HESI Comprehensive B
Study online at https://quizlet.com/_6jl70p
1. 66. The nurse is caring for a client with B
a cerebrovascular accident (CVA) who is Rationale:
receiving enteral tube feedings. Which Positioning the head of the bed flat when enter-
task performed by the UAP requires im- al feedings are in progress puts the client at risk
mediate intervention by the nurse? for aspiration (B). The others are all acceptable
tasks performed by the UAP (A, C, and D).
A.Suctions oral secretions from mouth
B.Positions head of bed flat when
changing sheets
C.Takes temperature using the axillary
method
D.Keeps head of bed elevated at 30 de-
grees
2. 62. When caring for a postsurgical client B
who has undergone multiple blood Rationale:
transfusions, which serum laboratory Multiple blood transfusions are a risk factor for
finding is of most concern to the nurse? hyperkalemia. A serum potassium level higher
than 5.0 mEq/L indicates hyperkalemia (B). The
A.Sodium level, 137 mEq/L others are normal findings (A, C, and D).
B.Potassium level, 5.5 mEq/L
C.Blood urea nitrogen (BUN) level, 18
mg/dL
D.Calcium level, 10 mEq/L
3. 47. Which vaccination should the nurse A
administer to a newborn? Rationale:
The hepatitis B vaccination should be given
A.Hepatitis B to all newborns before hospital discharge (A).
B.Human papilloma virus (HPV) HPV is not recommended until adolescence (B).
C.Varicella Varicella immunization begins at 12 months (C).
D.Meningococcal vaccine
, HESI Comprehensive B
Study online at https://quizlet.com/_6jl70p
Meningococcal vaccine is administered begin-
ning at 2 years (D).
4. 31. The nurse is caring for a client on the B
medical unit. Which task can be dele- Rationale:
gated to unlicensed assistive personnel Obtaining a fingerstick blood glucose level is a
(UAP)? simple treatment and is an appropriate skill for
UAP to perform (B). (A, C, and D) are skills that
A.Assess the need to change a central cannot be delegated to UAP.
line dressing.
B.Obtain a fingerstick blood glucose lev-
el.
C.Answer a family member's questions
about the client's plan of care.
D.Teach the client side effects to report
related to the current medication regi-
men.
5. 20. The nurse is caring for a client B,C,E
with an ischemic stroke who has a pre- Rationale:
scription for tissue plasminogen activa- Neurologic assessment, including the NIHSS,
tor (t-PA) IV. Which action(s) should the is indicated for the client receiving t-PA. This
nurse expect to implement? (Select all includes close monitoring for bleeding during
that apply.) and after the infusion; if bleeding or other signs
of neurologic impairment occur, the infusion
A.Administer aspirin with tissue plas- should be stopped (B, C, and E). Aspirin is
minogen activator (t-PA). contraindicated with t-PA because it increases
B.Complete the National Institute of the risk for bleeding (A). The administration of
Health Stroke Scale (NIHSS). t-PA within 6 hours of symptoms is concurrent
C.Assess the client for signs of bleeding with a diagnosis of a myocardial infarction and
during and after the infusion. within 4.5 hours of symptoms is concurrent for
D.Start t-PA within 6 hours after the on- a stroke (D).
, HESI Comprehensive B
Study online at https://quizlet.com/_6jl70p
set of stroke symptoms.
E.Initiate multidisciplinary consult for
potential rehabilitation.
6. 56. When caring for a client in la- B
bor, which finding is most important Rationale:
to report to the primary health care A fetal heart rate (FHR) of 100 beats/min may
provider? indicate fetal distress (B) because the average
FHR at term is 140 beats/min and the normal
A.Maternal heart rate, 90 beats/min. range is 110 to beats/min 160. The others (A,
B.Fetal heart rate, 100 beats/min C, and D) are normal findings for a woman in
C.Maternal blood pressure, 140/86 mm labor.
Hg
D.Maternal temperature, 100.0° F
7. 61. The nurse is caring for a client with C
heart failure who develops respiratory Rationale:
distress and coughs up pink frothy spu- Positioning the patient in a high Fowler's po-
tum. Which action should the nurse take sition with dangling feet will decrease further
first? venous return to the left ventricle (C). The other
actions should be performed after the change
A.Draw arterial blood gases. in position (A, B, and D).
