HESI comprehensive
HESI comprehensive Exam Study
Questions and Answers 100% Verified
2025 Updated
A nurse taking the vital signs of a client immediately after she has delivered a
newborn notes that the client's heart rate is 110 beats/min. What should the nurse
do first?
Recheck the heart rate in 1 hour
Offer the client oral fluids
Check the uterus and amount of lochia discharge Correct
Document the findings -Correct Answers ✔-If tachycardia is noted, the nurse
should first assess the location and firmness of the uterus and amount of lochia.
Additional assessments including blood pressure, estimated blood loss at delivery,
and hemoglobin and hematocrit determinations should be carried out. After
delivery, the normal heart rate ranges from 60 to 90 beats/min. Tachycardia may
indicate excitement, fatigue, dehydration, hypovolemia, pain, or infection.
Although the nurse would document the findings, it is most appropriate for the
nurse to assess the client to determine the cause of the tachycardia. Oral fluids are
important if the client is dehydrated, but further assessment of the problem is
required and dehydration would first need to be confirmed. Rechecking the heart
rate in 1 hour will delay necessary interventions.
A nurse reviews the laboratory results of a hospitalized pregnant client with a
diagnosis of sepsis who is at risk for disseminated intravascular coagulopathy
(DIC). Which laboratory finding would indicate to the nurse that DIC has
developed in the client?
Shortened prothrombin time
Increased platelet count
Positive result on d-dimer study Correct
Decreased fibrin-degradation products -Correct Answers ✔-The d-dimer study is
used to confirm the presence of fibrin split products; a positive result is indicative
of DIC. DIC is a life-threatening defect in coagulation. As plasma factors are
consumed, the circulating blood becomes deficient in clotting factors and unable to
clot. Even as anticoagulation is occurring, inappropriate coagulation is also taking
place in the microcirculation, and tiny clots form in the smallest blood vessels,
blocking blood flow to the organs and causing ischemia. Laboratory studies help
establish a diagnosis. The fibrinogen value and platelet count are usually
HESI comprehensive
,HESI comprehensive
decreased, prothrombin and activated partial thromboplastin times may be
prolonged, and levels of fibrin degradation products (the most sensitive
measurement) are increased.
The nurse is assessing a client who has a history of Prinzmetal's angina. The nurse
knows that what type of medication is given to treat this condition?
Calcium channel blockers Correct
ACE inhibitors
Inotropes
Beta blockers -Correct Answers ✔-Prinzmetal's, or variant, angina is prolonged
and severe and occurs at the same time each day, most often at rest. The treatment
of choice is usually a calcium channel blocker. Calcium channel blockers relax and
dilate the vascular smooth muscle, thus relieving the coronary artery spasm in
variant angina. Inotropes, beta blockers, and angiotensin-converting enzyme
(ACE) inhibitors are not given to treat this disorder.
Ciprofloxacin hydrochloride is prescribed to a client with a urinary tract infection.
The nurse provides instruction about the medication. What does the nurse tell the
client about how best to take the medication?
With aluminum hydroxide
With an antacid
With milk
2 hours after meals Correct -Correct Answers ✔-Ciprofloxacin hydrochloride is an
anti-infective in the fluoroquinolone family. It may be taken without regard to
meals, but the best dosing time is 2 hours after a meal. Milk may affect absorption.
Antacids (here, aluminum hydroxide) may reduce absorption and should be
administered 2 hours apart from the ciprofloxacin hydrochloride.
Ergotamine is prescribed to a client with cluster headaches. Which occurrence does
the nurse tell the client to report to the primary health care provider if she
experiences them while taking the medication?
Fatigue and lethargy
Dizziness and fatigue
Numbness and tingling of the fingers or toes Correct
Cough -Correct Answers ✔-Ergotamine is an antimigraine medication. Prolonged
administration or an excessive dosage may produce ergotamine poisoning
(ergotism). Signs/symptoms include nausea, vomiting, weakness in the legs, pain
in the limb muscles, and numbness and tingling of the fingers and toes. The client
is instructed to report these signs/symptoms to the primary health care provider if
HESI comprehensive
,HESI comprehensive
they occur. Cough, fatigue, lethargy, and dizziness are side effects and not adverse
effects of the medication.
