HESI COMPREHENSIVE EXIT EXAM 2024/ HESI
COMPREHENSIVE EXIT EXAM ACTUAL EXAM 180 QUESTIONS
AND CORRECT DETAILED ANSWERS (VERIFIED ANSWERS)
WITH RATIONALES |ALREADY GRADED A+||BRAND NEW!!
A clientis receivingparenteralnutrition(PN). The nursemonitorstheclientfor complicationsof the therapy and
should assess the client for which manifestations of hyperglycemia?
1. Fever,weakpulse,and thirst
2. Nausea,vomiting,and oliguria
3. Sweating,chills, and abdominalpain
4. Weakness,thirst,and increasedurineoutput- answer-4.
Weakness, thirst, and increased urine
output
A clienthasbeendischargedto homeon parenteralnutrition(PN). With eachvisit, thehomecarenurse should
assess which parameter most closely in monitoring this therapy?
1. Pulseand weight
2. Temperatureand weight
3. Pulseand bloodpressure
4. Temperatureand bloodpressure- answer-2.
Temperature and weight
The nurseis caring for a groupof adultclientson an acutecaremedical-surgicalnursing unit. The nurse understands
that which client would be the least likely candidate for parenteral nutrition (PN)?
1.A 66-year-old clientwith extensiveburns
2.A 42-year-old clientwhohas had an opencholecystectomy
3.A 27-year-old clientwith severeexacerbationof Crohn's disease
4.A 35-year-old clientwith persistentnauseaand vomitingfrom chemotherapy- answer-2. A 42-
year-old client who has had an open cholecystectomy
Rationale:
,Parenteral nutrition is indicated in clients whose gastrointestinal tracts are not functional or must be rested,
cannottakein a dietenterallyfor extendedperiods,or haveincreasedmetabolicneed.Examples of these
conditions include those clients with burns, exacerbation of Crohn's disease, and persistent nausea and vomiting
due to chemotherapy. Other clients would be those who have had extensive surgery, have multiple fractures, are
septic, or have advanced cancer or acquired immunodeficiency syndrome. The client with the open
cholecystectomy is not a candidate because this client would resume a regular diet within a few days following
surgery.
The nurse is making initial rounds at the beginning of the shift and notes that the parenteral nutrition
bagof
(PN)
an assignedclientis empty.Which solutionreadilyavailableon thenursing unit shouldthe nurse hang until
another PN solution is mixed and delivered to the nursing unit?
1.5% dextrose in water
2.10%
dextrosein water
3.5% dextrosein Ringer'slactate
4.5% dextrosein 0.9% sodiumchloride- answer-2. 10%
dextrose in water
Rationale:
The client is at risk for hypoglycemia; therefore the solution containing the highest amount of glucose
beshould
hung until thenewPN solutionbecomesavailable.BecausePN solutionscontainhigh glucose concentrations, the
10% dextrose in water solution is the best of the choices presented. The solution selected should be one that
minimizes the risk of hypoglycemia. The remaining options will not be as effective in minimizing the risk of
hypoglycemia.
The nurseis monitoringthestatusof a client'sfatemulsion(lipid) infusionand notesthattheinfusionis 1 hour
behind. Which action should the nurse take?
1. Adjust theinfusionrateto catchup overthenexthour.
2. Increasetheinfusionrateto catchup overthenext2 hours.
3. Ensurethatthefatemulsioninfusionrateis infusingat theprescribedrate.
4. Adjust theinfusionrateto run wideopenuntil thesolutionis back on time.- answer-3. Ensure
that the fat emulsion infusion rate is infusing at the prescribed rate.
Rationale:
The nurseshouldnot increasetherateof a fatemulsionto makeup thedifference iftheinfusiontiming falls
behind. Doing so could place the client at risk for fat overload. In addition, increasing the rate
,suddenlycan causefluid overload.The sameprinciple(not increasingtherate)appliesto PN or any intravenous (IV)
infusion. Therefore the remaining options are incorrect.
A clientreceivingparenteralnutrition(PN) in thehomesettinghas a weightgain of 5 lb in 1 week.The nurse
should next assess the client for the presence of which condition?
1. Thirst
2. Polyuria
3. Decreasedbloodpressure
4. Crackleson auscultationof thelungs - answer-4.
Crackles on auscultation of the lungs
Rationale:
Optimal weight gain when the client is receiving PN is 1 to 2 lb/week. The client who has a weight gain of 5
lb/week while receiving
PN is likely to have fluidretention. Thiscan resultin hypervolemia.Signs of
hypervolemiaincludeincreasedbloodpressure,crackleson lung auscultation,a boundingpulse,jugular vein
distention, headache, and weight gain more than desired. Thirst and polyuria are associated with hyperglycemia.
A decreased blood pressure is likely to be noted in deficient fluid volume.
The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. The notes
nurse
thata client'sintravenous(IV) siteis cool,pale,and swollen,and thesolutionis not infusing. The nurse concludes
that which complication has occurred?
