HESI Comprehensive Review for the
NCLEX-RN Examination
1. A nurse discovers a postpartum client with a boggy uterus that is displaced above and to the
right of the umbilicus.What nursing action is indicated? - ANS-1. Perform immediate fundal
massage.Ambulate to the bathroom or use bedpan to empty the bladder because cardinal signs
of bladder distention are present.
\1. Compare the signs and symptoms of acute glomerulonephritis (AGN) with those of
nephrosis. - ANS-1. AGN: gross hematuria, recent strep infection, hypertension, and mild
edema; nephrosis: severe edema, massive proteinuria, frothy-appearing urine, anorexia
\1. Describe feeding techniques for a child with cleft lip or palate. - ANS-1. Use lamb's nipple or
prosthesis. Feed the child upright, with frequent bubbling.
\1. Describe the information families should be given when a child is receiving oral iron
preparations. - ANS-1. Give oral iron on an empty stomach and with vitamin C. Use straws to
avoid discoloration teeth.Tarry stools are normal. Increase dietary sources of iron.
\1. Describe the purpose of bronchodilators. - ANS-1. To reverse bronchospasm
\1. Differentiate between a right-to-left and a left-to-right shunt in cardiac disease. - ANS-1. A
right-to-left shunt bypasses the lungs and delivers unoxygenated blood to the systemic
circulation, causing cyanosis. A left-to-right shunt moves oxygenated blood back through the
pulmonary circulation.
\1. How is congenital hypothyroidism diagnosed? - ANS-1. Newborn screening revealing a low
T4 and a high TSH
\1. List five prodromal signs of labor the nurse might teach the client. - ANS-1. Lightening,
Braxton Hicks contractions, increased bloody show, loss of mucous plug, burst of energy, and
nesting behaviors.
\1. List four categories of burns. - ANS-1. Thermal, radiation, chemical, electrical
\1. List normal findings in a neurovascular assessment. - ANS-1. Warm extremity, brisk capillary
refill, free movement, normal sensation of the affected extremity, and equal pulses
\1. List three potential causes of anemia. - ANS-1. Diet lacking in iron, folate, or vitamin B12;
use of salicylates, thiazides, diuretics; exposure to toxic agents, such as lead or insecticides
\1. List two contraindications to live virus immunization. - ANS-1. Immunocompromised child or
a child in a household with an immunocompromised individual
\1. Name five maternal variables associated with diagnosis of a high-risk pregnancy. - ANS-1.
Age (under 17 or over 34 years of age); parity (over 5); <3 months between pregnancies;
diagnosis of preeclampsia, diabetes mellitus, or cardiac disease.
\1. State the objective signs that signify ovulation. - ANS-1. Abundant, thin, clear cervical
mucus; spinnbarkeit (egg-white stretchiness) of cervical mucus; open cervical os; slight drop in
basal body temperature and then 0.5° to 1° F rise; ferning under the microscope
\1. The newborn transitional period consists of the first _____ of life. - ANS-1. 6 to 8 hours
\1. What are the classifications of the commonly prescribed eye drops for glaucoma? - ANS-1.
Parasympathomimetic for pupillary constriction; beta-adrenergic receptor-blocking agents to
,inhibit formation of aqueous humor; carbonic anhydrase inhibitors to reduce aqueous humor
production; and prostaglandin agonists to increase aqueous humor out flow
\1. What are the indications for a hysterectomy in a client who has fibromas? - ANS-1. Severe
menorrhagia leading to anemia, severe dysmenorrhea requiring narcotic analgesics, severe
uterine enlargement causing pressure on other organs, severe low back and pelvic pain
\1. What are the physical features of a child with Down syndrome? - ANS-1. Simian creases in
palms, hypotonia, protruding tongue, and upward-outward slant of eyes
\10. A woman asks why she is urinating so much in the postpartum period.The nurse bases the
response on what information? - ANS-10. Up to 3000 mL per day can be voided because of the
reduction in the 40% plasma volume increase during pregnancy.
\10. Describe an autograft. - ANS-10. Use of client's own skin for grafting.
