HESI Comprehensive B, Comprehensive Exam A, 202 3 exit exam v2 (Actual Exam from the Latest Tes t) (Graded A+ ) The charge nurse observes a student nurse enter the room of a client who is prescribed airborne precaution s. The application of which personal protective equipment by the student indicates a correct understanding of this precaution? A.Surgical mask, clean gloves, and gown B.Properly fitted N95 respirator or mask C.Sterile gloves and gown D.Goggles, clean glove s, and gown -------- Correct Answer -------- B Rationale: The use of personal protective equipment (PPE) for airborne precautions includes a properly prefitted N95 respirator or mask (B). (A, C and D) do not provide the appropriate respiratory equipment fo r airborne precautions. A surgical mask is used for preventing transmission of droplet precautions. The nurse empties a client's urinary drainage from an indwelling Foley catheter. Which finding should be reported to the primary health care provider? A.Am monia odor is noted when the catheter is emptied. B.240 mL of urinary output is produced in 12 hours. C.A 16 -French catheter was used for an adult female. D.Drainage system is hanging below the level of the bladder. -------- Correct Answer -----
--- B Ratio nale: An expected finding is between 400 and 750 mL in 12 hours = average of 30 mL/hr (B). Ammonia odor is an expected finding (A). Size 14 - to 18 -French catheters are common sizes used in the adult female (C). Below the level of the bladder is the correct position for the drainage bag (D). An adult female who presents at the mental clinic trembling and crying becomes distressed when the nurse attempts to conduct an assessment. She complains about the number of questions that are being asked, which she is convinced are going to cause her to have a heart attack. What action should the nurse take? A.Take the client's blood pressure and reassure her that questioning will not cause a heart attack. B.Explain that treatment is based on information obtained in the assessment. C.Encourage the client to relax so that she can provide the information requested. D.Empower the client to share her story of why she is here at the mental health clinic. --
------ Correct Answer -------- D Rationale: The client is exhibiting signs of moderate anxiety, which include voice tremors, shakiness, somatic complaints, and select ive inattention. (D) is the best method for addressing this client's level of anxiety by creating a shared understanding of the client's concerns. Although assessment of her blood pressure (A) might be a worthwhile intervention, reassuring her that questio ning will not cause a heart attack (A) is argumentative. (B) suggests that treatment cannot be provided without the information, which is manipulative. Asking the client to relax (C) is likely to increase her anxiety. Which information is most concerning to the nurse when caring for an older client with bilateral cataracts? A.States having difficulty with color perception B.Presents with opacity of the lens upon assessment C.Complains of seeing a cobweb -type structure in the visual field D.Reports the need to use a magnifying glass to see small print -------- Correct Answer -
------- C Rationale: Visualization of a cobweb - or hairnet -type structure is a sign of a retinal detachment, which constitutes a medical emergency. Clients with cataracts are at increas ed risk for retinal detachment (C). Distorted color perception (A), opacity of the lens (B), and gradual vision loss (D) are expected signs and symptom of cataracts, but do not need immediate attention. The nurse is caring for a client with a cerebrovascular accident (CVA) who is receiving enteral tube feedings. Which task performed by the UAP requires immediate intervention by the nurse? A.Suctions oral secretions from mouth B.Positions head of bed flat when changing sheets C.Takes temperature using the axillary method D.Keeps head of bed elevated at 30 degrees -------- Correct Answer -------- B Rationale: Positioning the head of the bed flat when enteral feedings are in progress puts the client at risk f or aspiration (B). The others are all acceptable tasks performed by the UAP (A, C, and D). When caring for a postsurgical client who has undergone multiple blood transfusions, which serum laboratory finding is of most concern to the nurse? A.Sodium level, 137 mEq/L B.Potassium level, 5.5 mEq/L C.Blood urea nitrogen (BUN) level, 18 mg/dL D.Calcium level, 10 mEq/L -------- Correct Answer -------- B Rationale: Multiple blood transfusions are a risk factor for hyperkalemia. A serum potassium level higher than 5.0 mEq/L indicates hyperkalemia (B). The others are normal findings (A, C, and D). Which vaccination should the nurse administer to a newborn? A.Hepatitis B B.Human papilloma virus (HPV) C.Varicella D.Meningococcal vaccine -------- Correct Answer -------- A Rationale: The hepatitis B vaccination should be given to all newborns before hospital discharge (A). HPV is not recommended until adolescence (B). Vari cella immunization begins at 12 months (C). Meningococcal vaccine is administered beginning at 2 years (D). The nurse is caring for a client on the medical unit. Which task can be delegated to unlicensed assistive personnel (UAP)? A.Assess the need to cha nge a central line dressing. B.Obtain a fingerstick blood glucose level. C.Answer a family member's questions about the client's plan of care. D.Teach the client side effects to report related to the current medication regimen. -------
