HESI COMPREHENSIVE EXAM A PRACTISE 2021This feeling occurs during
feeding with a breast infection.
B. This sensation occurs as breast
milk moves to the nipple.
C. The baby does not have good
latch-on.
D. The infant is not positioned
correctly.
B. This sensation occurs as breast milk
moves ...
a 2 day postpartum mother who is breastfeeding asks
why do i feel this tingling in my breasts after the baby sucks for a few minutes which information
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HESI COMPREHENSIVE EXAM A PRACTISE 2021
HESI Comprehensive Exam A Practice
1 A 2-day postpartum mother who is B. This sensation occurs as breast milk
. breastfeeding asks, "Why do I feel moves to the nipple.
this tingling in my breasts after the Rationale:
baby sucks for a few minutes?" When the mother's milk comes in,
Which information should the usually 2 to 3 days after delivery,
nurse provide? women often report they feel a tingling
A. This feeling occurs during sensation in their nipples (B) when let-
feeding with a breast infection. down occurs. (A, C, and D) provide
B. This sensation occurs as breast inaccurate information.
milk moves to the nipple.
C. The baby does not have good
latch-on.
D. The infant is not positioned
correctly.
2 A 40-year-old office worker who is A. Check the client's blood pressure.
. at 36 weeks' gestation presents to Rationale:
the occupational health clinic The blood pressure (A) should be
complaining of a pounding assessed first. Preeclampsia is a
headache, blurry vision, and multisystem disorder, and women older
swollen ankles. Which intervention than 35 years and have chronic
should the nurse implement first? hypertension are at increased risk.
A. Check the client's blood Classic signs include headache, visual
pressure. changes, edema, recent rapid weight
B. Teach her to elevate her feet gain, and elevated blood pressure. (B,
when sitting. C, and D) can be done if the blood
C. Obtain a 24-hour diet history to pressure is normal.
evaluate for the intake of salty
foods.
D. Assess the fetal heart rate.
3 A 50-year-old man arrives at the C. Ask about scrotal pain or blood in
. clinic with complaints of pain on the semen.
ejaculation. Which action should Rationale:
the nurse implement? Orchitis is an acute testicular
A. Teach the client testicular self- inflammation resulting from recurrent
examination (TSE). urinary tract infection, recurrent
B. Assess for the presence of blood sexually transmitted disease (STD), or
, in the urine. an indwelling urethral urinary catheter
C. Ask about scrotal pain or blood causing pain on ejaculation, scrotal
in the semen. pain, blood in the semen, and penile
D. Inquire about a history of kidney discharge, so the nurse should
stones. determine the presence of other
symptoms (C). Although all men
should practice TSE, the client's
symptoms are suggestive of an
inflammatory syndrome rather than
testicular cancer (A). Although
hematuria (B) is associated with renal
disease or calculi (D), the client's pain
is associated with ejaculate, not urine.
4 A 77-year-old female client states C. With age, more fatty tissue
. that she has never been so large develops in the abdomen and
around the waist and that she has decreased intestinal movement can
frequent periods of constipation. cause constipation.
Colon disease has been ruled out Rationale:
with a flexible sigmoidoscopy. With aging, the abdominal muscles
Which information should the nurse weaken as fatty tissue is deposited
provide to this client? around the trunk and waist. Slowing
A. As women age, they often become peristalsis also affects the emptying of
rounder in the middle because they the colon, resulting in constipation
do not exercise properly. (C). (A) is not the primary reason for
B. Further assessment is indicated the changes in body structure. (B) is
because loss of abdominal muscle not indicated because loss of muscle
tone and constipation do not occur tone and constipation are age-related
with aging. changes. (D) dismisses the client's
C. With age, more fatty tissue concerns and does not help her
develops in the abdomen and understand the changes that she is
decreased intestinal movement can experiencing.
cause constipation.
D. Because there is no evidence of a
diseased colon, there is no need to
worry about abdominal size.