\10. Describe developmental factors that would impact the school-age child with diabetes. -
ANS-10. Need to be like peers; assuming responsibility for own care; modi cation of diet; snacks
and exercise in school
\10. Describe the use of leucovorin. - ANS-10. Leucovorin is used as an antidote with
methotrexate to prevent toxic reactions.
\10. How can the nurse best evaluate the adequacy of fluid replacement in children? - ANS-10.
By monitoring urine output
\10. How is a child usually positioned after brain tumor surgery? - ANS-10. Flat or on either side
\10. Identify three ways to determine the presence of congenital hip dislocation in the newborn. -
ANS-10. Hip click determination, asymmetric gluteal folds, unequal limb lengths
\10. State three principles relative to the pattern of weight gain in pregnancy. - ANS-10. Total
gain should average 25 to 35 lb. Gain should be consistent throughout pregnancy.An average of
1 lb/week should be gained in the second and third trimesters.
\10. What care is indicated for a child with juvenile rheumatoid arthritis? - ANS-10. Prescribed
exercise to maintain mobility; splinting of affected joints; and teaching about medication
management and side
effects of drugs.
\10. What is the most common cause of nongonococcal urethritis? - ANS-10. Chlamydia
trachomatis
\10. What is the most common postoperative complication following a tonsillectomy? Describe
the signs and symptoms of this complication. - ANS-10. Hemorrhage; frequent swallowing,
vomiting fresh blood, and clearing throat
\10. What is the most important indicator of fetal autonomic nervous system integrity and
health? - ANS-10. FHR variability
\10. What medications are used to treat rheumatic fever? - ANS-10. Penicillin, erythromycin, and
aspirin
\10. What nursing interventions prevent corneal drying in a comatose client? - ANS-10. Irrigation
of eyes PRN with sterile prescribed solution, application of ophthalmic ointment every 8 hours,
close assessment for corneal ulceration or drying
\10. Where is the FHR best heard? - ANS-10. Through the fetal back in vertex, OA positions
\11. A woman's white blood count is 17,000; she is afebrile and has no symptoms of infection.
What nursing action is indicated? - ANS-11. Continue routine assessments; normal leukocytosis
occurs during postpartal period because of placental site healing.
,\11. Describe the function of an osmotic diuretic. - ANS-11. Osmotic diuretics remove water from
the CNS to reduce cerebral edema.
\11. Describe the method of collecting the trough and peak blood levels of antibiotics. - ANS-11.
Collection of trough: draw blood 30 minutes prior to administration of antibiotic. Collection of
peak: Draw blood 30 minutes after administration of antibiotic.
\11. During pregnancy a woman should add _____ calories to her diet and drink _____ of milk
per day. - ANS-11. 300; 3 cups
\11. How should a parent be instructed to child-proof a house? - ANS-11. By being taught to lock
all cabinets, to safely store all toxic household items in locked cabinets, and to examine the
house from the child's point of view
\11. Name four causes of decreased FHR variability. - ANS-11. Hypoxia, acidosis, drugs, fetal
sleep
\11. Normal FHR during labor is _____. - ANS-11. 110 to l60 bpm
\11. Should the normal newborn have a positive or negative Babinski reflex? - ANS-11. Positive;
the transient re ex is present until 12 to 18 months of age.
\11. What is the causative organism of syphilis? - ANS-11. Treponema pallidum (spirochete
bacteria)
\11. What is the relationship between hypoglycemia and exercise? - ANS-11. During exercise,
insulin uptake is increased and the risk for hypoglycemia occurs.
\11. When can a comatose client on IV hyperalimentation begin to receive tube feedings
instead? - ANS-11. When peristalsis resumes as evidenced by active bowel sounds, passage of
flatus or bowel movement
\12. A small-for-gestational-age newborn is identified as one who _____. - ANS-12. Has a
weight below the tenth percentile for estimated weeks of gestation.
\12. FHR can be auscultated by Doppler at _____ weeks' gestation. - ANS-12. 10 to 12
\12. List four nursing interventions for care of the client with Hodgkin disease. - ANS-12. Protect
from infection. Observe for anemia. Encourage high-nutrient foods. Provide emotional support
to client and family.
