EXIT HESI COMPREHENSIVE B COMPLETE TEST
PAPER WITH CORRECT ANSWERS
◉ Which intervention should be included in the plan of care for a
client admitted to the hospital with ulcerative colitis?
A.Administer stool softeners.
B.Place the client on fluid restriction.
C.Provide a low-residue diet.
D.Add a milk product to each meal.
Answer: C
Rationale:
A low-residue diet (C) will help decrease symptoms of diarrhea,
which are clinical manifestations of ulcerative colitis. (A, B, and D)
are contraindicated and could worsen the condition.
◉ The nurse is caring for a client with deep vein thrombosis who is
on a continuous IV heparin infusion. The activated partial
prothrombin time (aPTT) is 120 seconds. Which action should the
nurse take?
A.Increase the rate of the heparin infusion using a nomogram.
B.Decrease the heparin infusion rate and give vitamin K IM.
C.Continue the heparin infusion at the current prescribed rate.
,D.Stop the heparin drip and prepare to administer protamine
sulfate..
Answer: D
Rationale:
An aPTT more than 100 seconds is a critically high value; therefore,
the heparin should be stopped. The antidote for heparin is
protamine sulfate (D). Increasing the rate would increase the risk for
hemorrhage (A). The infusion should be stopped, and vitamin K is
the antidote for warfarin (Coumadin) (B). Keeping the infusion at
the current rate would increase the risk for hemorrhage (C).
◉ While assessing a client with recurring chest pain, the unit
secretary notifies the nurse that the client's health care provider is
on the telephone. What action should the nurse instruct the unit
secretary to implement?
A.Transfer the call into the room of the client.
B.Instruct the secretary to explain reason for the call.
C.Ask another nurse to take the phone call.
D.Ask the health care provider to see the client on the unit..
Answer: C
Rationale:
Another nurse should be asked to take the phone call (C), which
allows the nurse to stay at the bedside to complete the assessment
of the client's chest pain. (A and B) should not be done during an
acute change in the client's condition. Requesting the health care
,provider (D) to come to the unit is premature until the nurse
completes assessment of the client's status.
◉ Which instruction(s) should the nurse include in the discharge
teaching plan of a male client who has had a myocardial infarction
and who has a new prescription for nitroglycerin (NTG)? (Select all
that apply.)
A.Keep the medication in your pocket so that it can be accessed
quickly.
B.Call 911 if chest pain is not relieved after one nitroglycerin.
C.Store the medication in its original container and protect it from
light.
D.Activate the emergency medical system after three doses of
medication.
E.Do not use within 1 hour of taking sildenafil citrate (Viagra)..
Answer: B,C
Rationale:
Emergency action should be taken if chest pain is not relieved after
one nitroglycerin tablet (B). The medication should be kept in the
original container to protect from light (C). Keeping the medication
in the shirt pocket provides an environment that is too warm (A).
The newest guidelines recommend calling 911 after one
nitroglycerin tablet if chest pain is not relieved (D). Nitroglycerin
and other nitrates should never be taken with Viagra (E).
, ◉ The nurse prepares to administer 3 units of regular insulin and 20
units of NPH insulin subcutaneously to a client with an elevated
blood glucose level. Which procedure is correct?
A.Using one syringe, first insert air into the regular vial and then
insert air into the NPH vial.
B.Using one syringe, add the regular insulin into the syringe and
then add the NPH insulin.
C.Avoid combining the two insulins because incompatibility could
cause an adverse reaction.
D.Administer the regular insulin subcutaneously and then give the
NPH IV to prevent a separate stick..
Answer: B
Rationale:
The regular or "clear" insulin should be withdrawn into the syringe
first, followed by the NPH (B). Air should first be injected into the
NPH vial and then air should be inserted into the regular vial (A).
NPH and regular insulin are compatible, and combining will reduce
the number of injections (C). The insulin is ordered subcutaneously
and NPH cannot be given IV (D).
◉ An 8-year-old child is receiving digoxin (Lanoxin) for congestive
heart failure (CHF). In assessing the child, the nurse finds that her
apical heart rate is 80 beats/min, she complains of being slightly
nauseated, and her serum digoxin level is 1.2 ng/mL. What action
should the nurse take?
