HESI Comprehensive Exam B
1. An 8-year-old child is receiving digoxin 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?Ans: A.
Because the child's heart rate and digoxin level are within normal range, assess for the cause
of the nausea. Rationale: Nausea and vomiting are early signs of digoxin toxicity. However, the
normal resting heart rate for a child 8 to 10 years of age is 70 to 110 beats/min, and the
therapeutic range of serum digoxin levels is 0.5 to 2 ng/mL. Based on the objective data, option
A is the best of the choices provided because the serum digoxin level is within normal levels.
Option B is not warranted by the data presented. The digoxin level is within the therapeutic
range, and the child is not showing signs of toxicity. The child's pulse rate is within normal range
for her age group.
2. The nurse expects a clinical finding of cyanosis in an infant with which conditions? (Select all
that apply.) Ans: D. Tetralogy of Fallot & E. Transposition of the great vessels. Rationale: Both
tetralogy of Fallot and transposition of the great vessels are classified as cyanotic heart disease,
in which unoxygenated blood is pumped into the systemic circulation, causing cyanosis (D and
E). (A, B, and C) are all abnormal cardiac conditions, but are classified as acyanotic and involve
left-to-right shunts, increased pulmonary blood flow, or obstructive defects.
3. The nurse hears a series of long-duration, discontinuous, low-pitched sounds on auscultation of
a client's lower lung fields. Which documentation of this finding is correct? Ans: C. Course
crackles. Rationale: Course crackles are caused by air passing through airways that are
intermittently occluded by mucus. Fine crackles are a series of short-duration, discontinuous,
high-pitched sounds. Wheezes are continuous, high-pitched, musical or squeaking-type sounds.
Stridor is a continuous croupy sound of constant pitch and indicates partial obstruction of the
airway.
4. A 45-year-old female client is admitted to the psychiatric unit for evaluation. Her husband states
that she has been reluctant to leave home for the last 6 months. The client has not gone to work
for a month, has been terminated from her job, and has not left the house since that time. This
client is displaying symptoms of which disorder?Ans: C. Agoraphobia. Rationale: Agoraphobia is
the fear of crowds or of being in an open place. Option A is the fear of being in closed places.
Option B is the fear of high places. Option D is an abnormal fear of death or bodies after death.
A phobia is an unrealistic fear associated with severe anxiety.
5. Which clinical manifestation in the client with hyperthyroidism is most important to report to
the health care provider?Ans: C. Apical heart rate of 130 beats/min. Rationale:The apical heart
rate of 130 beats/min is a critical finding that could lead to heart failure or other cardiac
disorders. Options A, B, and D are all expected findings that should also be reported but are not
as critical.
6. When caring for a client hospitalized with Guillain-Barré syndrome, which information is most
important for the nurse to report to the primary health care provider?Ans: B. Decrease in
cognitive status of the client. Rationale: A decline in cognitive status in a client is indicative of
symptoms of hypoxia and a possible need to assist the client with mechanical ventilation. A
primary health care provider will need to be contacted immediately. Options A, C, and D are
, findings associated with Guillain-Barré syndrome that should also be reported but are not as
critical as the client's hypoxic status.
7. The nurse prepares to administer acetaminophen oral suspension to a child who weighs 66 lb.
The prescription reads: Administer 15 mg/kg every 6 hours by mouth. The Tylenol is available
150 mg/5 mL. What is the correct dosage as indicated on the figure.Ans: B. 15 mL.
8. A client in the psychiatric setting with an anxiety disorder reports chest pain. Which action
should the nurse take first?Ans: B. Assess the client's vital signs. Rationale: Although increased
heart rate, palpitations, and chest pain may be caused by anxiety, it is important that the nurse
assess the client and rule out physiologic causes. Nonpharmacologic measures should be taken
first. Options C and D may be considered but are not as high priority as the initial physiologic
assessment.
9. A client who is prescribed chlorpromazine HCl for schizophrenia develops rigidity, a shuffling
gait, and tremors. Which action by the nurse is most important?Ans: A. Administer a dose of
benztropine mesylate PRN. Rationale: Rigidity, shuffling gait, pill-rolling hand movements,
tremors, dyskinesia, and masklike face are extrapyramidal side effects associated with
chlorpromazine. It is most important for the nurse to administer an anticholinergic such as
benztropine mesylate to reverse these effects. Options B, C, and D may be appropriate
interventions but are not as urgent as option A.
