need. Examples
of these conditions include those clients with burns, exacerbation of Crohn's disease, and persistent
nausea and vomiting due to chemotherapy. Other clients would be those who have had extensive
surgery, have multiple fractures, are septic, or have advanced cancer or acquired immunodeficiency
syndrome. The client with the open cholecystectomy is not a candidate because this client would
resume a regular diet within a few days following surgery.
The nurse is making initial rounds at the beginning of the shift and notes that the parenteral nutrition
(PN) bag of an assigned client is empty. Which solution readily available on the nursing unit should the
nurse hang until another PN solution is mixed and delivered to the nursing unit?
1.5% dextrose in water
2.10% dextrose in water
3.5% dextrose in Ringer's lactate
4.5% dextrose in 0.9% sodium chloride - answer-2.
10% dextrose in water
Rationale:
The client is at risk for hypoglycemia; therefore the solution containing the highest amount of glucose
should be hung until the new PN solution becomes available. Because PN solutions contain high glucose
concentrations, the 10% dextrose in water solution is the best of the choices presented. The solution
selected should be one that minimizes the risk of hypoglycemia. The remaining options will not be as
effective in minimizing the risk of hypoglycemia.
The nurse is monitoring the status of a client's fat emulsion (lipid) infusion and notes that the infusion is
1 hour behind. Which action should the nurse take?
1.Adjust the infusion rate to catch up over the next hour.
2.Increase the infusion rate to catch up over the next 2 hours.
3.Ensure that the fat emulsion infusion rate is infusing at the prescribed rate.
4.Adjust the infusion rate to run wide open until the solution is back on time. - answer-3.
Ensure that the fat emulsion infusion rate is infusing at the prescribed rate.
Rationale:
The nurse should not increase the rate of a fat emulsion to make up the difference if the infusion timing
falls behind. Doing so could place the client at risk for fat overload. In addition, increasing the rate
,suddenly can cause fluid overload. The same principle (not increasing the rate) applies to PN or any
intravenous (IV) infusion. Therefore the remaining options are incorrect.
A client receiving parenteral nutrition (PN) in the home setting has a weight gain of 5 lb in 1 week. The
nurse should next assess the client for the presence of which condition?
1.Thirst
2.Polyuria
3.Decreased blood pressure
4.Crackles on auscultation of the lungs - answer-4.
Crackles on auscultation of the lungs
Rationale:
Optimal weight gain when the client is receiving PN is 1 to 2 lb/week. The client who has a weight gain
of 5 lb/week while receiving PN is likely to have fluid retention. This can result in hypervolemia. Signs of
hypervolemia include increased blood pressure, crackles on lung auscultation, a bounding pulse, jugular
vein distention, headache, and weight gain more than desired. Thirst and polyuria are associated with
hyperglycemia. A decreased blood pressure is likely to be noted in deficient fluid volume.
The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. The
nurse notes that a client's intravenous (IV) site is cool, pale, and swollen, and the solution is not infusing.
The nurse concludes that which complication has occurred?
1.Infection
2.Phlebitis
3.Infiltration
4.Thrombosis - answer-3.
Infiltration
Rationale:
An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue. Pallor,
coolness, and swelling are the results of IV fluid being deposited in the subcutaneous tissue. When the
pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop. The
corrective action is to remove the catheter and start a new IV line at another site. Infection, phlebitis,
and thrombosis are likely to be accompanied by warmth at the site, not coolness.
, The nurse is inserting an intravenous line into a client's vein. After the initial stick, the nurse would
continue to advance the catheter in which situation?
1.The catheter advances easily.
2.The vein is distended under the needle.
3.The client does not complain of discomfort.
4.Blood return shows in the backflash chamber of the catheter. - answer-4.
Blood return shows in the backflash chamber of the catheter.
Rationale:
The IV catheter has entered the lumen of the vein successfully when blood backflash shows in the IV
catheter. The vein should have been distended by the tourniquet before the vein was cannulated. Client
discomfort varies with the client, the site, and the nurse's insertion technique and is not a reliable
measure of catheter placement. The nurse should not advance the catheter until placement in the vein
is verified by blood return.
