HESI COMPREHENSIVE EXAM VERIFIED
QUESTIONS AND ANSWERS
EnalaprilBmaleateBisBprescribedBforBaBhospitalizedBclient.BWhichBassessmentBdoesBtheBnurseBperfo
rmBasBaBpriorityBbeforeBadministeringBtheBmedication?
CheckingBtheBclient'sBbloodBpressureB
CheckingBtheBclient'sBperipheralBpulses
CheckingBtheBmostBrecentBpotassiumBlevel
CheckingBtheBclient'sBintake-and-outputBrecordBforBtheBlastB24BhoursB-BCORRECTBANSWER-
CheckingBtheBclient'sBbloodBpressureB
Rationale:BEnalaprilBmaleateBisBanBangiotensin-
convertingBenzymeB(ACE)BinhibitorBusedBtoBtreatBhypertension.BOneBcommonBsideBeffectBisBpostur
alBhypotension.BThereforeBtheBnurseBwouldBcheckBtheBclient'sBbloodBpressureBimmediatelyBbefore
BadministeringBeachBdose.BCheckingBtheBclient'sBperipheralBpulses,BtheBresultsBofBtheBmostBrecentB
potassiumBlevel,BandBtheBintakeBandBoutputBforBtheBpreviousB24BhoursBareBnotBspecificallyBassocia
tedBwithBthisBmediation.
ABclientBisBscheduledBtoBundergoBanBupperBgastrointestinalB(GI)Bseries,BandBtheBnurseBprovidesBins
tructionsBtoBtheBclientBaboutBtheBtest.BWhichBstatementBbyBtheBclientBindicatesBaBneedBforBfurtherB
instruction?
"TheBtestBwillBtakeBaboutB30Bminutes."
"IBneedBtoBfastBforB8BhoursBbeforeBtheBtest."
"IBneedBtoBdrinkBcitrateBofBmagnesiaBtheBnightBbeforeBtheBtestBandBgiveBmyselfBaBFleetBenemaBonBt
heBmorningBofBtheBtest."B
"IBneedBtoBtakeBaBlaxativeBafterBtheBtestBisBcompleted,BbecauseBtheBliquidBthatBI'llBhaveBtoBdrinkBforB
theBtestBcanBbeBconstipating."B-BCORRECTBANSWER-
,"IBneedBtoBdrinkBcitrateBofBmagnesiaBtheBnightBbeforeBtheBtestBandBgiveBmyselfBaBFleetBenemaBonBt
heBmorningBofBtheBtest."B
Rationale:BNoBspecialBpreparationBisBnecessaryBbeforeBaBGIBseries,BexceptBthatBNPOB(nothingBbyBm
outh)BstatusBmustBbeBmaintainedBforB8BhoursBbeforeBtheBtest.BAnBupperBGIBseriesBinvolvesBvisualiz
ationBofBtheBesophagus,Bduodenum,BandBupperBjejunumBbyBmeansBofBtheBuseBofBaBcontrastBmediu
m.BItBinvolvesBswallowingBaBcontrastBmediumB(usuallyBbarium),BwhichBisBadministeredBinBaBflavore
dBmilkshake.BFilmsBareBtakenBatBintervalsBduringBtheBtest,BwhichBtakesBaboutB30Bminutes.BAfterBanB
upperBGIBseries,BtheBclientBisBprescribedBaBlaxativeBtoBhastenBeliminationBofBtheBbarium.BBariumBth
atBremainsBinBtheBcolonBmayBbecomeBhardBandBdifficultBtoBexpel,BleadingBtoBfecalBimpaction.
ABnurseBonBtheBeveningBshiftBchecksBaBprimaryBhealthBcareBprovider'sBprescriptionsBandBnotesBtha
tBtheBdoseBofBaBprescribedBmedicationBisBhigherBthanBtheBnormalBdose.BTheBnurseBcallsBtheBprimar
yBhealthBcareBprovider'sBansweringBserviceBandBisBtoldBthatBtheBprimaryBhealthBcareBproviderBisBoff
BforBtheBnightBandBwillBbeBavailableBinBtheBmorning.BWhatBshouldBtheBnurseBdoBnext?
