HESI Comprehensive Exam B
1. An 8-year-old child is receiving digoxin for congestive heart failure (CHF). In
assessing the child, the nurse finds that her apical heart rate is 80
beats/min, she complains of being slightly nauseated, and her serum
digoxin level is 1.2 ng/mL. What action should the nurse take?Ans: A.
Because the child's heart rate and digoxin level are within normal range,
assess for the cause of the nausea. Rationale: Nausea and vomiting are
early signs of digoxin toxicity. However, the normal resting heart rate for a
child 8 to 10 years of age is 70 to 110 beats/min, and the therapeutic range
of serum digoxin levels is 0.5 to 2 ng/mL. Based on the objective data,
option A is the best of the choices provided because the serum digoxin
level is within normal levels. Option B is not warranted by the data
presented. The digoxin level is within the therapeutic range, and the child is
not showing signs of toxicity. The child's pulse rate is within normal range
for her age group.
2. The nurse expects a clinical finding of cyanosis in an infant with which
conditions? (Select all that apply.) Ans: D. Tetralogy of Fallot & E.
Transposition of the great vessels. Rationale: Both tetralogy of Fallot and
transposition of the great vessels are classified as cyanotic heart disease, in
which unoxygenated blood is pumped into the systemic circulation, causing
cyanosis (D and E). (A, B, and C) are all abnormal cardiac conditions, but are
classified as acyanotic and involve left-to-right shunts, increased pulmonary
blood flow, or obstructive defects.
3. The nurse hears a series of long-duration, discontinuous, low-pitched
sounds on auscultation of a client's lower lung fields. Which documentation
of this finding is correct? Ans: C. Course crackles. Rationale: Course
crackles are caused by air passing through airways that are intermittently
occluded by mucus. Fine crackles are a series of short-duration,
discontinuous, high-pitched sounds. Wheezes are continuous, high-pitched,
musical or squeaking-type sounds. Stridor is a continuous croupy sound of
constant pitch and indicates partial obstruction of the airway.
4. A 45-year-old female client is admitted to the psychiatric unit for
evaluation. Her husband states that she has been reluctant to leave home
for the last 6 months. The client has not gone to work for a month, has
, been terminated from her job, and has not left the house since that time.
This client is displaying symptoms of which disorder?Ans: C. Agoraphobia.
Rationale: Agoraphobia is the fear of crowds or of being in an open place.
Option A is the fear of being in closed places. Option B is the fear of high
places. Option D is an abnormal fear of death or bodies after death. A
phobia is an unrealistic fear associated with severe anxiety.
5. Which clinical manifestation in the client with hyperthyroidism is most
important to report to the health care provider?Ans: C. Apical heart rate of
130 beats/min. Rationale:The apical heart rate of 130 beats/min is a critical
finding that could lead to heart failure or other cardiac disorders. Options
A, B, and D are all expected findings that should also be reported but are
not as critical.
6. When caring for a client hospitalized with Guillain-Barré syndrome, which
information is most important for the nurse to report to the primary health
care provider?Ans: B. Decrease in cognitive status of the client. Rationale:
A decline in cognitive status in a client is indicative of symptoms of hypoxia
and a possible need to assist the client with mechanical ventilation. A
primary health care provider will need to be contacted immediately.
Options A, C, and D are findings associated with Guillain-Barré syndrome
that should also be reported but are not as critical as the client's hypoxic
status.
7. The nurse prepares to administer acetaminophen oral suspension to a child
who weighs 66 lb. The prescription reads: Administer 15 mg/kg every 6
hours by mouth. The Tylenol is available 150 mg/5 mL. What is the correct
dosage as indicated on the figure.Ans: B. 15 mL.
8. A client in the psychiatric setting with an anxiety disorder reports chest
pain. Which action should the nurse take first?Ans: B. Assess the client's
vital signs. Rationale: Although increased heart rate, palpitations, and
chest pain may be caused by anxiety, it is important that the nurse assess
the client and rule out physiologic causes. Nonpharmacologic measures
should be taken first. Options C and D may be considered but are not as
high priority as the initial physiologic assessment.
9. A client who is prescribed chlorpromazine HCl for schizophrenia develops
rigidity, a shuffling gait, and tremors. Which action by the nurse is most
important?Ans: A. Administer a dose of benztropine mesylate PRN.
