HESI Comprehensive Exam A Practice Questions & Answers With Rtionale(Summer 2022)

HESI Comprehensive Exam A Practice Questions & Answers With Rtionale(Summer 2022) 1 A 2-day postpartum mother who is . breastfeeding asks, "Why do I feel this tingling in my breasts after the baby sucks for a few minutes?" Which information should the nurse provide? A. This feeling occurs during feeding with a breast infection. B. This sensation occurs as breast milk moves to the nipple. C. The baby does not have good latch-on. D. The infant is not positioned correctly. 2 A 40-year-old office worker who is . at 36 weeks' gestation presents to the occupational health clinic complaining of a pounding headache, blurry vision, and swollen ankles. Which intervention should the nurse implement first? A. Check the client's blood pressure. B. Teach her to elevate her feet when sitting. C. Obtain a 24-hour diet history to evaluate for the intake of salty foods. D. Assess the fetal heart rate. 3 A 50-year-old man arrives at the . clinic with complaints of pain on ejaculation. Which action should the nurse implement? A. Teach the client testicular self- examination (TSE). B. Assess for the presence of blood B. This sensation occurs as breast milk moves to the nipple. Rationale: When the mother's milk comes in, usually 2 to 3 days after delivery, women often report they feel a tingling sensation in their nipples (B) when let- down occurs. (A, C, and D) provide inaccurate information. A. Check the client's blood pressure. Rationale: The blood pressure (A) should be assessed first. Preeclampsia is a multisystem disorder, and women older than 35 years and have chronic hypertension are at increased risk. Classic signs include headache, visual changes, edema, recent rapid weight gain, and elevated blood pressure. (B, C, and D) can be done if the blood pressure is normal. C. Ask about scrotal pain or blood in the semen. Rationale: Orchitis is an acute testicular inflammation resulting from recurrent urinary tract infection, recurrent sexually transmitted disease (STD), or in the urine. C. Ask about scrotal pain or blood in the semen. D. Inquire about a history of kidney stones. 4 A 77-year-old female client states . that she has never been so large around the waist and that she has frequent periods of constipation. Colon disease has been ruled out with a flexible sigmoidoscopy. Which information should the nurse provide to this client? A. As women age, they often become rounder in the middle because they do not exercise properly. B. Further assessment is indicated because loss of abdominal muscle tone and constipation do not occur with aging. C. With age, more fatty tissue develops in the abdomen and decreased intestinal movement can cause constipation. D. Because there is no evidence of a diseased colon, there is no need to worry about abdominal size. 5 According to Erikson, which client . should the nurse identify as having difficulty completing the developmental stage of older adults? an indwelling urethral urinary catheter causing pain on ejaculation, scrotal pain, blood in the semen, and penile discharge, so the nurse should determine the presence of other symptoms (C). Although all men should practice TSE, the client's symptoms are suggestive of an inflammatory syndrome rather than testicular cancer (A). Although hematuria (B) is associated with renal disease or calculi (D), the client's pain is associated with ejaculate, not urine. C. With age, more fatty tissue develops in the abdomen and decreased intestinal movement can cause constipation. Rationale: With aging, the abdominal muscles weaken as fatty tissue is deposited around the trunk and waist. Slowing peristalsis also affects the emptying of the colon, resulting in constipation (C). (A) is not the primary reason for the changes in body structure. (B) is not indicated because loss of muscle tone and constipation are age-related changes. (D) dismisses the client's concerns and does not help her understand the changes that she is experiencing. D. A 75-year-old woman who wishes her friends were still alive so she could change some of the choices she made over the years A. A 60-year-old man who tells the nurse that he is feeling fine and really does not need any help from anyone B. A 78-year-old widower who has come to the mental health clinic for counseling after the recent death of his wife C. An 81-year-old woman who states that she enjoys having her grandchildren visit but is usually glad when they go home D. A 75-year-old woman who wishes her friends were still alive so she could change some of the choices she made over the years 6 After administration of an 0730 dose . of Humalog 50/50 insulin to a client with diabetes mellitus, which nursing action has the highest priority? A. Ensure that the client receives breakfast within 30 minutes. B. Remind the client to have a midmorning snack at 1000. C. Discuss the importance of a midafternoon snack with the client. D. Explain that the client's capillary glucose will be checked at 1130. 7 The antigout medication allopurinol Rationale: The older woman who wishes she could change the choices she has made in her lifetime is expressing despair and is still searching for integrity (D). The nurse uses Erikson stages of development over the life span to assess an older client's adjustment to aging and plans teaching strategies to assist the clients attain integrity versus despair. (A, B, and C) are normal developmental tasks of older adults. A. Ensure that the client receives breakfast within 30 minutes. Rationale: Insulin 50/50 contains 50% regular and 50% NPH insulin. Therefore, the onset of action is within 30 minutes and the nurse's priority action is to ensure that the client receives a breakfast tray to avoid a hypoglycemic reaction (A). (B, C, and D) are also important nursing actions but are of less immediacy than (A). A. "I take aspirin for my pain." . (Zyloprim) is prescribed for a client newly diagnosed with gout. Which comment by the client warrants intervention by the nurse? A. "I take aspirin for my pain." B. "I frequently eat fruit and drink fruit juices." C. "I drink a great deal of water, so I have to get up at night to urinate." Rationale: The client should be taught to avoid aspirin (A) because the ingestion of aspirin or diuretics can precipitate an attack of gout. (B, C, and D) are all appropriate for the treatment of gout. The client's urinary pH can be increased by the intake D. "I observe my skin daily to see if I have an allergic rash to the medication." 