CallBtheBnursingBsupervisor
AskBtheBansweringBserviceBtoBcontactBtheBon-callBprimaryBhealthBcareBproviderB
WithholdBtheBmedicationBuntilBtheBprimaryBhealthBcareBproviderBcanBbeBreachedBinBtheBmorning
AdministerBtheBmedicationBbutBconsultBtheBprimaryBhealthBcareBproviderBwhenBheBbecomesBavail
ableB-BCORRECTBANSWER-AskBtheBansweringBserviceBtoBcontactBtheBon-
callBprimaryBhealthBcareBproviderB
Rationale:BTheBnurseBhasBaBdutyBtoBprotectBtheBclientBfromBharm.BABnurseBwhoBbelievesBthatBaBpri
maryBhealthBcareBprovider'sBprescriptionBmayBbeBinBerrorBisBresponsibleBforBclarifyingBtheBprescrip
tionBbeforeBcarryingBitBout.BThereforeBtheBnurseBwouldBnotBadministerBtheBmedication;Binstead,Bt
heBnurseBwouldBwithholdBtheBmedicationBuntilBtheBdoseBcanBbeBclarified.BTheBnurseBwouldBnotBwa
itBuntilBtheBnextBmorningBtoBobtainBclarification.BItBisBprematureBtoBcallBtheBnursingBsupervisor.
AnBemergencyBdepartmentB(ED)BnurseBisBmonitoringBaBclientBwithBsuspectedBacuteBmyocardialBinf
arctionB(MI)BwhoBisBawaitingBtransferBtoBtheBcoronaryBintensiveBcareBunit.BTheBnurseBnotesBtheBsu
ddenBonsetBofBprematureBventricularBcontractionsB(PVCs)BonBtheBmonitor,BchecksBtheBclient'sBcaro
tidBpulse,BandBdeterminesBthatBtheBPVCsBareBnotBperfusing.BWhatBisBtheBnurse'sBmostBappropriateB
action?
,DocumentBtheBfindings
AskBtheBEDBprimaryBhealthBcareBproviderBtoBcheckBtheBclientB
ContinueBtoBmonitorBtheBclient'sBcardiacBstatus
InformBtheBclientBthatBPVCsBareBexpectedBafterBanBMIB-BCORRECTBANSWER-
AskBtheBEDBprimaryBhealthBcareBproviderBtoBcheckBtheBclientB
Rationale:BTheBmostBappropriateBactionBbyBtheBnurseBwouldBbeBtoBaskBtheBEDBhealthBcareBprovide
rBtoBcheckBtheBclient.BPVCsBareBaBresultBofBincreasedBirritabilityBofBventricularBcells.BPeripheralBpuls
esBmayBbeBabsentBorBdiminishedBwithBtheBPVCsBthemselvesBbecauseBtheBdecreasedBstrokeBvolum
eBofBtheBprematureBbeatsBmayBinBturnBdecreaseBperipheralBperfusion.BBecauseBotherBrhythmsBals
oBcauseBwidenedBQRSBcomplexes,BitBisBessentialBthatBtheBnurseBdetermineBwhetherBtheBprematur
eBbeatsBareBresultingBinBperfusionBofBtheBextremities.BThisBisBdoneBbyBpalpatingBtheBcarotid,Bbrachi
al,BorBfemoralBarteryBwhileBobservingBtheBmonitorBforBwidenedBcomplexesBorBbyBauscultatingBforBa
picalBheartBsounds.BInBtheBsituationBofBacuteBMI,BPVCsBmayBbeBconsideredBwarningBdysrhythmias,B
possiblyBheraldingBtheBonsetBofBventricularBtachycardiaBorBventricularBfibrillation.BTherefore,BtheB
nurseBwouldBnotBtellBtheBclientBthatBtheBPVCsBareBexpected.BAlthoughBtheBnurseBwillBcontinueBtoB
monitorBtheBclientBandBdocumentBtheBfindings,BtheseBareBnotBtheBmostBappropriateBactionsBofBth
oseBprovided.
NPOBstatusBisBimposedB8BhoursBbeforeBtheBprocedureBonBaBclientBscheduledBtoBundergoBelectroco
nvulsiveBtherapyB(ECT)BatB1Bp.m.BOnBtheBmorningBofBtheBprocedure,BtheBnurseBchecksBtheBclient'sBr
ecordBandBnotesBthatBtheBclientBroutinelyBtakesBanBoralBantihypertensiveBmedicationBeachBmornin
g.BWhatBactionBshouldBtheBnurseBtake?