- Correct Answer -------- B Rationale: Obtaining a fingerstick blood glucose level is a simple treatment and is an appropriate skill for UAP to perform (B). (A, C, and D) are skills that cannot be delegated to UAP. The nurse is caring for a client with an ischemic stroke who has a prescription for tissue plasminogen activator (t -PA) IV. Which action(s) should the nurse expect to implement? (Select all that apply.) A.Administer aspirin with tissue plasminogen activator (t -PA). B.Complete the National Institute of Health Stroke Scale (NIHSS). C.Assess the client for signs of bleeding during and after the infusion. D.Start t -PA within 6 hours after the onset of stroke symptoms. E.Initiate multidisciplinary consult for potential rehabilitation. -------- Correct Answer ------
-- B,C,E Rationale: Neurologic assessment, including the NIHSS, is indicated for the client receiving t -PA. This includes close monitoring for bleeding during and after the infusion; if bleeding or other signs of neurologic impairment occur, the infusion should be stopped (B, C, and E). Aspirin is contraindicated with t -PA because it increases the risk for bleeding (A). The administration of t -PA within 6 hours of symptoms is concurrent with a diagnosis of a myocardial infarction and within 4.5 hours of symptoms is concurrent for a stroke (D). When caring for a client in labor, which finding is most important to report to the primary health care provider? A.Maternal heart rate, 90 beats/min. B.Fetal heart rate, 100 beats/min C.Maternal blood pressure, 140/86 mm Hg D.Maternal t emperature, 100.0° F -------- Correct Answer -------- B Rationale: A fetal heart rate (FHR) of 100 beats/min may indicate fetal distress (B) because the average FHR at term is 140 beats/min and the normal range is 110 to beats/min 160. The others (A, C, an d D) are normal findings for a woman in labor. The nurse is caring for a client with heart failure who develops respiratory distress and coughs up pink frothy sputum. Which action should the nurse take first? A.Draw arterial blood gases. B.Notify the prim ary health care provider. C.Position in a high Fowler's position with the legs down. D.Obtain a chest X -ray. -------- Correct Answer -------- C Rationale: Positioning the patient in a high Fowler's position with dangling feet will decrease further venous r eturn to the left ventricle (C). The other actions should be performed after the change in position (A, B, and D). A client who is prescribed chlorpromazine HCl (Thorazine) for schizophrenia develops rigidity, a shuffling gait, and tremors. Which action b y the nurse is most important?A.Administer a dose of benztropine mesylate (Cogentin) PRN. B.Determine if the client has increased photosensitivity. C.Provide comfort measures for sore muscles. D.Assess the client for visual and auditory hallucinations. -------- Correct Answer -------- A Rationale: Rigidity, shuffling gait, pill -rolling hand movements, tremors, dyskinesia, and masklike face are extrapyramidal side effects associated with Thorazine. It is most important for the nurse to administer an antichol inergic such as Cogentin to reverse these effects (A). The others (B, C, D) may be appropriate interventions but are not as urgent as (A). A nurse is interviewing a mother during a well -child visit. Which finding would alert the nurse to continue further assessment of the infant? A.Two -month -old who is unable to roll from back to abdomen B.Ten -month -old who cannot sit without support C.Nine -month -old who cries when his mother leaves the room D.Eight -month -old who has not yet begun to speak words -------- Correct Answer -------- B Rationale: As a developmental milestone, infants should sit unsupported by 8 months (B). The milestone of rolling over is achieved at 5 to 6 months for most infants ( A). Stranger anxiety is common from 7 to 9 months (C). Speaking a few words is expected at about 12 months (D). Which intervention should be included in the plan of care for a client admitted to the hospital with ulcerative colitis? A.Administer stool sof teners. B.Place the client on fluid restriction. C.Provide a low -residue diet.