1. An 8-year-old child is receiving digoxin for congestive heart failure (CHF). In
assessing the child, the nurse finds that her apical heart rate is 80
beats/min, she complains of being slightly nauseated, and her serum
digoxin level is 1.2 ng/mL. What action should the nurse take?Ans: A.
Because the child's heart rate and digoxin level are within normal range,
assess for the cause of the nausea. Rationale: Nausea and vomiting are
early signs of digoxin toxicity. However, the normal resting heart rate for a
child 8 to 10 years of age is 70 to 110 beats/min, and the therapeutic range
of serum digoxin levels is 0.5 to 2 ng/mL. Based on the objective data,
option A is the best of the choices provided because the serum digoxin
level is within normal levels. Option B is not warranted by the data
presented. The digoxin level is within the therapeutic range, and the child is
not showing signs of toxicity. The child's pulse rate is within normal range
for her age group.
2. The nurse expects a clinical finding of cyanosis in an infant with which
conditions? (Select all that apply.) Ans: D. Tetralogy of Fallot & E.
Transposition of the great vessels. Rationale: Both tetralogy of Fallot and
transposition of the great vessels are classified as cyanotic heart disease, in
which unoxygenated blood is pumped into the systemic circulation, causing
cyanosis (D and E). (A, B, and C) are all abnormal cardiac conditions, but are
classified as acyanotic and involve left-to-right shunts, increased pulmonary
blood flow, or obstructive defects.
3. The nurse hears a series of long-duration, discontinuous, low-pitched
sounds on auscultation of a client's lower lung fields. Which documentation
of this finding is correct? Ans: C. Course crackles. Rationale: Course
crackles are caused by air passing through airways that are intermittently
occluded by mucus. Fine crackles are a series of short-duration,
discontinuous, high-pitched sounds. Wheezes are continuous, high-pitched,
musical or squeaking-type sounds. Stridor is a continuous croupy sound of
constant pitch and indicates partial obstruction of the airway.
4. A 45-year-old female client is admitted to the psychiatric unit for
evaluation. Her husband states that she has been reluctant to leave home
for the last 6 months. The client has not gone to work for a month, has
, been terminated from her job, and has not left the house since that time.
This client is displaying symptoms of which disorder?Ans: C. Agoraphobia.
Rationale: Agoraphobia is the fear of crowds or of being in an open place.
Option A is the fear of being in closed places. Option B is the fear of high
places. Option D is an abnormal fear of death or bodies after death. A
phobia is an unrealistic fear associated with severe anxiety.
5. Which clinical manifestation in the client with hyperthyroidism is most
important to report to the health care provider?Ans: C. Apical heart rate of
130 beats/min. Rationale:The apical heart rate of 130 beats/min is a critical
finding that could lead to heart failure or other cardiac disorders. Options
A, B, and D are all expected findings that should also be reported but are
not as critical.
6. When caring for a client hospitalized with Guillain-Barré syndrome, which
information is most important for the nurse to report to the primary health
care provider?Ans: B. Decrease in cognitive status of the client. Rationale:
A decline in cognitive status in a client is indicative of symptoms of hypoxia
and a possible need to assist the client with mechanical ventilation. A
primary health care provider will need to be contacted immediately.
Options A, C, and D are findings associated with Guillain-Barré syndrome
that should also be reported but are not as critical as the client's hypoxic
status.
7. The nurse prepares to administer acetaminophen oral suspension to a child
who weighs 66 lb. The prescription reads: Administer 15 mg/kg every 6
hours by mouth. The Tylenol is available 150 mg/5 mL. What is the correct
dosage as indicated on the figure.Ans: B. 15 mL.
8. A client in the psychiatric setting with an anxiety disorder reports chest
pain. Which action should the nurse take first?Ans: B. Assess the client's
vital signs. Rationale: Although increased heart rate, palpitations, and
chest pain may be caused by anxiety, it is important that the nurse assess
the client and rule out physiologic causes. Nonpharmacologic measures
should be taken first. Options C and D may be considered but are not as
high priority as the initial physiologic assessment.
9. A client who is prescribed chlorpromazine HCl for schizophrenia develops
rigidity, a shuffling gait, and tremors. Which action by the nurse is most
important?Ans: A. Administer a dose of benztropine mesylate PRN.