1. Infection
2. Phlebitis
3. Infiltration
4. Thrombosis- answer-3.
Infiltration
Rationale:
An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue. Pallor, coolness,
and
swellingaretheresultsof IV fluid beingdepositedin thesubcutaneoustissue.When the pressure in the tissues
exceeds the pressure in the tubing, the flow of the IV solution will stop. The corrective action is to remove the
catheter and start a new IV line at another Infection,
site. phlebitis, and thrombosis are likely to be accompanied
by warmth at the site, not coolness.
, The nurseis insertingan intravenousline into a client'svein. After theinitial stick, thenursewould continue to
advance the catheter in which situation?
1. The catheteradvanceseasily.
2. The vein is distendedundertheneedle.
3. The clientdoesnot complainof discomfort.
4. Blood returnshowsin thebackflashchamberof thecatheter.- answer-4. Blood
return shows in the backflash chamber of the catheter.
Rationale:
The IV catheter has entered the lumen of the vein successfully when blood backflash shows in the IV catheter.
The vein shouldhavebeendistendedby thetourniquetbeforethevein wascannulated.Client discomfort varies
with the client, the site, and the nurse's insertion technique and is not a reliable measure of catheter placement.
The nurse should not advance the catheter until placement in the vein is verified by blood return.
The nurse notes that the site of a client's peripheral intravenous (IV) catheter is reddened, warm, painful, and
slightly edematous proximal to the insertion point of the IV catheter. After taking appropriate
stepsto carefor the
client,thenurseshoulddocumentin themedicalrecordthattheclient experienced which condition?
1. Phlebitisof thevein
2. Infiltrationof theIV line
3. Hypersensitivityto theIV solution
4. Allergic reactionto theIV cathetermaterial- answer-1.
Phlebitis of the vein
Rationale:
Phlebitis at an IV site can be distinguished by client discomfort at the site and by redness, warmth, and swelling
proximalto the catheter. phlebitis
If occurs,the nurse should discontinue the line
IV and insert anew IV line at a
differentsite.Coolness atthesitewouldbe notedif theIV catheterwasinfiltrated.An allergic reaction produces a
rash, redness, and itching. A major reaction, such as hypersensitivity, can cause dyspnea, a swollen tongue, and
cyanosis
A client rings the call bell and complains of pain at the site of an intravenous (IV) infusion. The nurse assesses
the
siteand determinesthatphlebitishas developed.The nurseshouldtakewhich actionsin the care of this client?
Select all that apply.
1. Notify thehealthcareprovider(HCP).
COMPREHENSIVE EXIT EXAM ACTUAL EXAM 180 QUESTIONS
AND CORRECT DETAILED ANSWERS (VERIFIED ANSWERS)
WITH RATIONALES |ALREADY GRADED A+||BRAND NEW!!
A clientis receivingparenteralnutrition(PN). The nursemonitorstheclientfor complicationsof the therapy and
should assess the client for which manifestations of hyperglycemia?
1. Fever,weakpulse,and thirst
2. Nausea,vomiting,and oliguria
3. Sweating,chills, and abdominalpain
4. Weakness,thirst,and increasedurineoutput- answer-4.
Weakness, thirst, and increased urine
output
A clienthasbeendischargedto homeon parenteralnutrition(PN). With eachvisit, thehomecarenurse should
assess which parameter most closely in monitoring this therapy?
1. Pulseand weight
2. Temperatureand weight
3. Pulseand bloodpressure
4. Temperatureand bloodpressure- answer-2.
Temperature and weight
The nurseis caring for a groupof adultclientson an acutecaremedical-surgicalnursing unit. The nurse understands
that which client would be the least likely candidate for parenteral nutrition (PN)?
1.A 66-year-old clientwith extensiveburns
2.A 42-year-old clientwhohas had an opencholecystectomy
3.A 27-year-old clientwith severeexacerbationof Crohn's disease
4.A 35-year-old clientwith persistentnauseaand vomitingfrom chemotherapy- answer-2. A 42-
year-old client who has had an open cholecystectomy
Rationale:
,Parenteral nutrition is indicated in clients whose gastrointestinal tracts are not functional or must be rested,
cannottakein a dietenterallyfor extendedperiods,or haveincreasedmetabolicneed.Examples of these
conditions include those clients with burns, exacerbation of Crohn's disease, and persistent nausea and vomiting
due to chemotherapy. Other clients would be those who have had extensive surgery, have multiple fractures, are
septic, or have advanced cancer or acquired immunodeficiency syndrome. The client with the open
cholecystectomy is not a candidate because this client would resume a regular diet within a few days following
surgery.
The nurse is making initial rounds at the beginning of the shift and notes that the parenteral nutrition
bagof
(PN)
an assignedclientis empty.Which solutionreadilyavailableon thenursing unit shouldthe nurse hang until
another PN solution is mixed and delivered to the nursing unit?
