HESI COMPREHENSIVE EXAM ACTUAL 150 QUESTIONS WITH
DETAILED ANSWERS AND RATIONALES ALREADY GRADED
A+
A client who recently underwent coronary artery bypass graft surgery comes to the
primary health care provider'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?
"Tell me more about what you're feeling."
"That's a normal response after this type of surgery."
"It will take time, but I promise you, you will get over this depression."
"Every client who has this surgery feels the same way for about a month." - ANS...
-"Tell me more about what you're feeling."
Rationale: The therapeutic response by the nurse is, "Tell me more about what
you're feeling." When a client expresses feelings of depression, it is extremely
important for the nurse to further explore these feelings with the client. In stating,
"This is a normal response after this type of surgery" the nurse provides false
reassurance and avoids addressing the client's feelings. "It will take time, but I
promise you, you will get over the depression" is also a false reassurance, and it
does not encourage the expression of feelings. "Every client who has this surgery
feels the same way for about a month" is a generalization that avoids the client's
feelings.
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 action should be the nurse's priority?
Contact the primary health care provider
Document the findings
Check the fluid for protein
Continue to monitor the client and the FHR - ANS... -Contact the primary health
care provider
,Rationale: The priority action is for the nurse to contact the primary health care
provider. 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 primary health care provider. 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. The nurse would
continue to monitor the client and the FHR and would document the findings.
A nurse has assisted a primary health care provider 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 what does the
nurse immediately do?
Call the radiography department to obtain a chest x-ray
Check the client's blood glucose level to serve as a baseline measurement
Hang the prescribed bag of PN and start the infusion at the prescribed rate
Infuse normal saline solution through the catheter at a rate of 100 mL/hr to
maintain patency - ANS... -Call the radiography department to obtain a chest x-ray
Rationale: The nurse should immediately make arrangements to have a chest x-ray
done. 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. Hanging the prescribed bag of PN and starting the infusion
at the prescribed rate and infusing normal saline solution through the catheter at a
rate of 100 mL/hr to maintain patency are all incorrect because they could result in
the infusion of solution into a lung if a pneumothorax is present. Although the
nurse may obtain a blood glucose measurement to serve as a baseline, this action is
not the priority.
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 most appropriate response by
the nurse?
"HIV is rarely an issue in rape victims."
"Every rape victim is concerned about HIV."
"You're more likely to get pregnant than to contract HIV."
,"Let's talk about the information that you need to determine your risk of
contracting HIV." - ANS... -"Let's talk about the information that you need to
determine your risk of contracting HIV."
Rationale: The most appropriate response by the nurse is the one that encourages
the client to talk about her condition. 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.
However, stating, "You're more likely to get pregnant than to contract HIV" avoids
the client's concern. Similarly, "HIV is rarely an issue in rape victims" and "Every
rape victim is concerned about HIV" are generalized responses that avoid the
client's concern.
Enalapril maleate is prescribed for a hospitalized client. Which assessment does
the nurse perform as a priority before administering the medication?
Checking the client's blood pressure
Checking the client's peripheral pulses
Checking the most recent potassium level
Checking the client's intake-and-output record for the last 24 hours - ANS... -
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.
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?
"The test will take about 30 minutes."
"I need to fast for 8 hours before the test."
, "I need to drink citrate of magnesia the night before the test and give myself a Fleet
enema on the morning of the test."
"I need to take a laxative after the test is completed, because the liquid that I'll have
to drink for the test can be constipating." - ANS... -"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: No special preparation is necessary before a GI series, except that NPO
(nothing by mouth) status must be maintained for 8 hours before the test. 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. 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.
A nurse on the evening shift checks a primary health care provider's prescriptions
and notes that the dose of a prescribed medication is higher than the normal dose.
The nurse calls the primary health care provider's answering service and is told that
the primary health care provider is off for the night and will be available in the
morning. What should the nurse do next?
Call the nursing supervisor
Ask the answering service to contact the on-call primary health care provider
Withhold the medication until the primary health care provider can be reached in
the morning
Administer the medication but consult the primary health care provider when he
becomes available - ANS... -Ask the answering service to contact the on-call
primary health care provider
Rationale: The nurse has a duty to protect the client from harm. A nurse who
believes that a primary health care provider'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.
