HESI COMPREHENSIVE EXIT EXAM 1 (AND
RATIONALE) WITH VERIFIED SOLUTIONS
1.The lnurse lis lmonitoring lneurological lvital lsigns lfor la lmale lclient lwho
llost lconsciousness lafter lfalling land lhitting lhis lhead. lWhich lassessment
lfinding lis lthe learliest land lmost lsensitive lindication lof laltered lcerebral
lfunction?
a. Unequal lpupils.
b. Loss lof lcentral lreflexes.
c. Inability lto lopen lthe leyes.
d. Change lin llevel lof lconsciousness.: lD
(Neurological lvital lsigns linclude lserial lassessments lof lTPR, lblood
lpressure, land lcomponents lof lthe lGlasgow lcoma lscale l(GCS), lwhich
lincludes lverbal, lmuscu- lloskeletal, land lpupillary lresponses. lA lchange lin
lthe lclient's llevel lof lconsciousness, las lindicated lby lresponses lto
lcommands lduring lthe lGCS, lis lthe lfirst land lthe lmost lsensitive lsign lof
lchange lin lcerebral lfunction. lThe lother lassessment ldata lchoices lare llate
lsigns lof laltered lcerebral lfunction.)
2.A lnurse lis lplanning lto lteach lself-care lmeasures lto la lfemale lclient labout
lprevention lof lyeast linfections. lWhich linstructions lshould lthe lnurse
lprovide?
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,a. Use la ldouche lpreparation lno lmore lthan lonce la lmonth.
b. Increase ldaily lintake lof lfiber land lleafy lgreen lvegetables.
c. Select lnylon lunderwear lthat lis lloose-fitting, lwhite, land lcomfortable.
d. Avoid ltight-fitting lclothing land ldo lnot luse lbubble-bath lor lbath lsalts.: lD
(A lcommon lgenital ltract linfection lin lfemales lis lcandidiasis, lwhich lis lan
lovergrowth lof lthe lnormal lvaginal lflora lof lCandida lalbicans lthat lthrives
lin lan lenvironment lthat lis lwarm land lmoist land lis lperpetuated lby ltight-
fitting lclothing, lunderwear, lor lpantyhose lmade lof lnonabsorbent
lmaterials. lThe lclient lshould lwear lclothing lthat lis lloose lfitting land
labsorbent, lsuch las lcotton lunderwear, land lavoid lusing lbubble-bath lor
lbath lsalts lwhich lfurther lirritate lsensitive lgenital ltissue. lDouching lis lnot
lrecommended lbecause lit lcan lirritate lvaginal ltissue, lalter lpH, land
lcontribute lto lfungal lgrowth. lWhile lincreasing ldietary lfiber lintake
lencourages lhealthy, lnutritional lguidelines, lit lis lnot lthe lfocus lof lthe
lteaching. lCotton, lnot lnylon lundergarments, lprovide labsorbancy land
lreduce lmoisture lin lthe lperineal larea.)
3.A lclient lwho lhas lactive ltuberculosis l(TB) lis ladmitted lto lthe lmedical lunit.
What laction lis lmost limportant lfor lthe lnurse lto limplement?
a. Place lan lisolation lcart lin lthe lhallway.
b. Fit lthe lclient lwith la lrespirator lmask.
c. Don la lclean lgown lfor lclient lcare.
d. Assign lthe lclient lto la lnegative lair-flow lroom.: lD
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,(Active ltuberculosis lrequires limplementation lof lairborne lprecautions, lso
lthe lclient lshould lbe lassigned lto la lnegative lpressure lair-flow lroom.
lAlthough lisolation lgowns land lisolation lcarts lshould lbe limplemented lfor
lclients lin lisolation lwith lcontact lprecautions, lit lis lmost limportant lthat lair
lflow lfrom lthe lroom lis lminimized lwhen lthe lclient lhas lTB. lThe lrespirator
lmask lshould lbe limplemented lwhen lthe lclient lleaves lthe lisolation
lenvironment.)