AdministerBtheBantihypertensiveBwithBaBsmallBsipBofBwaterB
WithholdBtheBantihypertensiveBandBadministerBitBatBbedtime
AdministerBtheBmedicationBbyBwayBofBtheBintravenousB(IV)Broute
HoldBtheBantihypertensiveBandBresumeBitsBadministrationBonBtheBdayBafterBtheBECTB-
BCORRECTBANSWER-AdministerBtheBantihypertensiveBwithBaBsmallBsipBofBwaterB
, Rationale:BTheBnurseBshouldBadministerBtheBantihypertensiveBwithBaBsmallBsipBofBwater.BGeneralBa
nesthesiaBisBrequiredBforBECT,BsoBNPOBstatusBisBimposedBforB6BtoB8BhoursBbeforeBtreatmentBtoBhelp
BpreventBaspiration.BExceptionsBincludeBclientsBwhoBroutinelyBreceiveBcardiacBmedications,Bantihy
pertensiveBagents,BorBhistamineB(H2)Bblockers,BwhichBshouldBbeBadministeredBseveralBhoursBbefor
eBtreatmentBwithBaBsmallBsipBofBwater.BWithholdingBtheBantihypertensiveBandBadministeringBitBatB
bedtimeBandBwithholdingBtheBantihypertensiveBandBresumingBadministrationBonBtheBdayBafterBthe
BECTBareBincorrectBactions,BbecauseBantihypertensivesBmustBbeBadministeredBonBtime;Botherwise,B
theBriskBforBreboundBhypertensionBexists.BTheBnurseBwouldBnotBadministerBaBmedicationBbyBwayBo
fBaBrouteBthatBhasBnotBbeenBprescribed.
ABclientBwhoBrecentlyBunderwentBcoronaryBarteryBbypassBgraftBsurgeryBcomesBtoBtheBprimaryBhea
lthBcareBprovider'sBofficeBforBaBfollow-
upBvisit.BOnBassessment,BtheBclientBtellsBtheBnurseBthatBheBisBfeelingBdepressed.BWhichBresponseBb
yBtheBnurseBisBtherapeutic?
"TellBmeBmoreBaboutBwhatByou'reBfeeling."B
"That'sBaBnormalBresponseBafterBthisBtypeBofBsurgery."
"ItBwillBtakeBtime,BbutBIBpromiseByou,ByouBwillBgetBoverBthisBdepression."
"EveryBclientBwhoBhasBthisBsurgeryBfeelsBtheBsameBwayBforBaboutBaBmonth."B-BCORRECTBANSWER-
"TellBmeBmoreBaboutBwhatByou'reBfeeling."B
Rationale:BTheBtherapeuticBresponseBbyBtheBnurseBis,B"TellBmeBmoreBaboutBwhatByou'reBfeeling."B
WhenBaBclientBexpressesBfeelingsBofBdepression,BitBisBextremelyBimportantBforBtheBnurseBtoBfurthe
rBexploreBtheseBfeelingsBwithBtheBclient.BInBstating,B"ThisBisBaBnormalBresponseBafterBthisBtypeBofBsu
rgery"BtheBnurseBprovidesBfalseBreassuranceBandBavoidsBaddressingBtheBclient'sBfeelings.B"ItBwillBta
keBtime,BbutBIBpromiseByou,ByouBwillBgetBoverBtheBdepression"BisBalsoBaBfalseBreassurance,BandBitBd
oesBnotBencourageBtheBexpressionBofBfeelings.B"EveryBclientBwhoBhasBthisBsurgeryBfeelsBtheBsameB
wayBforBaboutBaBmonth"BisBaBgeneralizationBthatBavoidsBtheBclient'sBfeelings.
ABclientBinBlaborBexperiencesBspontaneousBruptureBofBtheBmembranes.BTheBnurseBimmediatelyBco
untsBtheBfetalBheartBrateB(FHR)BforB1BfullBminuteBandBthenBchecksBtheBamnioticBfluid.BTheBnurseBno
tesBthatBtheBfluidBisByellowBandBhasBaBstrongBodor.BWhichBactionBshouldBbeBtheBnurse'sBpriority?