A nurse working the evening shift is helping clients get ready for sleep. A female
client diagnosed with mania is hyperactive and pacing the hallway. What is the
most appropriate action the nurse can take?
Tell the client that other clients are trying to sleep and that she is being disruptive
Take the client to the bathroom and provide her with a warm bath Correct
Stay with the client and observe her behavior
Tell the client that it is time for sleep and that she needs to go to her room -Correct
Answers ✔-At bedtime, the nurse should take the client to the bathroom and
provide warm baths, soothing music, and medication when indicated. For the client
with mania, the nurse needs to promote relaxation, rest, and sleep and to minimize
manic behavior. The nurse should encourage frequent rest periods during the day
and keep the client in areas of low stimulation. The client should not consume
products containing caffeine. Staying with the client and observing her behavior,
telling the client that it is time to go to sleep and to go to her room, and telling the
client that other clients are trying to sleep and that she is being disruptive do not
address the client's needs and are not measures that will help the client relax and
sleep.
A client diagnosed with type 1 diabetes mellitus has just been told that she is 6
weeks pregnant. The nurse provides information to the client about dietary and
insulin needs. What comment by the client suggests an understanding of the
information?
"I know I will have to increase my insulin during this time period."
"My insulin needs should decrease during the first trimester." Correct
"Needs for insulin will not change during the first 3 months of pregnancy."
"I will have to double up on the insulin dose during this time span." -Correct
Answers ✔-Insulin needs generally decrease during the first trimester of pregnancy
because the secretion of placental hormones antagonistic to insulin remains low.
An increase in insulin need, lack of change in insulin need, and doubling of insulin
need are all incorrect.
A nurse develops a list of home care instructions for a client who is wearing a halo
fixation device after sustaining a cervical fracture. Which instructions should the
nurse include? Select all that apply.
Do not drive, because full range of vision is impaired with the device. Correct
Avoid sexual activity while the vest is in place.
HESI comprehensive
, HESI comprehensive
Apply powder under the vest to prevent irritation.
Wear snug clothing to prevent the device from shifting.
Use caution when leaning forward or backward. Correct
Use a straw to drink. Correct -Correct Answers ✔-Straws are used to drink, and
meat and other foods are cut into small pieces to facilitate swallowing. The weight
of the halo device alters balance; therefore the client should use caution when
leaning forward or backward. The client is also told not to drive, because full range
of vision is impaired with the device. A halo fixation (stabilization) device is used
to prevent the head and neck from moving after a neck injury. The halo fixation
device is not removed. Sexual activity does not have to be avoided; the client is
instructed to use a position of comfort. Powders and lotions are used sparingly or
not at all to prevent buildup of moisture and subsequent skin breakdown. The
client is instructed to wear loose clothing with a large neck. The halo fixation
device should not shift; if it does, the primary health care provider must be
notified. The client is taught to sleep with the head supported with a small pillow
to prevent unnecessary pressure and discomfort.
Empyema develops in a client with an infected pleural effusion, and the nurse
prepares the client for thoracentesis. The nurse is assisting the primary health care
provider with the procedure. What characteristics of the fluid removed during
thoracentesis should the nurse expect to note?
Clear and yellow
Thick and opaque Correct
Clear, with a foul odor
White and odorless -Correct Answers ✔-Empyema is the accumulation of pus in
the pleural space. Empyema fluid is thick, opaque, exudative, and intensely foul-
smelling. Clear and yellow, white and odorless, and clear and foul-smelling are
incorrect descriptions of the fluid that occurs in this disorder.
A client who was involved in a high-speed motor vehicle crash is brought to the
emergency department. Which finding indicates to the nurse that the client has
sustained a flail chest?
Asymmetrical chest movement Correct
Increased breath sounds on auscultation
Deep respirations, 18 breaths/min
Complaints of mild chest discomfort -Correct Answers ✔-The nurse specifically
notes paradoxical breathing (asymmetrical chest movement); oscillation of the
mediastinum; increasing dyspnea; rapid, shallow respirations; accessory muscle
breathing; restlessness; decreased breath sounds on auscultation; cyanosis; and
HESI comprehensive
HESI comprehensive Exam Study
Questions and Answers 100% Verified
2025 Updated
A nurse taking the vital signs of a client immediately after she has delivered a
newborn notes that the client's heart rate is 110 beats/min. What should the nurse
do first?