\12. Malodorous, frothy, greenish-yellow vaginal discharge is characteristic of which STD? -
ANS-12. Trichomonas vaginalis
\12. Normal maternal BP during labor is _____. - ANS-12. <140/90
\12. State the most important action to take when a cord prolapse is determined. - ANS-12.
Examiner should position mother to relieve pressure on the cord or push the presenting part off
the cord with fingers until
emergency delivery is accomplished.
\12. What interventions should the nurse perform first in caring for a child who has ingested a
poison? - ANS-12. Assessment of the child's respiratory, cardiac, and neurologic status
\12. What is the most common cause of uterine atony in the first 24 hours postpartum? -
ANS-12. A full bladder
\12. What is the most important principle in a bowel management program for a client with
neurologic deficits? - ANS-12. Establishment of regularity
\12. What nursing interventions increase intracranial pressure? - ANS-12. Suctioning and
positioning, turning
, \13. Define stroke. - ANS-13. A disruption of blood supply to a part of the brain, which results in
sudden loss of brain function
\13. Describe the mechanism of inheritance of Duchenne muscular dystrophy. - ANS-13.
Duchenne muscular dystrophy is inherited as an X-linked recessive trait.
\13. Describe the schedule of prenatal visits for a low-risk pregnant woman. - ANS-13. Once
every 4 weeks until 28 weeks; every 2 weeks from 28 to 36 weeks; then once a week until
delivery
\13. List four topics you would cover when teaching an immunosuppressed client about infection
control. - ANS-13. Handwashing technique. Avoid infected persons.Avoid crowds. Maintain daily
hygiene to prevent spread of microorganisms.
\13. Normal maternal pulse during labor is _____. - ANS-13. <100 bpm
\13. What early signs should the nurse assess for if lead poisoning is suspected? - ANS-13.
Anemia, acute cramping, abdominal pain, vomiting, constipation, anorexia, headache, lethargy,
hyperactivity, aggression,
impulsiveness, decreased interest in play, irritability, short attention span
\13. What is a reactive nonstress test? - ANS-13. FHR acceleration of 15 bpm for 15 seconds in
response to fetal movement
\13. What is the purpose of giving docusate sodium (Colace) to the postpartum client? -
ANS-13. To soften the stool in mothers with third- or fourth-degree episiotomies, hemorrhoids, or
cesarean section delivery.
\13. When suctioning the newborn with a bulb syringe, which should be suctioned first, the
mouth or the nose? - ANS-13. The mouth; stimulating the nares can initiate inspiration, which
could cause aspiration of mucus in oral pharynx.
\13. Which STD is characterized by remissions and exacerbations in both males and females? -
ANS-13. Herpes simplex type II
\14. A client with a diagnosis of stroke presents with symptoms of aphasia and right hemiparesis
but no memory or hearing deficit. In what hemisphere has the client suffered a lesion? -
ANS-14. Left
\14. A new mother asks the nurse whether circumcision is medically indicated in the newborn.
How should the nurse respond? - ANS-14. There is controversy concerning this issue, but we
do know it causes pain and trauma to the newborn, and the medical
indications (prevention of penile and cervical cancer) may be unfounded.
\14. Normal maternal temperature during labor is _____. - ANS-14. <100.4° F
\14. Outline a teaching plan for a client with an STD. - ANS-14. Signs and symptoms of STD;
mode of transmission; avoiding sex while infected; providing concise written instructions
regarding treatment, and requesting a return verbalization to ensure that the client understands;
teaching safer sex practices
\14. What are the dangers of the nipple-stimulation stress test? - ANS-14. The inability to control
oxytocin "dosage" and the chance of tetany/hyperstimulation
\14. What is the Gowers sign? - ANS-14. Gowers sign is an indicator of muscular dystrophy; to
stand, the child has to "walk" hands up legs.
\14. What should the fundal height be at 3 days postpartum for a woman who has had a vaginal
delivery? - ANS-14. Three fingerbreadths/cm below the umbilicus.