B.Notify the primary health care
provider.
C.Position in a high Fowler's position
with the legs down.
D.Obtain a chest X-ray.
8. 45. A client who is prescribed chlorpro- A
mazine HCl (Thorazine) for schizophre- Rationale:
nia develops rigidity, a shuffling gait, Rigidity, shuffling gait, pill-rolling hand move-
and tremors. Which action by the nurse ments, tremors, dyskinesia, and masklike face
is most important? are extrapyramidal side effects associated with
, HESI Comprehensive B
Study online at https://quizlet.com/_6jl70p
Thorazine. It is most important for the nurse to
A.Administer a dose of benztropine me- administer an anticholinergic such as Cogentin
sylate (Cogentin) PRN. to reverse these effects (A). The others (B, C, D)
B.Determine if the client has increased may be appropriate interventions but are not as
photosensitivity. urgent as (A).
C.Provide comfort measures for sore
muscles.
D.Assess the client for visual and audito-
ry hallucinations.
9. 46. A nurse is interviewing a mother B
during a well-child visit. Which finding
Rationale:
would alert the nurse to continue fur- As a developmental milestone, infants should
ther assessment of the infant? sit unsupported by 8 months (B). The milestone
of rolling over is achieved at 5 to 6 months for
A.Two-month-old who is unable to roll most infants (A). Stranger anxiety is common
from back to abdomen from 7 to 9 months (C). Speaking a few words
B.Ten-month-old who cannot sit without is expected at about 12 months (D).
support
C.Nine-month-old who cries when his
mother leaves the room
D.Eight-month-old who has not yet be-
gun to speak words
10. 7. Which intervention should be includ- C
ed in the plan of care for a client admit- Rationale:
ted to the hospital with ulcerative coli- A low-residue diet (C) will help decrease symp-
tis? toms of diarrhea, which are clinical manifesta-
tions of ulcerative colitis. (A, B, and D) are con-
A.Administer stool softeners. traindicated and could worsen the condition.
B.Place the client on fluid restriction.
C.Provide a low-residue diet.
D.Add a milk product to each meal.
Study online at https://quizlet.com/_6jl70p
1. 66. The nurse is caring for a client with B
a cerebrovascular accident (CVA) who is Rationale:
receiving enteral tube feedings. Which Positioning the head of the bed flat when enter-
task performed by the UAP requires im- al feedings are in progress puts the client at risk
mediate intervention by the nurse? for aspiration (B). The others are all acceptable
tasks performed by the UAP (A, C, and D).
A.Suctions oral secretions from mouth
B.Positions head of bed flat when
changing sheets
C.Takes temperature using the axillary
method
D.Keeps head of bed elevated at 30 de-
grees
2. 62. When caring for a postsurgical client B
who has undergone multiple blood Rationale:
transfusions, which serum laboratory Multiple blood transfusions are a risk factor for
finding is of most concern to the nurse? hyperkalemia. A serum potassium level higher
than 5.0 mEq/L indicates hyperkalemia (B). The
A.Sodium level, 137 mEq/L others are normal findings (A, C, and D).
B.Potassium level, 5.5 mEq/L
C.Blood urea nitrogen (BUN) level, 18
mg/dL
D.Calcium level, 10 mEq/L
3. 47. Which vaccination should the nurse A
administer to a newborn? Rationale:
The hepatitis B vaccination should be given
A.Hepatitis B to all newborns before hospital discharge (A).
B.Human papilloma virus (HPV) HPV is not recommended until adolescence (B).
C.Varicella Varicella immunization begins at 12 months (C).
D.Meningococcal vaccine
, HESI Comprehensive B
Study online at https://quizlet.com/_6jl70p
Meningococcal vaccine is administered begin-
ning at 2 years (D).
4. 31. The nurse is caring for a client on the B
medical unit. Which task can be dele- Rationale:
gated to unlicensed assistive personnel Obtaining a fingerstick blood glucose level is a
(UAP)? simple treatment and is an appropriate skill for
UAP to perform (B). (A, C, and D) are skills that
A.Assess the need to change a central cannot be delegated to UAP.
line dressing.
B.Obtain a fingerstick blood glucose lev-
el.