Recheck the heart rate in 1 hour
Offer the client oral fluids
Check the uterus and amount of lochia discharge Correct
Document the findings -Correct Answers ✔-If tachycardia is noted, the nurse
should first assess the location and firmness of the uterus and amount of lochia.
Additional assessments including blood pressure, estimated blood loss at delivery,
and hemoglobin and hematocrit determinations should be carried out. After
delivery, the normal heart rate ranges from 60 to 90 beats/min. Tachycardia may
indicate excitement, fatigue, dehydration, hypovolemia, pain, or infection.
Although the nurse would document the findings, it is most appropriate for the
nurse to assess the client to determine the cause of the tachycardia. Oral fluids are
important if the client is dehydrated, but further assessment of the problem is
required and dehydration would first need to be confirmed. Rechecking the heart
rate in 1 hour will delay necessary interventions.
A nurse reviews the laboratory results of a hospitalized pregnant client with a
diagnosis of sepsis who is at risk for disseminated intravascular coagulopathy
(DIC). Which laboratory finding would indicate to the nurse that DIC has
developed in the client?
Shortened prothrombin time
Increased platelet count
Positive result on d-dimer study Correct
Decreased fibrin-degradation products -Correct Answers ✔-The d-dimer study is
used to confirm the presence of fibrin split products; a positive result is indicative
of DIC. DIC is a life-threatening defect in coagulation. As plasma factors are
consumed, the circulating blood becomes deficient in clotting factors and unable to
clot. Even as anticoagulation is occurring, inappropriate coagulation is also taking
place in the microcirculation, and tiny clots form in the smallest blood vessels,
blocking blood flow to the organs and causing ischemia. Laboratory studies help
establish a diagnosis. The fibrinogen value and platelet count are usually
HESI comprehensive
,HESI comprehensive
decreased, prothrombin and activated partial thromboplastin times may be
prolonged, and levels of fibrin degradation products (the most sensitive
measurement) are increased.
The nurse is assessing a client who has a history of Prinzmetal's angina. The nurse
knows that what type of medication is given to treat this condition?
Calcium channel blockers Correct
ACE inhibitors
Inotropes
Beta blockers -Correct Answers ✔-Prinzmetal's, or variant, angina is prolonged
and severe and occurs at the same time each day, most often at rest. The treatment
of choice is usually a calcium channel blocker. Calcium channel blockers relax and
dilate the vascular smooth muscle, thus relieving the coronary artery spasm in
variant angina. Inotropes, beta blockers, and angiotensin-converting enzyme
(ACE) inhibitors are not given to treat this disorder.
Ciprofloxacin hydrochloride is prescribed to a client with a urinary tract infection.
The nurse provides instruction about the medication. What does the nurse tell the
client about how best to take the medication?
With aluminum hydroxide
With an antacid
With milk
2 hours after meals Correct -Correct Answers ✔-Ciprofloxacin hydrochloride is an
anti-infective in the fluoroquinolone family. It may be taken without regard to
meals, but the best dosing time is 2 hours after a meal. Milk may affect absorption.
Antacids (here, aluminum hydroxide) may reduce absorption and should be
administered 2 hours apart from the ciprofloxacin hydrochloride.
Ergotamine is prescribed to a client with cluster headaches. Which occurrence does
the nurse tell the client to report to the primary health care provider if she
experiences them while taking the medication?
Fatigue and lethargy
Dizziness and fatigue
Numbness and tingling of the fingers or toes Correct
Cough -Correct Answers ✔-Ergotamine is an antimigraine medication. Prolonged
administration or an excessive dosage may produce ergotamine poisoning
(ergotism). Signs/symptoms include nausea, vomiting, weakness in the legs, pain
in the limb muscles, and numbness and tingling of the fingers and toes. The client
is instructed to report these signs/symptoms to the primary health care provider if
HESI comprehensive
,HESI comprehensive
they occur. Cough, fatigue, lethargy, and dizziness are side effects and not adverse
effects of the medication.