The nurse notes that the site of a client's peripheral intravenous (IV) catheter is reddened, warm,
painful, and slightly edematous proximal to the insertion point of the IV catheter. After taking
appropriate steps to care for the client, the nurse should document in the medical record that the client
experienced which condition?
1.Phlebitis of the vein
2.Infiltration of the IV line
3.Hypersensitivity to the IV solution
4.Allergic reaction to the IV catheter material - answer-1.
Phlebitis of the vein
Rationale:
Phlebitis at an IV site can be distinguished by client discomfort at the site and by redness, warmth, and
swelling proximal to the catheter. If phlebitis occurs, the nurse should discontinue the IV line and insert
a new IV line at a different site. Coolness at the site would be noted if the IV catheter was infiltrated. An
allergic reaction produces a rash, redness, and itching. A major reaction, such as hypersensitivity, can
cause dyspnea, a swollen tongue, and cyanosis
A client rings the call bell and complains of pain at the site of an intravenous (IV) infusion. The nurse
assesses the site and determines that phlebitis has developed. The nurse should take which actions in
the care of this client? Select all that apply.
1.Notify the health care provider (HCP).
COMPREHENSIVE EXIT EXAM ACTUAL EXAM 180
QUESTIONS AND CORRECT DETAILED ANSWERS
(VERIFIED ANSWERS) WITH RATIONALES |ALREADY
GRADED A+||BRAND NEW!!
A client is receiving parenteral nutrition (PN). The nurse monitors the client for complications of the
therapy and should assess the client for which manifestations of hyperglycemia?
1.Fever, weak pulse, and thirst
2.Nausea, vomiting, and oliguria
3.Sweating, chills, and abdominal pain
4.Weakness, thirst, and increased urine output - answer-4.
Weakness, thirst, and increased urine output
A client has been discharged to home on parenteral nutrition (PN). With each visit, the home care nurse
should assess which parameter most closely in monitoring this therapy?
1.Pulse and weight
2.Temperature and weight
3.Pulse and blood pressure
4.Temperature and blood pressure - answer-2.
Temperature and weight
The nurse is caring for a group of adult clients on an acute care medical-surgical nursing unit. The nurse
understands that which client would be the least likely candidate for parenteral nutrition (PN)?
1.A 66-year-old client with extensive burns
2.A 42-year-old client who has had an open cholecystectomy
3.A 27-year-old client with severe exacerbation of Crohn's disease
4.A 35-year-old client with persistent nausea and vomiting from chemotherapy - answer-2.
A 42-year-old client who has had an open cholecystectomy
Rationale:
,Parenteral nutrition is indicated in clients whose gastrointestinal tracts are not functional or must be
rested, cannot take in a diet enterally for extended periods, or have increased metabolic need. Examples
of these conditions include those clients with burns, exacerbation of Crohn's disease, and persistent
nausea and vomiting due to chemotherapy. Other clients would be those who have had extensive
surgery, have multiple fractures, are septic, or have advanced cancer or acquired immunodeficiency
syndrome. The client with the open cholecystectomy is not a candidate because this client would
resume a regular diet within a few days following surgery.
The nurse is making initial rounds at the beginning of the shift and notes that the parenteral nutrition
(PN) bag of an assigned client is empty. Which solution readily available on the nursing unit should the
nurse hang until another PN solution is mixed and delivered to the nursing unit?
1.5% dextrose in water
2.10% dextrose in water
3.5% dextrose in Ringer's lactate
4.5% dextrose in 0.9% sodium chloride - answer-2.
10% dextrose in water
Rationale:
The client is at risk for hypoglycemia; therefore the solution containing the highest amount of glucose
should be hung until the new PN solution becomes available. Because PN solutions contain high glucose
concentrations, the 10% dextrose in water solution is the best of the choices presented. The solution
selected should be one that minimizes the risk of hypoglycemia. The remaining options will not be as
effective in minimizing the risk of hypoglycemia.