ContactBtheBprimaryBhealthBcareBproviderB
QUESTIONS AND ANSWERS
EnalaprilBmaleateBisBprescribedBforBaBhospitalizedBclient.BWhichBassessmentBdoesBtheBnurseBperfo
rmBasBaBpriorityBbeforeBadministeringBtheBmedication?
CheckingBtheBclient'sBbloodBpressureB
CheckingBtheBclient'sBperipheralBpulses
CheckingBtheBmostBrecentBpotassiumBlevel
CheckingBtheBclient'sBintake-and-outputBrecordBforBtheBlastB24BhoursB-BCORRECTBANSWER-
CheckingBtheBclient'sBbloodBpressureB
Rationale:BEnalaprilBmaleateBisBanBangiotensin-
convertingBenzymeB(ACE)BinhibitorBusedBtoBtreatBhypertension.BOneBcommonBsideBeffectBisBpostur
alBhypotension.BThereforeBtheBnurseBwouldBcheckBtheBclient'sBbloodBpressureBimmediatelyBbefore
BadministeringBeachBdose.BCheckingBtheBclient'sBperipheralBpulses,BtheBresultsBofBtheBmostBrecentB
potassiumBlevel,BandBtheBintakeBandBoutputBforBtheBpreviousB24BhoursBareBnotBspecificallyBassocia
tedBwithBthisBmediation.
ABclientBisBscheduledBtoBundergoBanBupperBgastrointestinalB(GI)Bseries,BandBtheBnurseBprovidesBins
tructionsBtoBtheBclientBaboutBtheBtest.BWhichBstatementBbyBtheBclientBindicatesBaBneedBforBfurtherB
instruction?
"TheBtestBwillBtakeBaboutB30Bminutes."
"IBneedBtoBfastBforB8BhoursBbeforeBtheBtest."
"IBneedBtoBdrinkBcitrateBofBmagnesiaBtheBnightBbeforeBtheBtestBandBgiveBmyselfBaBFleetBenemaBonBt
heBmorningBofBtheBtest."B
"IBneedBtoBtakeBaBlaxativeBafterBtheBtestBisBcompleted,BbecauseBtheBliquidBthatBI'llBhaveBtoBdrinkBforB
theBtestBcanBbeBconstipating."B-BCORRECTBANSWER-
,"IBneedBtoBdrinkBcitrateBofBmagnesiaBtheBnightBbeforeBtheBtestBandBgiveBmyselfBaBFleetBenemaBonBt
heBmorningBofBtheBtest."B
Rationale:BNoBspecialBpreparationBisBnecessaryBbeforeBaBGIBseries,BexceptBthatBNPOB(nothingBbyBm
outh)BstatusBmustBbeBmaintainedBforB8BhoursBbeforeBtheBtest.BAnBupperBGIBseriesBinvolvesBvisualiz
ationBofBtheBesophagus,Bduodenum,BandBupperBjejunumBbyBmeansBofBtheBuseBofBaBcontrastBmediu
m.BItBinvolvesBswallowingBaBcontrastBmediumB(usuallyBbarium),BwhichBisBadministeredBinBaBflavore
dBmilkshake.BFilmsBareBtakenBatBintervalsBduringBtheBtest,BwhichBtakesBaboutB30Bminutes.BAfterBanB
upperBGIBseries,BtheBclientBisBprescribedBaBlaxativeBtoBhastenBeliminationBofBtheBbarium.BBariumBth
atBremainsBinBtheBcolonBmayBbecomeBhardBandBdifficultBtoBexpel,BleadingBtoBfecalBimpaction.
ABnurseBonBtheBeveningBshiftBchecksBaBprimaryBhealthBcareBprovider'sBprescriptionsBandBnotesBtha
tBtheBdoseBofBaBprescribedBmedicationBisBhigherBthanBtheBnormalBdose.BTheBnurseBcallsBtheBprimar
yBhealthBcareBprovider'sBansweringBserviceBandBisBtoldBthatBtheBprimaryBhealthBcareBproviderBisBoff
BforBtheBnightBandBwillBbeBavailableBinBtheBmorning.BWhatBshouldBtheBnurseBdoBnext?
