HESI COMPREHENSIVE EXAM NEWEST ACTUAL EXAM TEST BANK
HESI COMPREHENSIVE EXAM NEWEST ACTUAL EXAM TEST BANK
COMPLETE 250 QUESTIONS AND CORRECT DETAILED ANSWERS
(VERIFIED ANSWERS) WITH RATIONALES |ALREADY GRADED
A+||BRAND NEW VERSION!!
NPO status is imposed 8 hours before the procedure on a client scheduled to
undergo electroconvulsive therapy (ECT) at 1 p.m. On the morning of the
procedure, the nurse checks the client's record and notes that the client routinely
takes an oral antihypertensive medication each morning. What action should the
nurse take?
Administer the antihypertensive with a small sip of water
Withhold the antihypertensive and administer it at bedtime
Administer the medication by way of the intravenous (IV) route
Hold the antihypertensive and resume its administration on the day after the ECT -
Correct Answer-Administer the antihypertensive with a small sip of water
Rationale: The nurse should administer the antihypertensive with a small sip of
water. General anesthesia is required for ECT, so NPO status is imposed for 6 to 8
hours before treatment to help prevent aspiration. Exceptions include clients
who routinely receive cardiac medications, antihypertensive agents, or
histamine (H2) blockers, which should be administered several hours before
treatment with a small sip of water. Withholding the antihypertensive and
administering it at bedtime and withholding the antihypertensive and resuming
administration on the day after the ECT are incorrect actions, because
antihypertensives must be administered on time; otherwise, the risk for
rebound hypertension exists. The nurse would not administer a medication by
way of a route that has not been prescribed.
1|Page
, HESI COMPREHENSIVE EXAM NEWEST ACTUAL EXAM TEST BANK
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." -
Correct Answer-"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?
2|Page
, HESI COMPREHENSIVE EXAM NEWEST ACTUAL EXAM TEST BANK
Contact the primary health care provider
Document the findings
Check the fluid for protein
Continue to monitor the client and the FHR - Correct Answer-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
3|Page
, HESI COMPREHENSIVE EXAM NEWEST ACTUAL EXAM TEST BANK
Infuse normal saline solution through the catheter at a rate of 100 mL/hr to
maintain patency - Correct Answer-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." - Correct Answer-"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
4|Page
HESI COMPREHENSIVE EXAM NEWEST ACTUAL EXAM TEST BANK
COMPLETE 250 QUESTIONS AND CORRECT DETAILED ANSWERS
(VERIFIED ANSWERS) WITH RATIONALES |ALREADY GRADED
A+||BRAND NEW VERSION!!
NPO status is imposed 8 hours before the procedure on a client scheduled to
undergo electroconvulsive therapy (ECT) at 1 p.m. On the morning of the
procedure, the nurse checks the client's record and notes that the client routinely
takes an oral antihypertensive medication each morning. What action should the
nurse take?
Administer the antihypertensive with a small sip of water
Withhold the antihypertensive and administer it at bedtime
Administer the medication by way of the intravenous (IV) route
Hold the antihypertensive and resume its administration on the day after the ECT -
Correct Answer-Administer the antihypertensive with a small sip of water
Rationale: The nurse should administer the antihypertensive with a small sip of
water. General anesthesia is required for ECT, so NPO status is imposed for 6 to 8
hours before treatment to help prevent aspiration. Exceptions include clients
who routinely receive cardiac medications, antihypertensive agents, or
histamine (H2) blockers, which should be administered several hours before
treatment with a small sip of water. Withholding the antihypertensive and
administering it at bedtime and withholding the antihypertensive and resuming
administration on the day after the ECT are incorrect actions, because
antihypertensives must be administered on time; otherwise, the risk for
rebound hypertension exists. The nurse would not administer a medication by
way of a route that has not been prescribed.
1|Page
, HESI COMPREHENSIVE EXAM NEWEST ACTUAL EXAM TEST BANK
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." -
Correct Answer-"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?
2|Page
, HESI COMPREHENSIVE EXAM NEWEST ACTUAL EXAM TEST BANK
Contact the primary health care provider
Document the findings
Check the fluid for protein
Continue to monitor the client and the FHR - Correct Answer-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
3|Page
, HESI COMPREHENSIVE EXAM NEWEST ACTUAL EXAM TEST BANK
Infuse normal saline solution through the catheter at a rate of 100 mL/hr to
maintain patency - Correct Answer-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." - Correct Answer-"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
4|Page