4.The lnurse lis lplanning lto lconduct lnutritional lassessments land ldiet
lteaching lto lclients lat la lfamily lhealth lclinic. lWhich lindividual lhas lthe lgreatest
lnutritional land lenergy ldemands?
a. lA lpregnant lwoman.
b. lA lteenager lbeginning lpuberty.
c. lA l3-month-old linfant.
d. lA lschool-aged lchild.: lA
A lpregnant lwoman's lmetabolic ldemands lare l20 lto l24% lmore lthan lthe
lbasic lmeta- lbolic lrate. lThe lother lclients lrequire lonly l15 lto l20% lmore
lthan lthe lbasic lmetabolic lrate.
5.What lnursing ldelivery lof lcare lprovides lthe lnurse lto lplan land ldirect lcare
lof la lgroup lof lclients lover la l24-hour lperiod?
a. Team lnursing.
b. Primary lnursing.
c. Case lmanagement.
d. Functional lnursing.: lB
(Primary lnursing lis la lmodel lof ldelivery lof lcare lwhere la lnurse lis
laccountable lfor lplanning lcare lfor lclients laround lthe lclock. lFunctional
lnursing lis la lcare ldelivery lmodel lthat lprovides lclient lcare lby lassignment
lof lfunctions lor ltasks. lTeam lnursing lis la lcare ldelivery lmodel lwhere
lassignments lto la lgroup lof lclients lare lprovided lby la lmixed-staff lteam.
lCase lmanagement lis lthe ldelivery lof lcare lthat luses la lcollaborative
lprocess lof lassessment, lplanning, lfacilitation, land ladvocacy lfor loptions
land lservices lto lmeet lan lindividual's lhealth lneeds land lpromote lquality
lcost-effective loutcomes.)
6.Which lapproach lshould lthe lnurse luse lwhen lpreparing la ltoddler lfor
la lprocedure?
a. Demonstrate lthe lprocedure lusing la ldoll.
b. Avoid lasking lthe lchild lto lmake lchoices.
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, c. Plan la lteaching lsession lto llast labout l20 lminutes.
d. Show lequipment lbut lprevent lchild lfrom lhandling lit.: lA
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RATIONALE) WITH VERIFIED SOLUTIONS
1.The lnurse lis lmonitoring lneurological lvital lsigns lfor la lmale lclient lwho
llost lconsciousness lafter lfalling land lhitting lhis lhead. lWhich lassessment
lfinding lis lthe learliest land lmost lsensitive lindication lof laltered lcerebral
lfunction?
a. Unequal lpupils.
b. Loss lof lcentral lreflexes.
c. Inability lto lopen lthe leyes.
d. Change lin llevel lof lconsciousness.: lD
(Neurological lvital lsigns linclude lserial lassessments lof lTPR, lblood
lpressure, land lcomponents lof lthe lGlasgow lcoma lscale l(GCS), lwhich
lincludes lverbal, lmuscu- lloskeletal, land lpupillary lresponses. lA lchange lin
lthe lclient's llevel lof lconsciousness, las lindicated lby lresponses lto
lcommands lduring lthe lGCS, lis lthe lfirst land lthe lmost lsensitive lsign lof
lchange lin lcerebral lfunction. lThe lother lassessment ldata lchoices lare llate
lsigns lof laltered lcerebral lfunction.)
2.A lnurse lis lplanning lto lteach lself-care lmeasures lto la lfemale lclient labout
lprevention lof lyeast linfections. lWhich linstructions lshould lthe lnurse
lprovide?
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,a. Use la ldouche lpreparation lno lmore lthan lonce la lmonth.
b. Increase ldaily lintake lof lfiber land lleafy lgreen lvegetables.
c. Select lnylon lunderwear lthat lis lloose-fitting, lwhite, land lcomfortable.