1.5% dextrose in water
2.10%
dextrosein water
3.5% dextrosein Ringer'slactate
4.5% dextrosein 0.9% sodiumchloride- answer-2. 10%
dextrose in water
Rationale:
The client is at risk for hypoglycemia; therefore the solution containing the highest amount of glucose
beshould
hung until thenewPN solutionbecomesavailable.BecausePN solutionscontainhigh glucose concentrations, the
10% dextrose in water solution is the best of the choices presented. The solution selected should be one that
minimizes the risk of hypoglycemia. The remaining options will not be as effective in minimizing the risk of
hypoglycemia.
The nurseis monitoringthestatusof a client'sfatemulsion(lipid) infusionand notesthattheinfusionis 1 hour
behind. Which action should the nurse take?
1. Adjust theinfusionrateto catchup overthenexthour.
2. Increasetheinfusionrateto catchup overthenext2 hours.
3. Ensurethatthefatemulsioninfusionrateis infusingat theprescribedrate.
4. Adjust theinfusionrateto run wideopenuntil thesolutionis back on time.- answer-3. Ensure
that the fat emulsion infusion rate is infusing at the prescribed rate.
Rationale:
The nurseshouldnot increasetherateof a fatemulsionto makeup thedifference iftheinfusiontiming falls
behind. Doing so could place the client at risk for fat overload. In addition, increasing the rate
,suddenlycan causefluid overload.The sameprinciple(not increasingtherate)appliesto PN or any intravenous (IV)
infusion. Therefore the remaining options are incorrect.
A clientreceivingparenteralnutrition(PN) in thehomesettinghas a weightgain of 5 lb in 1 week.The nurse
should next assess the client for the presence of which condition?
1. Thirst
2. Polyuria
3. Decreasedbloodpressure
4. Crackleson auscultationof thelungs - answer-4.
Crackles on auscultation of the lungs
Rationale:
Optimal weight gain when the client is receiving PN is 1 to 2 lb/week. The client who has a weight gain of 5
lb/week while receiving
PN is likely to have fluidretention. Thiscan resultin hypervolemia.Signs of
hypervolemiaincludeincreasedbloodpressure,crackleson lung auscultation,a boundingpulse,jugular vein
distention, headache, and weight gain more than desired. Thirst and polyuria are associated with hyperglycemia.
A decreased blood pressure is likely to be noted in deficient fluid volume.
The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. The notes
nurse
thata client'sintravenous(IV) siteis cool,pale,and swollen,and thesolutionis not infusing. The nurse concludes
that which complication has occurred?
1. Infection
2. Phlebitis
3. Infiltration
4. Thrombosis- answer-3.
Infiltration
Rationale:
An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue. Pallor, coolness,
and
swellingaretheresultsof IV fluid beingdepositedin thesubcutaneoustissue.When the pressure in the tissues
exceeds the pressure in the tubing, the flow of the IV solution will stop. The corrective action is to remove the
catheter and start a new IV line at another Infection,
site. phlebitis, and thrombosis are likely to be accompanied
by warmth at the site, not coolness.
, The nurseis insertingan intravenousline into a client'svein. After theinitial stick, thenursewould continue to
advance the catheter in which situation?
1. The catheteradvanceseasily.
2. The vein is distendedundertheneedle.
3. The clientdoesnot complainof discomfort.
4. Blood returnshowsin thebackflashchamberof thecatheter.- answer-4. Blood
return shows in the backflash chamber of the catheter.
Rationale:
The IV catheter has entered the lumen of the vein successfully when blood backflash shows in the IV catheter.
The vein shouldhavebeendistendedby thetourniquetbeforethevein wascannulated.Client discomfort varies
with the client, the site, and the nurse's insertion technique and is not a reliable measure of catheter placement.
The nurse should not advance the catheter until placement in the vein is verified by blood return.
The nurse notes that the site of a client's peripheral intravenous (IV) catheter is reddened, warm, painful, and
slightly edematous proximal to the insertion point of the IV catheter. After taking appropriate
stepsto carefor the
client,thenurseshoulddocumentin themedicalrecordthattheclient experienced which condition?
1. Phlebitisof thevein
2. Infiltrationof theIV line
3. Hypersensitivityto theIV solution
4. Allergic reactionto theIV cathetermaterial- answer-1.
Phlebitis of the vein
Rationale:
Phlebitis at an IV site can be distinguished by client discomfort at the site and by redness, warmth, and swelling
proximalto the catheter. phlebitis
If occurs,the nurse should discontinue the line
IV and insert anew IV line at a
differentsite.Coolness atthesitewouldbe notedif theIV catheterwasinfiltrated.An allergic reaction produces a
rash, redness, and itching. A major reaction, such as hypersensitivity, can cause dyspnea, a swollen tongue, and
cyanosis
A client rings the call bell and complains of pain at the site of an intravenous (IV) infusion. The nurse assesses
the
siteand determinesthatphlebitishas developed.The nurseshouldtakewhich actionsin the care of this client?
Select all that apply.
1. Notify thehealthcareprovider(HCP).