NCLEX-RN Examination
1. A nurse discovers a postpartum client with a boggy uterus that is displaced above and to the
right of the umbilicus.What nursing action is indicated? - ANS-1. Perform immediate fundal
massage.Ambulate to the bathroom or use bedpan to empty the bladder because cardinal signs
of bladder distention are present.
\1. Compare the signs and symptoms of acute glomerulonephritis (AGN) with those of
nephrosis. - ANS-1. AGN: gross hematuria, recent strep infection, hypertension, and mild
edema; nephrosis: severe edema, massive proteinuria, frothy-appearing urine, anorexia
\1. Describe feeding techniques for a child with cleft lip or palate. - ANS-1. Use lamb's nipple or
prosthesis. Feed the child upright, with frequent bubbling.
\1. Describe the information families should be given when a child is receiving oral iron
preparations. - ANS-1. Give oral iron on an empty stomach and with vitamin C. Use straws to
avoid discoloration teeth.Tarry stools are normal. Increase dietary sources of iron.
\1. Describe the purpose of bronchodilators. - ANS-1. To reverse bronchospasm
\1. Differentiate between a right-to-left and a left-to-right shunt in cardiac disease. - ANS-1. A
right-to-left shunt bypasses the lungs and delivers unoxygenated blood to the systemic
circulation, causing cyanosis. A left-to-right shunt moves oxygenated blood back through the
pulmonary circulation.
\1. How is congenital hypothyroidism diagnosed? - ANS-1. Newborn screening revealing a low
T4 and a high TSH
\1. List five prodromal signs of labor the nurse might teach the client. - ANS-1. Lightening,
Braxton Hicks contractions, increased bloody show, loss of mucous plug, burst of energy, and
nesting behaviors.
\1. List four categories of burns. - ANS-1. Thermal, radiation, chemical, electrical
\1. List normal findings in a neurovascular assessment. - ANS-1. Warm extremity, brisk capillary
refill, free movement, normal sensation of the affected extremity, and equal pulses
\1. List three potential causes of anemia. - ANS-1. Diet lacking in iron, folate, or vitamin B12;
use of salicylates, thiazides, diuretics; exposure to toxic agents, such as lead or insecticides
\1. List two contraindications to live virus immunization. - ANS-1. Immunocompromised child or
a child in a household with an immunocompromised individual
\1. Name five maternal variables associated with diagnosis of a high-risk pregnancy. - ANS-1.
Age (under 17 or over 34 years of age); parity (over 5); <3 months between pregnancies;
diagnosis of preeclampsia, diabetes mellitus, or cardiac disease.
\1. State the objective signs that signify ovulation. - ANS-1. Abundant, thin, clear cervical
mucus; spinnbarkeit (egg-white stretchiness) of cervical mucus; open cervical os; slight drop in
basal body temperature and then 0.5° to 1° F rise; ferning under the microscope
\1. The newborn transitional period consists of the first _____ of life. - ANS-1. 6 to 8 hours
\1. What are the classifications of the commonly prescribed eye drops for glaucoma? - ANS-1.
Parasympathomimetic for pupillary constriction; beta-adrenergic receptor-blocking agents to
,inhibit formation of aqueous humor; carbonic anhydrase inhibitors to reduce aqueous humor
production; and prostaglandin agonists to increase aqueous humor out flow
\1. What are the indications for a hysterectomy in a client who has fibromas? - ANS-1. Severe
menorrhagia leading to anemia, severe dysmenorrhea requiring narcotic analgesics, severe
uterine enlargement causing pressure on other organs, severe low back and pelvic pain
\1. What are the physical features of a child with Down syndrome? - ANS-1. Simian creases in
palms, hypotonia, protruding tongue, and upward-outward slant of eyes
\10. A woman asks why she is urinating so much in the postpartum period.The nurse bases the
response on what information? - ANS-10. Up to 3000 mL per day can be voided because of the
reduction in the 40% plasma volume increase during pregnancy.
\10. Describe an autograft. - ANS-10. Use of client's own skin for grafting.
