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HESI Exit Exam 3 – Question and Answers with Rationales
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HESI Exit Exam 3 – Question and Answers with RationalesHESI Exit Exam 3 – Question and Answers with Rationales
1. A home care nurse is instructing a client with hyperemesis gravidarum about
measures to ease the nausea and vomiting. The nurse tells the client to:
A. Eat foods high in calories and fat
B. Lie down for at least 20 minutes after meals
C. Eat carbohydrates such as cereals, rice, and pasta Correct
D. Consume primarily soups and liquids at mealtimes
Rationale: Low-fat foods and easily digested carbohydrates such as fruit, breads, cereals,
rice, and pasta provide important nutrients and help prevent a low blood glucose level,
which can cause nausea. Soups and other liquids should be taken between meals to
avoid distending the stomach and triggering nausea. Sitting upright after meals reduces
gastric reflux. Additionally, food portions should be small and foods with strong odors
should be eliminated from the diet, because food smells often incite nausea.
A nurse is caring for a client with preeclampsia who is receiving a magnesium sulfate
infusion to prevent eclampsia. Which finding indicates to the nurse that the medication
is effective?
E. Clonus is present. Incorrect
F. Magnesium level is 10 mg/dL.
G. Deep tendon reflexes are absent.
H. The client experiences diuresis within 24 to 48 hours. Correct
Rationale: Magnesium sulfate is effective in preventing seizures (eclampsia) if diuresis
occurs within 24 to 48 hours of the start of the infusion. As part of the therapeutic
response, renal perfusion is increased and the client is free of visual disturbances,
headache, epigastric pain, clonus (the rapid rhythmic jerking motion of the foot that
occurs when the client’s lower leg is supported and the foot is sharply dorsiflexed), and
seizure activity. Hyperreflexia indicates cerebral irritability. Clonus is normally not
present. The therapeutic magnesium level is 4 to 8 mg/dL. Reflexes range from 1+ to
A client with preeclampsia who is receiving magnesium sulfate in an intravenous
infusion exhibits signs of magnesium toxicity. The nurse immediately prepares for the
administration of:
I. Vitamin K
J. Protamine sulfate Incorrect
K. Calcium gluconate Correct
L. Naloxone hydrochloride
,HESI Exit Exam 3 – Question and Answers with Rationales
Rationale: Calcium gluconate is the antidote to magnesium sulfate because it
antagonizes the effects of magnesium at the neuromuscular junction. It should be
readily available whenever magnesium is administered. Vitamin K is the antidote in
cases of hemorrhage induced by the administration of oral anticoagulants such as
warfarin sodium (Coumadin). Protamine sulfate is the antidote in cases of hemorrhage
induced by the administration of heparin. Naloxone hydrochloride is administered to
,HESI Exit Exam 3 – Question and Answers with Rationales
A nurse instructs a pregnant client about foods that are high in folic acid. Which item
does the nurse tell the client is the best source of folic acid?