CallBtheBnursingBsupervisor
AskBtheBansweringBserviceBtoBcontactBtheBon-callBprimaryBhealthBcareBproviderB
WithholdBtheBmedicationBuntilBtheBprimaryBhealthBcareBproviderBcanBbeBreachedBinBtheBmorning
AdministerBtheBmedicationBbutBconsultBtheBprimaryBhealthBcareBproviderBwhenBheBbecomesBavail
ableB-BCORRECTBANSWER-AskBtheBansweringBserviceBtoBcontactBtheBon-
callBprimaryBhealthBcareBproviderB
Rationale:BTheBnurseBhasBaBdutyBtoBprotectBtheBclientBfromBharm.BABnurseBwhoBbelievesBthatBaBpri
maryBhealthBcareBprovider'sBprescriptionBmayBbeBinBerrorBisBresponsibleBforBclarifyingBtheBprescrip
tionBbeforeBcarryingBitBout.BThereforeBtheBnurseBwouldBnotBadministerBtheBmedication;Binstead,Bt
heBnurseBwouldBwithholdBtheBmedicationBuntilBtheBdoseBcanBbeBclarified.BTheBnurseBwouldBnotBwa
itBuntilBtheBnextBmorningBtoBobtainBclarification.BItBisBprematureBtoBcallBtheBnursingBsupervisor.
AnBemergencyBdepartmentB(ED)BnurseBisBmonitoringBaBclientBwithBsuspectedBacuteBmyocardialBinf
arctionB(MI)BwhoBisBawaitingBtransferBtoBtheBcoronaryBintensiveBcareBunit.BTheBnurseBnotesBtheBsu
ddenBonsetBofBprematureBventricularBcontractionsB(PVCs)BonBtheBmonitor,BchecksBtheBclient'sBcaro
tidBpulse,BandBdeterminesBthatBtheBPVCsBareBnotBperfusing.BWhatBisBtheBnurse'sBmostBappropriateB
action?
,DocumentBtheBfindings
AskBtheBEDBprimaryBhealthBcareBproviderBtoBcheckBtheBclientB
ContinueBtoBmonitorBtheBclient'sBcardiacBstatus
InformBtheBclientBthatBPVCsBareBexpectedBafterBanBMIB-BCORRECTBANSWER-
AskBtheBEDBprimaryBhealthBcareBproviderBtoBcheckBtheBclientB
Rationale:BTheBmostBappropriateBactionBbyBtheBnurseBwouldBbeBtoBaskBtheBEDBhealthBcareBprovide
rBtoBcheckBtheBclient.BPVCsBareBaBresultBofBincreasedBirritabilityBofBventricularBcells.BPeripheralBpuls
esBmayBbeBabsentBorBdiminishedBwithBtheBPVCsBthemselvesBbecauseBtheBdecreasedBstrokeBvolum
eBofBtheBprematureBbeatsBmayBinBturnBdecreaseBperipheralBperfusion.BBecauseBotherBrhythmsBals
oBcauseBwidenedBQRSBcomplexes,BitBisBessentialBthatBtheBnurseBdetermineBwhetherBtheBprematur
eBbeatsBareBresultingBinBperfusionBofBtheBextremities.BThisBisBdoneBbyBpalpatingBtheBcarotid,Bbrachi
al,BorBfemoralBarteryBwhileBobservingBtheBmonitorBforBwidenedBcomplexesBorBbyBauscultatingBforBa
picalBheartBsounds.BInBtheBsituationBofBacuteBMI,BPVCsBmayBbeBconsideredBwarningBdysrhythmias,B
possiblyBheraldingBtheBonsetBofBventricularBtachycardiaBorBventricularBfibrillation.BTherefore,BtheB
nurseBwouldBnotBtellBtheBclientBthatBtheBPVCsBareBexpected.BAlthoughBtheBnurseBwillBcontinueBtoB
monitorBtheBclientBandBdocumentBtheBfindings,BtheseBareBnotBtheBmostBappropriateBactionsBofBth
oseBprovided.
NPOBstatusBisBimposedB8BhoursBbeforeBtheBprocedureBonBaBclientBscheduledBtoBundergoBelectroco
nvulsiveBtherapyB(ECT)BatB1Bp.m.BOnBtheBmorningBofBtheBprocedure,BtheBnurseBchecksBtheBclient'sBr
ecordBandBnotesBthatBtheBclientBroutinelyBtakesBanBoralBantihypertensiveBmedicationBeachBmornin
g.BWhatBactionBshouldBtheBnurseBtake?