\10. Describe developmental factors that would impact the school-age child with diabetes. -
ANS-10. Need to be like peers; assuming responsibility for own care; modi cation of diet; snacks
and exercise in school
\10. Describe the use of leucovorin. - ANS-10. Leucovorin is used as an antidote with
methotrexate to prevent toxic reactions.
\10. How can the nurse best evaluate the adequacy of fluid replacement in children? - ANS-10.
By monitoring urine output
\10. How is a child usually positioned after brain tumor surgery? - ANS-10. Flat or on either side
\10. Identify three ways to determine the presence of congenital hip dislocation in the newborn. -
ANS-10. Hip click determination, asymmetric gluteal folds, unequal limb lengths
\10. State three principles relative to the pattern of weight gain in pregnancy. - ANS-10. Total
gain should average 25 to 35 lb. Gain should be consistent throughout pregnancy.An average of
1 lb/week should be gained in the second and third trimesters.
\10. What care is indicated for a child with juvenile rheumatoid arthritis? - ANS-10. Prescribed
exercise to maintain mobility; splinting of affected joints; and teaching about medication
management and side
effects of drugs.
\10. What is the most common cause of nongonococcal urethritis? - ANS-10. Chlamydia
trachomatis
\10. What is the most common postoperative complication following a tonsillectomy? Describe
the signs and symptoms of this complication. - ANS-10. Hemorrhage; frequent swallowing,
vomiting fresh blood, and clearing throat
\10. What is the most important indicator of fetal autonomic nervous system integrity and
health? - ANS-10. FHR variability
\10. What medications are used to treat rheumatic fever? - ANS-10. Penicillin, erythromycin, and
aspirin
\10. What nursing interventions prevent corneal drying in a comatose client? - ANS-10. Irrigation
of eyes PRN with sterile prescribed solution, application of ophthalmic ointment every 8 hours,
close assessment for corneal ulceration or drying
\10. Where is the FHR best heard? - ANS-10. Through the fetal back in vertex, OA positions
\11. A woman's white blood count is 17,000; she is afebrile and has no symptoms of infection.
What nursing action is indicated? - ANS-11. Continue routine assessments; normal leukocytosis
occurs during postpartal period because of placental site healing.
,\11. Describe the function of an osmotic diuretic. - ANS-11. Osmotic diuretics remove water from
the CNS to reduce cerebral edema.
\11. Describe the method of collecting the trough and peak blood levels of antibiotics. - ANS-11.
Collection of trough: draw blood 30 minutes prior to administration of antibiotic. Collection of
peak: Draw blood 30 minutes after administration of antibiotic.
\11. During pregnancy a woman should add _____ calories to her diet and drink _____ of milk
per day. - ANS-11. 300; 3 cups
\11. How should a parent be instructed to child-proof a house? - ANS-11. By being taught to lock
all cabinets, to safely store all toxic household items in locked cabinets, and to examine the
house from the child's point of view
\11. Name four causes of decreased FHR variability. - ANS-11. Hypoxia, acidosis, drugs, fetal
sleep
\11. Normal FHR during labor is _____. - ANS-11. 110 to l60 bpm
\11. Should the normal newborn have a positive or negative Babinski reflex? - ANS-11. Positive;
the transient re ex is present until 12 to 18 months of age.
\11. What is the causative organism of syphilis? - ANS-11. Treponema pallidum (spirochete
bacteria)
\11. What is the relationship between hypoglycemia and exercise? - ANS-11. During exercise,
insulin uptake is increased and the risk for hypoglycemia occurs.
\11. When can a comatose client on IV hyperalimentation begin to receive tube feedings
instead? - ANS-11. When peristalsis resumes as evidenced by active bowel sounds, passage of
flatus or bowel movement
\12. A small-for-gestational-age newborn is identified as one who _____. - ANS-12. Has a
weight below the tenth percentile for estimated weeks of gestation.
\12. FHR can be auscultated by Doppler at _____ weeks' gestation. - ANS-12. 10 to 12
\12. List four nursing interventions for care of the client with Hodgkin disease. - ANS-12. Protect
from infection. Observe for anemia. Encourage high-nutrient foods. Provide emotional support
to client and family.