5 According to Erikson, which client D. A 75-year-old woman who wishes
. should the nurse identify as having her friends were still alive so she
difficulty completing the could change some of the choices she
developmental stage of older adults? made over the years
, A. A 60-year-old man who tells the Rationale:
nurse that he is feeling fine and The older woman who wishes she
really does not need any help from could change the choices she has
anyone made in her lifetime is expressing
B. A 78-year-old widower who has despair and is still searching for
come to the mental health clinic for integrity (D). The nurse uses Erikson
counseling after the recent death of stages of development over the life
his wife span to assess an older client's
C. An 81-year-old woman who states adjustment to aging and plans
that she enjoys having her teaching strategies to assist the clients
grandchildren visit but is usually attain integrity versus despair. (A, B,
glad when they go home and C) are normal developmental
D. A 75-year-old woman who wishes tasks of older adults.
her friends were still alive so she
could change some of the choices she
made over the years
6 After administration of an 0730 dose A. Ensure that the client receives
. of Humalog 50/50 insulin to a client breakfast within 30 minutes.
with diabetes mellitus, which Rationale:
nursing action has the highest Insulin 50/50 contains 50% regular
priority? and 50% NPH insulin. Therefore, the
A. Ensure that the client receives onset of action is within 30 minutes
breakfast within 30 minutes. and the nurse's priority action is to
B. Remind the client to have a ensure that the client receives a
midmorning snack at 1000. breakfast tray to avoid a
C. Discuss the importance of a hypoglycemic reaction (A). (B, C, and
midafternoon snack with the client. D) are also important nursing actions
D. Explain that the client's capillary but are of less immediacy than (A).
glucose will be checked at 1130.
7 The antigout medication allopurinol A. "I take aspirin for my pain."
. (Zyloprim) is prescribed for a client newly Rationale:
diagnosed with gout. Which comment by The client should be taught to
the client warrants intervention by the avoid aspirin (A) because the
nurse? ingestion of aspirin or diuretics
A. "I take aspirin for my pain." can precipitate an attack of
B. "I frequently eat fruit and drink fruit gout. (B, C, and D) are all
juices." appropriate for the treatment of
C. "I drink a great deal of water, so I have gout. The client's urinary pH
to get up at night to urinate." can be increased by the intake
, D. "I observe my skin daily to see if I have of alkaline ash foods, such as
an allergic rash to the medication." citrus fruits and juices, which
will help reduce stone
formation (B). Increasing
fluids helps prevent urinary
calculi (stone) formation and
should be encouraged, even if
the client must get up at night
to urinate (C). Allopurinol has
a rare but potentially fatal
hypersensitivity syndrome,
which is characterized by a
rash and fever. The medication
should be discontinued
immediately if this occurs (D).
8 Because of census overload, the charge A. A stage 3 sacral pressure
. nurse of an acute care medical unit must ulcer, with colonized
select a client who can be transferred back methicillin-resistant
to a residential facility. The client with Staphylococcus aureus
which symptomology is the most stable? (MRSA)
A. A stage 3 sacral pressure ulcer, with Rationale:
colonized methicillin-resistant The client with colonized
Staphylococcus aureus (MRSA) MRSA (A) is the most stable
B. Pneumonia, with a sputum culture of client, because colonization
gram-negative bacteria does not cause symptomatic
C. Urinary tract infection, with positive disease. The gram-negative
blood cultures organisms causing pneumonia
D. Culture of a diabetic foot ulcer shows are typically resistant to drug
gram-positive cocci therapy (B), which makes
recovery very difficult. Positive
blood cultures (C) indicate a
systemic infection. Poor
circulation places the diabetic
with an infected ulcer (D) at
high risk for poor healing and
bone infection.
9 The charge nurse of a 16-bed medical unit B. Assign the UAPs to take
. is making 0700 to 1900 shift assignments. vital signs and obtain daily
The team consists of two RNs, two PNs, weights.
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