AdministerBtheBantihypertensiveBwithBaBsmallBsipBofBwaterB
WithholdBtheBantihypertensiveBandBadministerBitBatBbedtime
AdministerBtheBmedicationBbyBwayBofBtheBintravenousB(IV)Broute
HoldBtheBantihypertensiveBandBresumeBitsBadministrationBonBtheBdayBafterBtheBECTB-
BCORRECTBANSWER-AdministerBtheBantihypertensiveBwithBaBsmallBsipBofBwaterB
, Rationale:BTheBnurseBshouldBadministerBtheBantihypertensiveBwithBaBsmallBsipBofBwater.BGeneralBa
nesthesiaBisBrequiredBforBECT,BsoBNPOBstatusBisBimposedBforB6BtoB8BhoursBbeforeBtreatmentBtoBhelp
BpreventBaspiration.BExceptionsBincludeBclientsBwhoBroutinelyBreceiveBcardiacBmedications,Bantihy
pertensiveBagents,BorBhistamineB(H2)Bblockers,BwhichBshouldBbeBadministeredBseveralBhoursBbefor
eBtreatmentBwithBaBsmallBsipBofBwater.BWithholdingBtheBantihypertensiveBandBadministeringBitBatB
bedtimeBandBwithholdingBtheBantihypertensiveBandBresumingBadministrationBonBtheBdayBafterBthe
BECTBareBincorrectBactions,BbecauseBantihypertensivesBmustBbeBadministeredBonBtime;Botherwise,B
theBriskBforBreboundBhypertensionBexists.BTheBnurseBwouldBnotBadministerBaBmedicationBbyBwayBo
fBaBrouteBthatBhasBnotBbeenBprescribed.
ABclientBwhoBrecentlyBunderwentBcoronaryBarteryBbypassBgraftBsurgeryBcomesBtoBtheBprimaryBhea
lthBcareBprovider'sBofficeBforBaBfollow-
upBvisit.BOnBassessment,BtheBclientBtellsBtheBnurseBthatBheBisBfeelingBdepressed.BWhichBresponseBb
yBtheBnurseBisBtherapeutic?
"TellBmeBmoreBaboutBwhatByou'reBfeeling."B
"That'sBaBnormalBresponseBafterBthisBtypeBofBsurgery."
"ItBwillBtakeBtime,BbutBIBpromiseByou,ByouBwillBgetBoverBthisBdepression."
"EveryBclientBwhoBhasBthisBsurgeryBfeelsBtheBsameBwayBforBaboutBaBmonth."B-BCORRECTBANSWER-
"TellBmeBmoreBaboutBwhatByou'reBfeeling."B
Rationale:BTheBtherapeuticBresponseBbyBtheBnurseBis,B"TellBmeBmoreBaboutBwhatByou'reBfeeling."B
WhenBaBclientBexpressesBfeelingsBofBdepression,BitBisBextremelyBimportantBforBtheBnurseBtoBfurthe
rBexploreBtheseBfeelingsBwithBtheBclient.BInBstating,B"ThisBisBaBnormalBresponseBafterBthisBtypeBofBsu
rgery"BtheBnurseBprovidesBfalseBreassuranceBandBavoidsBaddressingBtheBclient'sBfeelings.B"ItBwillBta
keBtime,BbutBIBpromiseByou,ByouBwillBgetBoverBtheBdepression"BisBalsoBaBfalseBreassurance,BandBitBd
oesBnotBencourageBtheBexpressionBofBfeelings.B"EveryBclientBwhoBhasBthisBsurgeryBfeelsBtheBsameB
wayBforBaboutBaBmonth"BisBaBgeneralizationBthatBavoidsBtheBclient'sBfeelings.
ABclientBinBlaborBexperiencesBspontaneousBruptureBofBtheBmembranes.BTheBnurseBimmediatelyBco
untsBtheBfetalBheartBrateB(FHR)BforB1BfullBminuteBandBthenBchecksBtheBamnioticBfluid.BTheBnurseBno
tesBthatBtheBfluidBisByellowBandBhasBaBstrongBodor.BWhichBactionBshouldBbeBtheBnurse'sBpriority?
ContactBtheBprimaryBhealthBcareBproviderB