8 Because of census overload, the charge . nurse of an acute care medical unit must select a client who can be transferred back to a residential facility. The client with which symptomology is the most stable? A. A stage 3 sacral pressure ulcer, with colonized methicillin-resistant Staphylococcus aureus (MRSA) B. Pneumonia, with a sputum culture of gram-negative bacteria C. Urinary tract infection, with positive blood cultures D. Culture of a diabetic foot ulcer shows gram-positive cocci 9 The charge nurse of a 16-bed medical unit . is making 0700 to 1900 shift assignments. The team consists of two RNs, two PNs, of alkaline ash foods, such as citrus fruits and juices, which will help reduce stone formation (B). Increasing fluids helps prevent urinary calculi (stone) formation and should be encouraged, even if the client must get up at night to urinate (C). Allopurinol has a rare but potentially fatal hypersensitivity syndrome, which is characterized by a rash and fever. The medication should be discontinued immediately if this occurs (D). A. A stage 3 sacral pressure ulcer, with colonized methicillin-resistant Staphylococcus aureus (MRSA) Rationale: The client with colonized MRSA (A) is the most stable client, because colonization does not cause symptomatic disease. The gram-negative organisms causing pneumonia are typically resistant to drug therapy (B), which makes recovery very difficult. Positive blood cultures (C) indicate a systemic infection. Poor circulation places the diabetic with an infected ulcer (D) at high risk for poor healing and bone infection. B. Assign the UAPs to take vital signs and obtain daily weights. and two UAP. Which assignment is the most effective use of the available team members? A. Assign the PNs to perform am care and assist with feeding the clients. B. Assign the UAPs to take vital signs and obtain daily weights. C. Assign the RNs to answer the call lights and administer all medications. D. Assign the PNs to assist health care providers on rounds and perform glucometer checks. 10. The charge nurse of a medical surgical unit is alerted to an impending disaster requiring implementation of the hospital's disaster plan. Specific facts about the nature of this disaster are not yet known. Which instruction should the charge nurse give to the other staff members at this time? A. Prepare to evacuate the unit, starting with the bedridden clients. B. UAPs should report to the emergency center to handle transports. C. The licensed staff should Rationale: A UAP can take vital signs and daily weights on stable clients (B). UAPs can perform am care and feed clients, which is a better use of personnel than assigning the task to the PN (A). All team members can answer call lights and PNs can administer some of the medications, so assigning the RN (C) these tasks is not an effective use of the available personnel. The RN is the best team member to assist on rounds (D), and the UAP can perform glucometer checks, so assigning the PN these tasks is not an effective use of available personnel. D. Continue with current assignments until more instructions are received. Rationale: When faced with an impending disaster, hospital personnel may be alerted but should continue with current client care assignments until further instructions are received (D). Evacuation is typically a response of last resort that begins with clients who are most able to ambulate (A). (B) is premature and is likely to increase the chaos if incoming casualties are anticipated. (C) is poor begin counting wheelchairs and IV poles on the unit. D. Continue with current assignments until more instructions are received. 11. The charge nurse overhears a staff member asking for a doughnut from a client's meal tray. Which action should the charge nurse implement? A. Advise the client that food from the meal tray should not be shared with others. B. Leave the room and discuss the incident privately with the staff member. C. Objectively document the situation as observed on a variance report. D. Call the nurse-manager to the client's room immediately. 12. The charge nurse working in the surgical department is making shift assignments. The shift personnel include an RN with 12 years of nursing experience, an RN with 2 years of nursing experience, and an RN with 3 months of nursing experience. Which client should the charge nurse assign to the RN with 3 months of experience? A. A client who is 2 days postoperative with a right total knee replacement B. A client who is scheduled for a sigmoid colostomy utilization of personnel. B. Leave the room and discuss the incident privately with the staff member. Rationale: Discussing the incident privately (B) promotes open communication between the charge nurse and staff member. The client is free to share unwanted food (A) with family or friends, but the employee should not ask for the client's food. (C) is not necessary, and the charge nurse can respond to this situation without implementing (D). A. A client who is 2 days postoperative with a right total knee replacement Rationale: (A) is the least critical client and should be assigned to the RN with the least experience. A client with a knee replacement is probably ambulating and able to perform self-care, and a physical therapist is likely to be assisting with the client's care. (B) will require a high level of nursing care when returned from surgery. (C) means that there is a