\12. Malodorous, frothy, greenish-yellow vaginal discharge is characteristic of which STD? -
ANS-12. Trichomonas vaginalis
\12. Normal maternal BP during labor is _____. - ANS-12. <140/90
\12. State the most important action to take when a cord prolapse is determined. - ANS-12.
Examiner should position mother to relieve pressure on the cord or push the presenting part off
the cord with fingers until
emergency delivery is accomplished.
\12. What interventions should the nurse perform first in caring for a child who has ingested a
poison? - ANS-12. Assessment of the child's respiratory, cardiac, and neurologic status
\12. What is the most common cause of uterine atony in the first 24 hours postpartum? -
ANS-12. A full bladder
\12. What is the most important principle in a bowel management program for a client with
neurologic deficits? - ANS-12. Establishment of regularity
\12. What nursing interventions increase intracranial pressure? - ANS-12. Suctioning and
positioning, turning
, \13. Define stroke. - ANS-13. A disruption of blood supply to a part of the brain, which results in
sudden loss of brain function
\13. Describe the mechanism of inheritance of Duchenne muscular dystrophy. - ANS-13.
Duchenne muscular dystrophy is inherited as an X-linked recessive trait.
\13. Describe the schedule of prenatal visits for a low-risk pregnant woman. - ANS-13. Once
every 4 weeks until 28 weeks; every 2 weeks from 28 to 36 weeks; then once a week until
delivery
\13. List four topics you would cover when teaching an immunosuppressed client about infection
control. - ANS-13. Handwashing technique. Avoid infected persons.Avoid crowds. Maintain daily
hygiene to prevent spread of microorganisms.
\13. Normal maternal pulse during labor is _____. - ANS-13. <100 bpm
\13. What early signs should the nurse assess for if lead poisoning is suspected? - ANS-13.
Anemia, acute cramping, abdominal pain, vomiting, constipation, anorexia, headache, lethargy,
hyperactivity, aggression,
impulsiveness, decreased interest in play, irritability, short attention span
\13. What is a reactive nonstress test? - ANS-13. FHR acceleration of 15 bpm for 15 seconds in
response to fetal movement
\13. What is the purpose of giving docusate sodium (Colace) to the postpartum client? -
ANS-13. To soften the stool in mothers with third- or fourth-degree episiotomies, hemorrhoids, or
cesarean section delivery.
\13. When suctioning the newborn with a bulb syringe, which should be suctioned first, the
mouth or the nose? - ANS-13. The mouth; stimulating the nares can initiate inspiration, which
could cause aspiration of mucus in oral pharynx.
\13. Which STD is characterized by remissions and exacerbations in both males and females? -
ANS-13. Herpes simplex type II
\14. A client with a diagnosis of stroke presents with symptoms of aphasia and right hemiparesis
but no memory or hearing deficit. In what hemisphere has the client suffered a lesion? -
ANS-14. Left
\14. A new mother asks the nurse whether circumcision is medically indicated in the newborn.
How should the nurse respond? - ANS-14. There is controversy concerning this issue, but we
do know it causes pain and trauma to the newborn, and the medical
indications (prevention of penile and cervical cancer) may be unfounded.
\14. Normal maternal temperature during labor is _____. - ANS-14. <100.4° F
\14. Outline a teaching plan for a client with an STD. - ANS-14. Signs and symptoms of STD;
mode of transmission; avoiding sex while infected; providing concise written instructions
regarding treatment, and requesting a return verbalization to ensure that the client understands;
teaching safer sex practices
\14. What are the dangers of the nipple-stimulation stress test? - ANS-14. The inability to control
oxytocin "dosage" and the chance of tetany/hyperstimulation
\14. What is the Gowers sign? - ANS-14. Gowers sign is an indicator of muscular dystrophy; to
stand, the child has to "walk" hands up legs.
\14. What should the fundal height be at 3 days postpartum for a woman who has had a vaginal
delivery? - ANS-14. Three fingerbreadths/cm below the umbilicus.
