HESI COMPREHENSIVE EXAM (B)
ACTUAL EXAM ALL QUESTIONS AND
WELL ELABORATED ANSWERS TOP
RATED VERSION FOR ALREADY A+
GRADED HIGHLY RECOMMENDED
|NEW AND REVISED
1. Themnursemismcaringmformamclientmwithmanmischemicmstrokemwhomhasmamprescriptionmformtiss
uemplasminogenmactivatorm(t-
PA)mIV.mWhichmactionsmshouldmthemnursemexpectmtomimplement?m-
mCORRECTmANSWERmNeurologicmassessment,mincludingmthemNIHSS,mismindicatedmformthemc
lientmreceivingmt-
PA.mThismincludesmclosemmonitoringmformbleedingmduringmandmaftermtheminfusion;mifmbleedi
ngmormothermsignsmofmneurologicmimpairmentmoccur,mtheminfusionmshouldmbemstopped
2. ThemnursemanticipatesmadministeringmRho(D)mimmunemglobulinm(RhoGAM)mtomwhichmindi
viduals?m(Selectmallmthatmapply.)m-mCORRECTmANSWERmAnmRh-
negativemwomanmwhomhasmhadmammiscarriagematm24mweeks,mAnmRh-
negativemmothermaftermdeliverymofmanmRh-
positiveminfantmwithmamnegativemdirectmCoombsmtest,m&mAnmRh-
negativemmothermwithmamnegativemantibodymtitermatm28mweeksm(RhoGAMmshouldmnevermb
emgivenmtomanminfantmormfather!)
3. Amclientmwithmnon-
HodgkinmlymphomamhasmbeenmprescribedmcyclophosphamidemIVmformtherapy.mWhichmass
essmentmfindingmwouldmneedmtombemreportedmimmediatelymtomthemoncologist?m-
mCORRECTmANSWERmChills,mfever,mandmsoremthroat--
Cyclophosphamidemismanmimmunosuppressivemdrugmusedmtomtreatmlymphomamandmputsmt
hemclientmatmriskmforminfection.mSignsmandmsymptomsmofmanminfectionmshouldmbemreportedm
tomthemoncologistmimmediately
, 4. Whichmnursingminterventionmshouldmbemimplementedmpostoperativelyminmanminfantmwithm
spinambifidamaftermrepairmofmammeningocele?m-
mCORRECTmANSWERmplaceminfantminmpronemposition--
alleviatesmpressuremonmthemsurgicalmsite,mwhichmisminmthemsacrum.mFluidsmshouldmbemincre
asedmpostoperativelymtompreventmdehydration.mAmhigh-
fibermdietmshouldmbemimplementedmtompreventmconstipation.
5. Amprimiparampresentsmtomthemperinatalmunitmdescribingmrupturemofmthemmembranesm(RO
M),mwhichmoccurredm12mhoursmpriormtomcomingmtomthemhospital.mAnmoxytocinminfusionmism
begun,mandm8mhoursmlatermthemclient'smcontractionsmaremirregularmandmmild.mWhatmvitalmsi
gnmshouldmthemnursemmonitormwithmgreatermfrequencymthanmthemtypicalmunitmprotocol?m-
mCORRECTmANSWERmMaternalmtemperature--
mthismshouldmbemmonitoredmfrequentlymasmamprimarymindicatormofminfection.mThismclient'sm
rupturemofmmembranesm(ROM)moccurredmatmleastm20mhoursmagom(12mhoursmbeforemcomin
gmtomthemhospital,minmadditionmtom8mhoursmsincemhospitalmadmission).mDeliverymismnotmim
minent,mandmtheremismanmincreasedmriskmofmthemdevelopmentmofminfectionm24mhoursmafter
mROM.
6. Whenmassessingmamnormalmnewborn,mwhichmfindingsmshouldmthemnursemexpect?m(Selectma
llmthatmapply.)m-
mCORRECTmANSWERmUmbilicalmcordmcontainsmonemveinmandmtwomarteriesm&mSlightlymede
matousmlabiaminmthemfemalemnewborn
7. Amclientminmthempsychiatricmsettingmwithmanmanxietymdisordermreportsmchestmpain.mWhichma
ctionmshouldmthemnursemtakemfirst?m-mCORRECTmANSWERmaccessmclient'smvitalmsigns
8. Themnursemismcaringmformamclientmwhomismexperiencingmseverempain.mThemexpectedmoutcom
emthemnursemwritesmformthemclientmreads,m"Themclientmwillmstatemmympainmism<2mwithinm45m
minutesmaftermpainmmedicationmhasmbeenmadministered."mFormulatingmthemexpectedmout
comemismanmexamplemofmwhichmstepminmthemnursingmprocess?m-
mCORRECTmANSWERmPlanning--
allowsmthemnursemtomsetmgoalsmformcaremandmelicitmthemexpectedmoutcomembymidentifyingm
appropriatemnursingmactions.