10. A nurse is assessing a client with heart failure who has been prescribed digoxin for therapy.
Which finding indicates an issue with the medication management?Ans: B. Serum potassium
level, 2.9 mEq/L. Rationale:A serum potassium level of 2.9 mEq/L is low, and side effects of
digoxin toxicity are exacerbated when the potassium level is low. Options A, C, and D are all
expected findings when caring for a client with congestive heart failure.
11. A client who is first day postoperative after a mastectomy becomes increasingly restless and
agitated. Vital signs are temperature, 100° F; pulse, 98 beats/min; respirations, 24 breaths/min;
and blood pressure, 120/80 mm Hg. Which intervention should the nurse implement first?Ans:
B. Assess the incision for any drainage or redness. Rationale: The nurse's priority is to observe
for possible hemorrhage. The client is at high risk for hypovolemic shock and is exhibiting early
symptoms of shock. Remember, in early shock the blood pressure may be stable or increase
slightly as a compensatory mechanism. If there is no obvious indication of bleeding, the client
should then be assessed for the need of an analgesic and options A, C, and D should be
implemented.
12. A client with human immunodeficiency virus (HIV) develops a painful blistering skin rash on the
right lateral abdominal area. Which drug should the nurse expect to administer to treat this
condition?Ans: B. Acyclovir sodium. Rationale: The clinical manifestations listed are consistent
with herpes zoster (shingles). Acyclovir sodium is an antiviral used to treat herpes zoster or
shingles. Levofloxacin is an antibiotic and may be used to treat pneumonia or other infections in
the HIV client. Fluconazole is an antifungal and is used to treat candidiasis in the HIV client.
Esomeprazole is a protein pump inhibitor used for gastroesophageal reflux disease.
13. Which data obtained during a respiratory assessment for a 78-year-old client is most important
to report to the primary health care provider?Ans: B. Pulse oximetry reading of 89%. Rationale:
An oxygen saturation lower than 90% indicates hypoxia. Options A, C, and D are all normal
findings.
1. An 8-year-old child is receiving digoxin 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?Ans: A.
Because the child's heart rate and digoxin level are within normal range, assess for the cause
of the nausea. Rationale: Nausea and vomiting are early signs of digoxin toxicity. However, the
normal resting heart rate for a child 8 to 10 years of age is 70 to 110 beats/min, and the
therapeutic range of serum digoxin levels is 0.5 to 2 ng/mL. Based on the objective data, option
A is the best of the choices provided because the serum digoxin level is within normal levels.
Option B is not warranted by the data presented. The digoxin level is within the therapeutic
range, and the child is not showing signs of toxicity. The child's pulse rate is within normal range
for her age group.
2. The nurse expects a clinical finding of cyanosis in an infant with which conditions? (Select all
that apply.) Ans: D. Tetralogy of Fallot & E. Transposition of the great vessels. Rationale: Both
tetralogy of Fallot and transposition of the great vessels are classified as cyanotic heart disease,
in which unoxygenated blood is pumped into the systemic circulation, causing cyanosis (D and
E). (A, B, and C) are all abnormal cardiac conditions, but are classified as acyanotic and involve
left-to-right shunts, increased pulmonary blood flow, or obstructive defects.
3. The nurse hears a series of long-duration, discontinuous, low-pitched sounds on auscultation of
a client's lower lung fields. Which documentation of this finding is correct? Ans: C. Course
crackles. Rationale: Course crackles are caused by air passing through airways that are
intermittently occluded by mucus. Fine crackles are a series of short-duration, discontinuous,
high-pitched sounds. Wheezes are continuous, high-pitched, musical or squeaking-type sounds.
Stridor is a continuous croupy sound of constant pitch and indicates partial obstruction of the
airway.
4. A 45-year-old female client is admitted to the psychiatric unit for evaluation. Her husband states
that she has been reluctant to leave home for the last 6 months. The client has not gone to work
for a month, has been terminated from her job, and has not left the house since that time. This
client is displaying symptoms of which disorder?Ans: C. Agoraphobia. Rationale: Agoraphobia is
the fear of crowds or of being in an open place. Option A is the fear of being in closed places.