The nurse is monitoring the status of a client's fat emulsion (lipid) infusion and notes that the infusion is
1 hour behind. Which action should the nurse take?
1.Adjust the infusion rate to catch up over the next hour.
2.Increase the infusion rate to catch up over the next 2 hours.
3.Ensure that the fat emulsion infusion rate is infusing at the prescribed rate.
4.Adjust the infusion rate to run wide open until the solution is back on time. - answer-3.
Ensure that the fat emulsion infusion rate is infusing at the prescribed rate.
Rationale:
The nurse should not increase the rate of a fat emulsion to make up the difference if the infusion timing
falls behind. Doing so could place the client at risk for fat overload. In addition, increasing the rate
,suddenly can cause fluid overload. The same principle (not increasing the rate) applies to PN or any
intravenous (IV) infusion. Therefore the remaining options are incorrect.
A client receiving parenteral nutrition (PN) in the home setting has a weight gain of 5 lb in 1 week. The
nurse should next assess the client for the presence of which condition?
1.Thirst
2.Polyuria
3.Decreased blood pressure
4.Crackles on auscultation of the lungs - answer-4.
Crackles on auscultation of the lungs
Rationale:
Optimal weight gain when the client is receiving PN is 1 to 2 lb/week. The client who has a weight gain
of 5 lb/week while receiving PN is likely to have fluid retention. This can result in hypervolemia. Signs of
hypervolemia include increased blood pressure, crackles on lung auscultation, a bounding pulse, jugular
vein distention, headache, and weight gain more than desired. Thirst and polyuria are associated with
hyperglycemia. A decreased blood pressure is likely to be noted in deficient fluid volume.
The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. The
nurse notes that a client's intravenous (IV) site is cool, pale, and swollen, and the solution is not infusing.
The nurse concludes that which complication has occurred?
1.Infection
2.Phlebitis
3.Infiltration
4.Thrombosis - answer-3.
Infiltration
Rationale:
An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue. Pallor,
coolness, and swelling are the results of IV fluid being deposited in the subcutaneous tissue. When the
pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop. The
corrective action is to remove the catheter and start a new IV line at another site. Infection, phlebitis,
and thrombosis are likely to be accompanied by warmth at the site, not coolness.
, The nurse is inserting an intravenous line into a client's vein. After the initial stick, the nurse would
continue to advance the catheter in which situation?
1.The catheter advances easily.
2.The vein is distended under the needle.
3.The client does not complain of discomfort.
4.Blood return shows in the backflash chamber of the catheter. - answer-4.
Blood return shows in the backflash chamber of the catheter.
Rationale:
The IV catheter has entered the lumen of the vein successfully when blood backflash shows in the IV
catheter. The vein should have been distended by the tourniquet before the vein was cannulated. Client
discomfort varies with the client, the site, and the nurse's insertion technique and is not a reliable
measure of catheter placement. The nurse should not advance the catheter until placement in the vein
is verified by blood return.
The nurse notes that the site of a client's peripheral intravenous (IV) catheter is reddened, warm,
painful, and slightly edematous proximal to the insertion point of the IV catheter. After taking
appropriate steps to care for the client, the nurse should document in the medical record that the client
experienced which condition?
1.Phlebitis of the vein
2.Infiltration of the IV line
3.Hypersensitivity to the IV solution
4.Allergic reaction to the IV catheter material - answer-1.
Phlebitis of the vein
Rationale:
Phlebitis at an IV site can be distinguished by client discomfort at the site and by redness, warmth, and
swelling proximal to the catheter. If phlebitis occurs, the nurse should discontinue the IV line and insert
a new IV line at a different site. Coolness at the site would be noted if the IV catheter was infiltrated. An
allergic reaction produces a rash, redness, and itching. A major reaction, such as hypersensitivity, can
cause dyspnea, a swollen tongue, and cyanosis
A client rings the call bell and complains of pain at the site of an intravenous (IV) infusion. The nurse
assesses the site and determines that phlebitis has developed. The nurse should take which actions in
the care of this client? Select all that apply.
1.Notify the health care provider (HCP).