ACTUAL EXAM ALL QUESTIONS AND
WELL ELABORATED ANSWERS TOP
RATED VERSION FOR ALREADY A+
GRADED HIGHLY RECOMMENDED
|NEW AND REVISED
1. Themnursemismcaringmformamclientmwithmanmischemicmstrokemwhomhasmamprescriptionmformtiss
uemplasminogenmactivatorm(t-
PA)mIV.mWhichmactionsmshouldmthemnursemexpectmtomimplement?m-
mCORRECTmANSWERmNeurologicmassessment,mincludingmthemNIHSS,mismindicatedmformthemc
lientmreceivingmt-
PA.mThismincludesmclosemmonitoringmformbleedingmduringmandmaftermtheminfusion;mifmbleedi
ngmormothermsignsmofmneurologicmimpairmentmoccur,mtheminfusionmshouldmbemstopped
2. ThemnursemanticipatesmadministeringmRho(D)mimmunemglobulinm(RhoGAM)mtomwhichmindi
viduals?m(Selectmallmthatmapply.)m-mCORRECTmANSWERmAnmRh-
negativemwomanmwhomhasmhadmammiscarriagematm24mweeks,mAnmRh-
negativemmothermaftermdeliverymofmanmRh-
positiveminfantmwithmamnegativemdirectmCoombsmtest,m&mAnmRh-
negativemmothermwithmamnegativemantibodymtitermatm28mweeksm(RhoGAMmshouldmnevermb
emgivenmtomanminfantmormfather!)
3. Amclientmwithmnon-
HodgkinmlymphomamhasmbeenmprescribedmcyclophosphamidemIVmformtherapy.mWhichmass
essmentmfindingmwouldmneedmtombemreportedmimmediatelymtomthemoncologist?m-
mCORRECTmANSWERmChills,mfever,mandmsoremthroat--
Cyclophosphamidemismanmimmunosuppressivemdrugmusedmtomtreatmlymphomamandmputsmt
hemclientmatmriskmforminfection.mSignsmandmsymptomsmofmanminfectionmshouldmbemreportedm
tomthemoncologistmimmediately
, 4. Whichmnursingminterventionmshouldmbemimplementedmpostoperativelyminmanminfantmwithm
spinambifidamaftermrepairmofmammeningocele?m-
mCORRECTmANSWERmplaceminfantminmpronemposition--
alleviatesmpressuremonmthemsurgicalmsite,mwhichmisminmthemsacrum.mFluidsmshouldmbemincre
asedmpostoperativelymtompreventmdehydration.mAmhigh-
fibermdietmshouldmbemimplementedmtompreventmconstipation.
5. Amprimiparampresentsmtomthemperinatalmunitmdescribingmrupturemofmthemmembranesm(RO
M),mwhichmoccurredm12mhoursmpriormtomcomingmtomthemhospital.mAnmoxytocinminfusionmism
begun,mandm8mhoursmlatermthemclient'smcontractionsmaremirregularmandmmild.mWhatmvitalmsi
gnmshouldmthemnursemmonitormwithmgreatermfrequencymthanmthemtypicalmunitmprotocol?m-
mCORRECTmANSWERmMaternalmtemperature--
mthismshouldmbemmonitoredmfrequentlymasmamprimarymindicatormofminfection.mThismclient'sm
rupturemofmmembranesm(ROM)moccurredmatmleastm20mhoursmagom(12mhoursmbeforemcomin
gmtomthemhospital,minmadditionmtom8mhoursmsincemhospitalmadmission).mDeliverymismnotmim
minent,mandmtheremismanmincreasedmriskmofmthemdevelopmentmofminfectionm24mhoursmafter
mROM.
6. Whenmassessingmamnormalmnewborn,mwhichmfindingsmshouldmthemnursemexpect?m(Selectma
llmthatmapply.)m-
mCORRECTmANSWERmUmbilicalmcordmcontainsmonemveinmandmtwomarteriesm&mSlightlymede
matousmlabiaminmthemfemalemnewborn
7. Amclientminmthempsychiatricmsettingmwithmanmanxietymdisordermreportsmchestmpain.mWhichma
ctionmshouldmthemnursemtakemfirst?m-mCORRECTmANSWERmaccessmclient'smvitalmsigns
8. Themnursemismcaringmformamclientmwhomismexperiencingmseverempain.mThemexpectedmoutcom
emthemnursemwritesmformthemclientmreads,m"Themclientmwillmstatemmympainmism<2mwithinm45m
minutesmaftermpainmmedicationmhasmbeenmadministered."mFormulatingmthemexpectedmout
comemismanmexamplemofmwhichmstepminmthemnursingmprocess?m-
mCORRECTmANSWERmPlanning--
allowsmthemnursemtomsetmgoalsmformcaremandmelicitmthemexpectedmoutcomembymidentifyingm
appropriatemnursingmactions.