HESI Comprehensive Exam
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 - correct answer 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." - correct answer "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 -
correct answer 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 unit. The nurse notes the sudden onset of
premature ventricular contractions (PVCs) on the monitor, checks the client's carotid pulse, and
determines that the PVCs are not perfusing. What is the nurse's most appropriate action?
Document the findings
Ask the ED primary health care provider to check the client
Continue to monitor the client's cardiac status
Inform the client that PVCs are expected after an MI - correct answer Ask the ED primary health care
provider to check the client
Rationale: The most appropriate action by the nurse would be to ask the ED health care provider to
check the client. PVCs are a result of increased irritability of ventricular cells. Peripheral pulses may be
,absent or diminished with the PVCs themselves because the decreased stroke volume of the premature
beats may in turn decrease peripheral perfusion. Because other rhythms also cause widened QRS
complexes, it is essential that the nurse determine whether the premature beats are resulting in
perfusion of the extremities. This is done by palpating the carotid, brachial, or femoral artery while
observing the monitor for widened complexes or by auscultating for apical heart sounds. In the situation
of acute MI, PVCs may be considered warning dysrhythmias, possibly heralding the onset of ventricular
tachycardia or ventricular fibrillation. Therefore, the nurse would not tell the client that the PVCs are
expected. Although the nurse will continue to monitor the client and document the findings, these are
not the most appropriate actions of those provided.
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.
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?
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