M. Milk
N. Steak
O. Chicken
P. Lima beans Correct
Rationale: The best sources of folic acid are liver; kidney, pinto, lima, and black
beans; and fresh dark-green leafy vegetables. Other good sources of folic acid are
orange juice, peanuts, refried beans, and peas. Milk is high in calcium. Chicken and
A nurse is providing instructions to a mother of an infant with seborrheic dermatitis
(cradle cap) about treatment of the condition. The nurse tells the mother to:
Q. Avoid the use of shampoo on the infant’s scalp Incorrect
R. Apply oil to the affected area on the infant’s scalp Correct
S. Wash the infant’s scalp daily, using only tepid water
T. Shampoo the infant’s scalp, avoiding the anterior fontanel area
Rationale: Seborrheic dermatitis, a chronic inflammation of the scalp or other areas of
the skin, is characterized by yellow, scaly, oily lesions. It sometimes results when
parents do not wash over the anterior fontanel carefully for fear that they will hurt the
infant. Treatment includes the application of oil (e.g., mineral oil) to the area to help
soften the lesions followed by gentle removal of the scaly lesions with a comb before
the head is shampooed. The nurse should teach the mother how to shampoo the scalp
and explain that she will not damage the fontanel with normal gentle shampooing. The
A nurse is monitoring a client who was given an epidural opioid for a cesarean birth. The
nurse notes that the client’s oxygen saturation on pulse oximetry is 92%. The nurse first:
U. Notifies the registered nurse
V. Documents the findings
W. Instructs the client to take several deep breaths Correct
X. Administers 100% oxygen by way of face mask Incorrect
Rationale: If the client has been given an epidural opioid, the nurse should monitor the
client’s respiratory status closely. If the oxygen saturation falls below 95%, the nurse
instructs the client to take several deep breaths to increase the level. Although the
finding would be documented, action is required to increase the oxygen saturation
level. It is not necessary to contact the registered nurse. If the deep breaths fail to
increase the oxygen saturation level, the registered nurse is notified and may prescribe
A client who delivered a healthy newborn 11 days ago calls the clinic and tells the nurse
that she is experiencing a white vaginal discharge. The nurse tells the client:
Y. To perform a vaginal douche
Z. To come to the clinic for a checkup Incorrect
, HESI Exit Exam 3 – Question and Answers with Rationales
AA. That this is an indication of an infection
BB. That this is a normal postpartum occurrence Correct
Rationale: For the first 3 days following childbirth, lochia consists almost entirely of
blood, with small particles of decidua and mucus, and is called lochia rubra because of
its red color. The amount of blood decreases by about the fourth day, and which time
the lochia changes from red to pink or brown-tinged; this stage is called lochia serosa.
By about the 11th day, the erythrocyte component of lochia has decreased and the
discharge becomes white or cream-colored. This final stage is known as lochia alba.
Lochia alba contains leukocytes, decidual cells, epithelial cells, fat, cervical mucus, and
bacteria. It is present in most women until the third week after childbirth but may
persist for as long as 6 weeks. Lochia alba is a normal finding during the postpartum
A rubella antibody screen is performed in a pregnant client, and the results indicate
that the client is not immune to rubella. The nurse tells the client that:
CC. A rubella vaccine must be administered immediately
Incorrect DD. A rubella vaccine must be administered after
childbirth Correct EE. She will not contract rubella if she is
exposed to the disease
FF. She does not need to be concerned about being exposed to rubella
Rationale: A prenatal rubella antibody screen is performed in every pregnant woman to
determine whether she is immune to rubella, which can cause serious fetal anomalies. If
she is not immune, rubella vaccine is offered after childbirth to keep her from
contracting rubella during subsequent pregnancies. The vaccine is a live virus, and
defects might occur in the fetus if the vaccine were administered during pregnancy or if
the mother were to become pregnant soon after it was administered. Administering a
rubella vaccine immediately places the fetus at risk. Telling the client that she does not
need to be concerned about being exposed to rubella is incorrect, because the
A nurse is monitoring a client who delivered a healthy newborn 12 hours ago. The nurse
takes the client’s temperature and notes that it is 38° C (100.4° F). The most
appropriate nursing action would be to:
GG. Notify the registered nurse
HH. Recheck the temperature in 1 hour Incorrect
II. Encourage the intake of oral fluids Correct
JJ. Tell the client that antibiotics will be prescribed
Rationale: A temperature of 38° C (100.4° F) is common during the 24 hours after
childbirth. It may be the result of dehydration or normal postpartum leukocytosis. If the
increased temperature persists for longer than 24 hours or exceeds 38° C, infection is a
possibility, and the fever is reported to the registered nurse. Because the client
delivered her baby just 12 hours ago, the most appropriate nursing action is to
encourage the intake of oral fluids.
A nurse is assessing the uterine fundus of a client who has just delivered a baby and
notes that the fundus is boggy. The nurse massages the fundus, and then presses to
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