An emergency department (ED) nurse is monitoring a client with suspected acute
myocardial infarction (MI) who is awaiting transfer to the coronary intensive care
DETAILED ANSWERS AND RATIONALES ALREADY GRADED
A+
A client who recently underwent coronary artery bypass graft surgery comes to the
primary health care provider'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?
"Tell me more about what you're feeling."
"That's a normal response after this type of surgery."
"It will take time, but I promise you, you will get over this depression."
"Every client who has this surgery feels the same way for about a month." - ANS...
-"Tell me more about what you're feeling."
Rationale: The therapeutic response by the nurse is, "Tell me more about what
you're feeling." When a client expresses feelings of depression, it is extremely
important for the nurse to further explore these feelings with the client. In stating,
"This is a normal response after this type of surgery" the nurse provides false
reassurance and avoids addressing the client's feelings. "It will take time, but I
promise you, you will get over the depression" is also a false reassurance, and it
does not encourage the expression of feelings. "Every client who has this surgery
feels the same way for about a month" is a generalization that avoids the client's
feelings.
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 action should be the nurse's priority?
Contact the primary health care provider
Document the findings
Check the fluid for protein
Continue to monitor the client and the FHR - ANS... -Contact the primary health
care provider
,Rationale: The priority action is for the nurse to contact the primary health care
provider. 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 primary health care provider. 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. The nurse would
continue to monitor the client and the FHR and would document the findings.
A nurse has assisted a primary health care provider 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 what does the
nurse immediately do?
Call the radiography department to obtain a chest x-ray
Check the client's blood glucose level to serve as a baseline measurement
Hang the prescribed bag of PN and start the infusion at the prescribed rate
Infuse normal saline solution through the catheter at a rate of 100 mL/hr to
maintain patency - ANS... -Call the radiography department to obtain a chest x-ray
Rationale: The nurse should immediately make arrangements to have a chest x-ray
done. 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. Hanging the prescribed bag of PN and starting the infusion
at the prescribed rate and infusing normal saline solution through the catheter at a
rate of 100 mL/hr to maintain patency are all incorrect because they could result in
the infusion of solution into a lung if a pneumothorax is present. Although the
nurse may obtain a blood glucose measurement to serve as a baseline, this action is
not the priority.
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 most appropriate response by
the nurse?
"HIV is rarely an issue in rape victims."
"Every rape victim is concerned about HIV."
"You're more likely to get pregnant than to contract HIV."
,"Let's talk about the information that you need to determine your risk of
contracting HIV." - ANS... -"Let's talk about the information that you need to
determine your risk of contracting HIV."
Rationale: The most appropriate response by the nurse is the one that encourages
the client to talk about her condition. 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.
However, stating, "You're more likely to get pregnant than to contract HIV" avoids
the client's concern. Similarly, "HIV is rarely an issue in rape victims" and "Every
rape victim is concerned about HIV" are generalized responses that avoid the
client's concern.
Enalapril maleate is prescribed for a hospitalized client. Which assessment does
the nurse perform as a priority before administering the medication?
Checking the client's blood pressure
Checking the client's peripheral pulses
Checking the most recent potassium level
Checking the client's intake-and-output record for the last 24 hours - ANS... -
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.
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?
"The test will take about 30 minutes."
"I need to fast for 8 hours before the test."
, "I need to drink citrate of magnesia the night before the test and give myself a Fleet
enema on the morning of the test."
"I need to take a laxative after the test is completed, because the liquid that I'll have
to drink for the test can be constipating." - ANS... -"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: No special preparation is necessary before a GI series, except that NPO
(nothing by mouth) status must be maintained for 8 hours before the test. 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. 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.
A nurse on the evening shift checks a primary health care provider's prescriptions
and notes that the dose of a prescribed medication is higher than the normal dose.
The nurse calls the primary health care provider's answering service and is told that
the primary health care provider is off for the night and will be available in the
morning. What should the nurse do next?
Call the nursing supervisor
Ask the answering service to contact the on-call primary health care provider
Withhold the medication until the primary health care provider can be reached in
the morning
Administer the medication but consult the primary health care provider when he
becomes available - ANS... -Ask the answering service to contact the on-call
primary health care provider
Rationale: The nurse has a duty to protect the client from harm. A nurse who
believes that a primary health care provider'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.
An emergency department (ED) nurse is monitoring a client with suspected acute
myocardial infarction (MI) who is awaiting transfer to the coronary intensive care
