HESI COMPREHENSIVE EXAM NEWEST ACTUAL EXAM TEST BANK
COMPLETE 150 QUESTIONS AND CORRECT DETAILED ANSWERS
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A young adult female arrives at the emergency department with a black right eye
and is bleeding from the left side of her head. She reports that her boyfriend has
been abusing her physically. The nurse performs a history and physical
examination. How should the nurse document these findings?
a. Client alleges that her boyfriend beat her up. Client is bleeding from the left
side of the face.
b. Client reports her boyfriend hit her in the eye and on the head. Bruises and
lacerations present on face.
c. Client presents with a right black eye and a cut on the left side of her head that
is bleeding. Reports abusive boyfriend responsible for injuries. Needs referral to a
safe place to stay.
d. Young adult female presents with periorbital ecchymosis on right side, 3 cm
laceration on left parietal area, approximately 1 cm deep with tissue bridging.
States her boyfriend is abusive. - Correct Answer-D
A retired office worker is admitted to the psychiatric inpatient unit with a
diagnosis of major depression. The initial nursing care plan includes the goal,
"Assist client to express feelings of anger." Which nursing intervention is most
important to include in the client's plan of care?
a. Teach that anger will subside after two weeks on antidepressants.
b. Ask client to describe triggers of anger.
c. Gather more data about social support.
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, HESI COMPREHENSIVE EXAM NEWEST ACTUAL EXAM
d. Collaborate with the treatment team about revising the goal. - Correct Answer-
B
The nurse determines that a client's body weight is 105% above the standardized
height-weight scale. Which related factor should the nurse include in the nursing
problem, "Imbalanced nutrition: more than body requirements?"
a. Morbidly obese.
b. Markedly obese.
c. Inadequate lifestyle changes in diet and exercise.
d. Increased morbidity and mortality risks. - Correct Answer-C
A child is receiving maintainance intravenous (IV) fluids at the rate of 1000 ml for
the first 10 kg of body weight, plus 50 ml/kg per day for each kilogram between 10
and 20. How many milliliters per hour should the nurse program the infusion
pump for a child who weighs 19.5 kg? (Enter numeric value only. If rounding is
required, round to the nearest whole number.) - Correct Answer-61
A 6-year-old child is alert but quiet when brought to the emergency center with
periorbital ecchymosis and ecchymosis behind the ears. The nurse suspects
potential child abuse and continues to assess the child for additional
manifestations of a basilar skull fracture. What assessment finding would be
consistent with a basilar skull fracture?
a. Asymmetry of the face and eye movements.
b. Abnormal position and movement of the arm.
c. Hematemesis and abdominal distention.
d. Rhinorrhoea or otorrhoea with Halo sign - Correct Answer-D
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, HESI COMPREHENSIVE EXAM NEWEST ACTUAL EXAM
The nurse is assessing a client and identifies the presence of petechiae. Which
documentation best describes this finding?
a. Purplish-red pinpoint lesions of the skin.
b. Purple to bluish discoloration of the skin.
c. Small circumscribed elevations containing purulent fluid.
d. Generalized reddish discoloration of an area of skin. - Correct Answer-A
A client is receiving atenolol (Tenormin) 25 mg PO after a myocardial infarction.
The nurse determines the client's apical pulse is 65 beats per minute. What action
should the nurse implement next?
a. Notify the healthcare provider.
b. Measure the blood pressure.
c. Administer the medication.
d. Reassess the apical pulse. - Correct Answer-C
The parents of a 14-year-old boy express concern about their son's behavior,
which ranges from clean-cut and personable to "grungy" and sullen. They have
tried talking with him and disciplining him, but he continues to demonstrate
confusing behaviors. Which information is best for the nurse to provide?
a. Adolescents who demonstrate labile behaviors are at risk for self-injury.
b. Rebelliousness requires consequences to prevent socially deviant behavior.
c. Early adolescence is a developmental stage of normal experimentation.
d. The parents should consider hospitalization to prevent self injury. - Correct
Answer-C
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, HESI COMPREHENSIVE EXAM NEWEST ACTUAL EXAM
The nurse is assessing an older client and determines that the client's left upper
eyelid droops, covering more of the iris than the right eyelid. Which description
should the nurse use to document this finding?
a. Ptosis on the left eyelid.
b. A nystagmus on the left.
c. Astigmatism on the right.
d. Exophthalmos on the right. - Correct Answer-A
The nurse is caring for a client who is unable to void. The plan of care establishes
an objective for the client to ingest at least 1000 ml of fluid between 7:00 am and
3:30 pm. Which client response should the nurse document that indicates a
successful outcome?
a. Demonstrates adequate fluid intake and output.
b. Voids at least 1000 ml between 7am and 3 pm.
c. Verbalizes abdominal comfort without pressure.
d. Drinks 240 ml of fluid five times during the shift. - Correct Answer-D
The nurse obtains a heart rate of 92 and a blood pressure of 110/76 prior to
administering a scheduled dose of verapamil (Calan) for a client with atrial flutter.
Which action should the nurse implement?
a. Administer the dose as prescribed.
b. Withhold the drug and notify the healthcare provider.
c. Give intravenous (IV) calcium gluconate.
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