Option B is the fear of high places. Option D is an abnormal fear of death or bodies after death.
A phobia is an unrealistic fear associated with severe anxiety.
5. Which clinical manifestation in the client with hyperthyroidism is most important to report to
the health care provider?Ans: C. Apical heart rate of 130 beats/min. Rationale:The apical heart
rate of 130 beats/min is a critical finding that could lead to heart failure or other cardiac
disorders. Options A, B, and D are all expected findings that should also be reported but are not
as critical.
6. When caring for a client hospitalized with Guillain-Barré syndrome, which information is most
important for the nurse to report to the primary health care provider?Ans: B. Decrease in
cognitive status of the client. Rationale: A decline in cognitive status in a client is indicative of
symptoms of hypoxia and a possible need to assist the client with mechanical ventilation. A
primary health care provider will need to be contacted immediately. Options A, C, and D are
, findings associated with Guillain-Barré syndrome that should also be reported but are not as
critical as the client's hypoxic status.
7. The nurse prepares to administer acetaminophen oral suspension to a child who weighs 66 lb.
The prescription reads: Administer 15 mg/kg every 6 hours by mouth. The Tylenol is available
150 mg/5 mL. What is the correct dosage as indicated on the figure.Ans: B. 15 mL.
8. A client in the psychiatric setting with an anxiety disorder reports chest pain. Which action
should the nurse take first?Ans: B. Assess the client's vital signs. Rationale: Although increased
heart rate, palpitations, and chest pain may be caused by anxiety, it is important that the nurse
assess the client and rule out physiologic causes. Nonpharmacologic measures should be taken
first. Options C and D may be considered but are not as high priority as the initial physiologic
assessment.
9. A client who is prescribed chlorpromazine HCl for schizophrenia develops rigidity, a shuffling
gait, and tremors. Which action by the nurse is most important?Ans: A. Administer a dose of
benztropine mesylate PRN. Rationale: Rigidity, shuffling gait, pill-rolling hand movements,
tremors, dyskinesia, and masklike face are extrapyramidal side effects associated with
chlorpromazine. It is most important for the nurse to administer an anticholinergic such as
benztropine mesylate to reverse these effects. Options B, C, and D may be appropriate
interventions but are not as urgent as option A.
10. A nurse is assessing a client with heart failure who has been prescribed digoxin for therapy.
Which finding indicates an issue with the medication management?Ans: B. Serum potassium
level, 2.9 mEq/L. Rationale:A serum potassium level of 2.9 mEq/L is low, and side effects of
digoxin toxicity are exacerbated when the potassium level is low. Options A, C, and D are all
expected findings when caring for a client with congestive heart failure.
11. A client who is first day postoperative after a mastectomy becomes increasingly restless and
agitated. Vital signs are temperature, 100° F; pulse, 98 beats/min; respirations, 24 breaths/min;
and blood pressure, 120/80 mm Hg. Which intervention should the nurse implement first?Ans:
B. Assess the incision for any drainage or redness. Rationale: The nurse's priority is to observe
for possible hemorrhage. The client is at high risk for hypovolemic shock and is exhibiting early
symptoms of shock. Remember, in early shock the blood pressure may be stable or increase
slightly as a compensatory mechanism. If there is no obvious indication of bleeding, the client
should then be assessed for the need of an analgesic and options A, C, and D should be
implemented.
12. A client with human immunodeficiency virus (HIV) develops a painful blistering skin rash on the
right lateral abdominal area. Which drug should the nurse expect to administer to treat this
condition?Ans: B. Acyclovir sodium. Rationale: The clinical manifestations listed are consistent
with herpes zoster (shingles). Acyclovir sodium is an antiviral used to treat herpes zoster or
shingles. Levofloxacin is an antibiotic and may be used to treat pneumonia or other infections in
the HIV client. Fluconazole is an antifungal and is used to treat candidiasis in the HIV client.
Esomeprazole is a protein pump inhibitor used for gastroesophageal reflux disease.
13. Which data obtained during a respiratory assessment for a 78-year-old client is most important
to report to the primary health care provider?Ans: B. Pulse oximetry reading of 89%. Rationale:
An oxygen saturation lower than 90% indicates hypoxia. Options A, C, and D are all normal
findings.