A nurse working the evening shift is helping clients get ready for sleep. A female
client diagnosed with mania is hyperactive and pacing the hallway. What is the
most appropriate action the nurse can take?
Tell the client that other clients are trying to sleep and that she is being disruptive
Take the client to the bathroom and provide her with a warm bath Correct
Stay with the client and observe her behavior
Tell the client that it is time for sleep and that she needs to go to her room -Correct
Answers ✔-At bedtime, the nurse should take the client to the bathroom and
provide warm baths, soothing music, and medication when indicated. For the client
with mania, the nurse needs to promote relaxation, rest, and sleep and to minimize
manic behavior. The nurse should encourage frequent rest periods during the day
and keep the client in areas of low stimulation. The client should not consume
products containing caffeine. Staying with the client and observing her behavior,
telling the client that it is time to go to sleep and to go to her room, and telling the
client that other clients are trying to sleep and that she is being disruptive do not
address the client's needs and are not measures that will help the client relax and
sleep.
A client diagnosed with type 1 diabetes mellitus has just been told that she is 6
weeks pregnant. The nurse provides information to the client about dietary and
insulin needs. What comment by the client suggests an understanding of the
information?
"I know I will have to increase my insulin during this time period."
"My insulin needs should decrease during the first trimester." Correct
"Needs for insulin will not change during the first 3 months of pregnancy."
"I will have to double up on the insulin dose during this time span." -Correct
Answers ✔-Insulin needs generally decrease during the first trimester of pregnancy
because the secretion of placental hormones antagonistic to insulin remains low.
An increase in insulin need, lack of change in insulin need, and doubling of insulin
need are all incorrect.
A nurse develops a list of home care instructions for a client who is wearing a halo
fixation device after sustaining a cervical fracture. Which instructions should the
nurse include? Select all that apply.
Do not drive, because full range of vision is impaired with the device. Correct
Avoid sexual activity while the vest is in place.
HESI comprehensive
, HESI comprehensive
Apply powder under the vest to prevent irritation.
Wear snug clothing to prevent the device from shifting.
Use caution when leaning forward or backward. Correct
Use a straw to drink. Correct -Correct Answers ✔-Straws are used to drink, and
meat and other foods are cut into small pieces to facilitate swallowing. The weight
of the halo device alters balance; therefore the client should use caution when
leaning forward or backward. The client is also told not to drive, because full range
of vision is impaired with the device. A halo fixation (stabilization) device is used
to prevent the head and neck from moving after a neck injury. The halo fixation
device is not removed. Sexual activity does not have to be avoided; the client is
instructed to use a position of comfort. Powders and lotions are used sparingly or
not at all to prevent buildup of moisture and subsequent skin breakdown. The
client is instructed to wear loose clothing with a large neck. The halo fixation
device should not shift; if it does, the primary health care provider must be
notified. The client is taught to sleep with the head supported with a small pillow
to prevent unnecessary pressure and discomfort.
Empyema develops in a client with an infected pleural effusion, and the nurse
prepares the client for thoracentesis. The nurse is assisting the primary health care
provider with the procedure. What characteristics of the fluid removed during
thoracentesis should the nurse expect to note?
Clear and yellow
Thick and opaque Correct
Clear, with a foul odor
White and odorless -Correct Answers ✔-Empyema is the accumulation of pus in
the pleural space. Empyema fluid is thick, opaque, exudative, and intensely foul-
smelling. Clear and yellow, white and odorless, and clear and foul-smelling are
incorrect descriptions of the fluid that occurs in this disorder.
A client who was involved in a high-speed motor vehicle crash is brought to the
emergency department. Which finding indicates to the nurse that the client has
sustained a flail chest?
Asymmetrical chest movement Correct
Increased breath sounds on auscultation
Deep respirations, 18 breaths/min
Complaints of mild chest discomfort -Correct Answers ✔-The nurse specifically
notes paradoxical breathing (asymmetrical chest movement); oscillation of the
mediastinum; increasing dyspnea; rapid, shallow respirations; accessory muscle
breathing; restlessness; decreased breath sounds on auscultation; cyanosis; and
HESI comprehensive