C.Answer a family member's questions
about the client's plan of care.
D.Teach the client side effects to report
related to the current medication regi-
men.
5. 20. The nurse is caring for a client B,C,E
with an ischemic stroke who has a pre- Rationale:
scription for tissue plasminogen activa- Neurologic assessment, including the NIHSS,
tor (t-PA) IV. Which action(s) should the is indicated for the client receiving t-PA. This
nurse expect to implement? (Select all includes close monitoring for bleeding during
that apply.) and after the infusion; if bleeding or other signs
of neurologic impairment occur, the infusion
A.Administer aspirin with tissue plas- should be stopped (B, C, and E). Aspirin is
minogen activator (t-PA). contraindicated with t-PA because it increases
B.Complete the National Institute of the risk for bleeding (A). The administration of
Health Stroke Scale (NIHSS). t-PA within 6 hours of symptoms is concurrent
C.Assess the client for signs of bleeding with a diagnosis of a myocardial infarction and
during and after the infusion. within 4.5 hours of symptoms is concurrent for
D.Start t-PA within 6 hours after the on- a stroke (D).
, HESI Comprehensive B
Study online at https://quizlet.com/_6jl70p
set of stroke symptoms.
E.Initiate multidisciplinary consult for
potential rehabilitation.
6. 56. When caring for a client in la- B
bor, which finding is most important Rationale:
to report to the primary health care A fetal heart rate (FHR) of 100 beats/min may
provider? indicate fetal distress (B) because the average
FHR at term is 140 beats/min and the normal
A.Maternal heart rate, 90 beats/min. range is 110 to beats/min 160. The others (A,
B.Fetal heart rate, 100 beats/min C, and D) are normal findings for a woman in
C.Maternal blood pressure, 140/86 mm labor.
Hg
D.Maternal temperature, 100.0° F
7. 61. The nurse is caring for a client with C
heart failure who develops respiratory Rationale:
distress and coughs up pink frothy spu- Positioning the patient in a high Fowler's po-
tum. Which action should the nurse take sition with dangling feet will decrease further
first? venous return to the left ventricle (C). The other
actions should be performed after the change
A.Draw arterial blood gases. in position (A, B, and D).
B.Notify the primary health care
provider.
C.Position in a high Fowler's position
with the legs down.
D.Obtain a chest X-ray.
8. 45. A client who is prescribed chlorpro- A
mazine HCl (Thorazine) for schizophre- Rationale:
nia develops rigidity, a shuffling gait, Rigidity, shuffling gait, pill-rolling hand move-
and tremors. Which action by the nurse ments, tremors, dyskinesia, and masklike face
is most important? are extrapyramidal side effects associated with
, HESI Comprehensive B
Study online at https://quizlet.com/_6jl70p
Thorazine. It is most important for the nurse to
A.Administer a dose of benztropine me- administer an anticholinergic such as Cogentin
sylate (Cogentin) PRN. to reverse these effects (A). The others (B, C, D)
B.Determine if the client has increased may be appropriate interventions but are not as
photosensitivity. urgent as (A).
C.Provide comfort measures for sore
muscles.
D.Assess the client for visual and audito-
ry hallucinations.
9. 46. A nurse is interviewing a mother B
during a well-child visit. Which finding
Rationale:
would alert the nurse to continue fur- As a developmental milestone, infants should
ther assessment of the infant? sit unsupported by 8 months (B). The milestone
of rolling over is achieved at 5 to 6 months for
A.Two-month-old who is unable to roll most infants (A). Stranger anxiety is common
from back to abdomen from 7 to 9 months (C). Speaking a few words
B.Ten-month-old who cannot sit without is expected at about 12 months (D).
support
C.Nine-month-old who cries when his
mother leaves the room
D.Eight-month-old who has not yet be-
gun to speak words
10. 7. Which intervention should be includ- C
ed in the plan of care for a client admit- Rationale:
ted to the hospital with ulcerative coli- A low-residue diet (C) will help decrease symp-
tis? toms of diarrhea, which are clinical manifesta-
tions of ulcerative colitis. (A, B, and D) are con-
A.Administer stool softeners. traindicated and could worsen the condition.
B.Place the client on fluid restriction.
C.Provide a low-residue diet.
D.Add a milk product to each meal.