d. Avoid ltight-fitting lclothing land ldo lnot luse lbubble-bath lor lbath lsalts.: lD
(A lcommon lgenital ltract linfection lin lfemales lis lcandidiasis, lwhich lis lan
lovergrowth lof lthe lnormal lvaginal lflora lof lCandida lalbicans lthat lthrives
lin lan lenvironment lthat lis lwarm land lmoist land lis lperpetuated lby ltight-
fitting lclothing, lunderwear, lor lpantyhose lmade lof lnonabsorbent
lmaterials. lThe lclient lshould lwear lclothing lthat lis lloose lfitting land
labsorbent, lsuch las lcotton lunderwear, land lavoid lusing lbubble-bath lor
lbath lsalts lwhich lfurther lirritate lsensitive lgenital ltissue. lDouching lis lnot
lrecommended lbecause lit lcan lirritate lvaginal ltissue, lalter lpH, land
lcontribute lto lfungal lgrowth. lWhile lincreasing ldietary lfiber lintake
lencourages lhealthy, lnutritional lguidelines, lit lis lnot lthe lfocus lof lthe
lteaching. lCotton, lnot lnylon lundergarments, lprovide labsorbancy land
lreduce lmoisture lin lthe lperineal larea.)
3.A lclient lwho lhas lactive ltuberculosis l(TB) lis ladmitted lto lthe lmedical lunit.
What laction lis lmost limportant lfor lthe lnurse lto limplement?
a. Place lan lisolation lcart lin lthe lhallway.
b. Fit lthe lclient lwith la lrespirator lmask.
c. Don la lclean lgown lfor lclient lcare.
d. Assign lthe lclient lto la lnegative lair-flow lroom.: lD
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l94
,(Active ltuberculosis lrequires limplementation lof lairborne lprecautions, lso
lthe lclient lshould lbe lassigned lto la lnegative lpressure lair-flow lroom.
lAlthough lisolation lgowns land lisolation lcarts lshould lbe limplemented lfor
lclients lin lisolation lwith lcontact lprecautions, lit lis lmost limportant lthat lair
lflow lfrom lthe lroom lis lminimized lwhen lthe lclient lhas lTB. lThe lrespirator
lmask lshould lbe limplemented lwhen lthe lclient lleaves lthe lisolation
lenvironment.)
4.The lnurse lis lplanning lto lconduct lnutritional lassessments land ldiet
lteaching lto lclients lat la lfamily lhealth lclinic. lWhich lindividual lhas lthe lgreatest
lnutritional land lenergy ldemands?
a. lA lpregnant lwoman.
b. lA lteenager lbeginning lpuberty.
c. lA l3-month-old linfant.
d. lA lschool-aged lchild.: lA
A lpregnant lwoman's lmetabolic ldemands lare l20 lto l24% lmore lthan lthe
lbasic lmeta- lbolic lrate. lThe lother lclients lrequire lonly l15 lto l20% lmore
lthan lthe lbasic lmetabolic lrate.
5.What lnursing ldelivery lof lcare lprovides lthe lnurse lto lplan land ldirect lcare
lof la lgroup lof lclients lover la l24-hour lperiod?
a. Team lnursing.
b. Primary lnursing.
c. Case lmanagement.
d. Functional lnursing.: lB
(Primary lnursing lis la lmodel lof ldelivery lof lcare lwhere la lnurse lis
laccountable lfor lplanning lcare lfor lclients laround lthe lclock. lFunctional
lnursing lis la lcare ldelivery lmodel lthat lprovides lclient lcare lby lassignment
lof lfunctions lor ltasks. lTeam lnursing lis la lcare ldelivery lmodel lwhere
lassignments lto la lgroup lof lclients lare lprovided lby la lmixed-staff lteam.
lCase lmanagement lis lthe ldelivery lof lcare lthat luses la lcollaborative
lprocess lof lassessment, lplanning, lfacilitation, land ladvocacy lfor loptions
land lservices lto lmeet lan lindividual's lhealth lneeds land lpromote lquality
lcost-effective loutcomes.)
6.Which lapproach lshould lthe lnurse luse lwhen lpreparing la ltoddler lfor
la lprocedure?
a. Demonstrate lthe lprocedure lusing la ldoll.
b. Avoid lasking lthe lchild lto lmake lchoices.
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, c. Plan la lteaching lsession lto llast labout l20 lminutes.
d. Show lequipment lbut lprevent lchild lfrom lhandling lit.: lA
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l94