PAPER WITH CORRECT ANSWERS
◉ Which intervention should be included in the plan of care for a
client admitted to the hospital with ulcerative colitis?
A.Administer stool softeners.
B.Place the client on fluid restriction.
C.Provide a low-residue diet.
D.Add a milk product to each meal.
Answer: C
Rationale:
A low-residue diet (C) will help decrease symptoms of diarrhea,
which are clinical manifestations of ulcerative colitis. (A, B, and D)
are contraindicated and could worsen the condition.
◉ The nurse is caring for a client with deep vein thrombosis who is
on a continuous IV heparin infusion. The activated partial
prothrombin time (aPTT) is 120 seconds. Which action should the
nurse take?
A.Increase the rate of the heparin infusion using a nomogram.
B.Decrease the heparin infusion rate and give vitamin K IM.
C.Continue the heparin infusion at the current prescribed rate.
,D.Stop the heparin drip and prepare to administer protamine
sulfate..
Answer: D
Rationale:
An aPTT more than 100 seconds is a critically high value; therefore,
the heparin should be stopped. The antidote for heparin is
protamine sulfate (D). Increasing the rate would increase the risk for
hemorrhage (A). The infusion should be stopped, and vitamin K is
the antidote for warfarin (Coumadin) (B). Keeping the infusion at
the current rate would increase the risk for hemorrhage (C).
◉ While assessing a client with recurring chest pain, the unit
secretary notifies the nurse that the client's health care provider is
on the telephone. What action should the nurse instruct the unit
secretary to implement?
A.Transfer the call into the room of the client.
B.Instruct the secretary to explain reason for the call.
C.Ask another nurse to take the phone call.
D.Ask the health care provider to see the client on the unit..
Answer: C
Rationale:
Another nurse should be asked to take the phone call (C), which
allows the nurse to stay at the bedside to complete the assessment
of the client's chest pain. (A and B) should not be done during an
acute change in the client's condition. Requesting the health care
,provider (D) to come to the unit is premature until the nurse
completes assessment of the client's status.
◉ Which instruction(s) should the nurse include in the discharge
teaching plan of a male client who has had a myocardial infarction
and who has a new prescription for nitroglycerin (NTG)? (Select all
that apply.)
A.Keep the medication in your pocket so that it can be accessed
quickly.
B.Call 911 if chest pain is not relieved after one nitroglycerin.
C.Store the medication in its original container and protect it from
light.
D.Activate the emergency medical system after three doses of
medication.
E.Do not use within 1 hour of taking sildenafil citrate (Viagra)..
Answer: B,C
Rationale:
Emergency action should be taken if chest pain is not relieved after
one nitroglycerin tablet (B). The medication should be kept in the
original container to protect from light (C). Keeping the medication
in the shirt pocket provides an environment that is too warm (A).
The newest guidelines recommend calling 911 after one
nitroglycerin tablet if chest pain is not relieved (D). Nitroglycerin
and other nitrates should never be taken with Viagra (E).
, ◉ The nurse prepares to administer 3 units of regular insulin and 20
units of NPH insulin subcutaneously to a client with an elevated
blood glucose level. Which procedure is correct?
A.Using one syringe, first insert air into the regular vial and then
insert air into the NPH vial.
B.Using one syringe, add the regular insulin into the syringe and
then add the NPH insulin.
C.Avoid combining the two insulins because incompatibility could
cause an adverse reaction.
D.Administer the regular insulin subcutaneously and then give the
NPH IV to prevent a separate stick..
Answer: B
Rationale:
The regular or "clear" insulin should be withdrawn into the syringe
first, followed by the NPH (B). Air should first be injected into the
NPH vial and then air should be inserted into the regular vial (A).
NPH and regular insulin are compatible, and combining will reduce
the number of injections (C). The insulin is ordered subcutaneously
and NPH cannot be given IV (D).
◉ An 8-year-old child is receiving digoxin (Lanoxin) for congestive
heart failure (CHF). In assessing the child, the nurse finds that her
apical heart rate is 80 beats/min, she complains of being slightly
nauseated, and her serum digoxin level is 1.2 ng/mL. What action
should the nurse take?
