HESI Exam Prep Test Bank P a g e | 1
Leadership HESI Exam Prep Test Bank 3
Rationales/ Hesi Leadership Exam Prep Test
Bank Latest (New!)| GUARANTEED PASS
1-Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment does the nurse
perform as a priority before administering the medication?
A. Checking the client's blood pressure
B. Checking the client's peripheral pulses
C. Checking the most recent potassium level
D. Checking the client's intake-and-output record for the last 24 hours
A. Checking the client's blood pressure
Checking the client's blood pressure
Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor used to treat hypertension. One
common side effect is postural hypotension. Therefore the nurse would check the client's blood
pressure immediately before administering each dose. Checking the client's peripheral pulses, the
results of the most recent potassium level, and the intake and output for the previous 24 hours are
not specifically associated with this mediation.
2-A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse provides
instructions to the client about the test. Which statement by the client indicates a need for further
P a g e 1 | 214
, HESI Exam Prep Test Bank P a g e | 2
instruction?
A. "The test will take about 30 minutes."
B. "I need to fast for 8 hours before the test."
C. "I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the
morning of the test."
D. "I need to take a laxative after the test is completed, because the liquid that I'll have to drink for the
test can be constipating."
C. "I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the
morning of the test."
An upper GI series involves visualization of the esophagus, duodenum, and upper jejunum by means of
the use of a contrast medium. It involves swallowing a contrast medium (usually barium), which is
administered in a flavored milkshake. Films are taken at intervals during the test, which takes about 30
minutes. No special preparation is necessary before a GI series, except that NPO status must be
maintained for 8 hours before the test. After an upper GI series, the client is prescribed a laxative to
hasten elimination of the barium. Barium that remains in the colon may become hard and difficult to
expel, leading to fecal impaction.
A female client reports that her hair is becoming coarse and breaking off, that the outer part of her
eyebrows have disappeared, and that her eyes are all puffy. Which follow-up question is best for the
nurse to ask?
a. "Is there a history of female baldness in your family?"
b. "Are you under any unusual stress at home or work?"
c. "Do you work with hazardous chemicals?"
d. "Have you noticed any changes in your fingernails?"
Have you noticed any changes in your fingernails?
Rationale: The pattern of reported manifestations is suggestive of hypothyroidism
After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and
malnutrition. The client is drowsy but responding to verbal stimuli and reports recently spitting up
blood. What assessment finding warrants immediate intervention by the nurse?
a. Bruises on arms and legs
b. Round and tight abdomen
c. Pitting edema in lower legs
d. Capillary refill of 8 seconds
Capillary refill of 8 seconds
P a g e 2 | 214
, HESI Exam Prep Test Bank P a g e | 3
Rationale: The client is bleeding and hypovolemia is likely. Capillary refill is greater than 3 to 5 seconds
indicates poor perfusion and requires immediate attention
After the nurse witnesses a preoperative client sign the surgical consent form, the nurse signs the
form as a witness. What are the legal implications of the nurse's signature on the client's surgical
consent form? (Select all that apply)
a. The client voluntarily grants permission for the procedure to be done
b. The surgeon has explained to the client why the surgery is necessary.
c. The client is competent to sign the consent without impairment of judgment
d. The client understands the risks and benefits associated with the procedure
e. After considering alternatives to surgery, the client elects to have the procedure.
a. The client voluntarily grants permission for the procedure to be done
c. The client is competent to sign the consent without impairment of judgment
d. The client understands the risks and benefits associated with the procedure
Rationale: Inform consent is required for any invasive procedure. The nurse's signature as a witness to
the client's signature on surgical consent indicates that the client voluntary gives consent for the
scheduled procedure. C is competent to give consent, and D and understand the risk and benefits of
the procedure.
Following surgery, a male client with antisocial personality disorder frequently requests that a specific
nurse be assigned to his care and is belligerent when another nurse is assigned. What action should
the charge nurse implement?
a. Ask the client to explain why he constantly request the nurse
b. Encourage the client to verbalize his feelings about the nurse
c. Reassure the client that his request will be met whenever possible.
d. Advise the client that assignments are not based on client requests
Advise the client that assignments are not based on clients requests
Rationale: Those with antisocial personality disorders are manipulative in order to meet their own
needs. The charge nurse must set limits on this behavior. The client's superficial charm and emotional
maturity prevent effective therapeutic communication and (A and B) will be used to the client's
advantage. C encourage further manipulative behavior.
A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant.
While providing care, the nurse finds the radiation implant in the bed. What action should the nurse
take?
a. Call the radiology department
P a g e 3 | 214
, HESI Exam Prep Test Bank P a g e | 4
b. Reinsert the implant into the vagina
c. Apply double gloves to retrieve the implant for disposal.
d. Place the implant in a lead container using long-handled forceps
Place the implant in a lead container using long-handled forceps
Rationale: Solid or sealed radiation sources, such as Cesium which is removed after treatment, are
inserted into an applicator or cervical implant to emit continuous, low energy radiation for adjacent
tumor tissues. If the radiation source or the applicator become dislodged long-handled forceps should
be used to retrieve the radiation implant to prevent injury due to direct handling. The applicator is then
placed in the lead container.
The client with which type of wound is most likely to need immediate intervention by the nurse?
a. Laceration
b. Abrasion
c. Contusion
d. Ulceration
Laceration
Rationale: A laceration is a wound that is produced by the tearing of soft body tissue. This type of
wound is often irregular and jagged. A laceration wound is often contaminated with bacteria and
debris from whatever object caused the cut
The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which
intervention has the highest priority for inclusion in this client's plan of care?
a. Record urine output every hour
b. Monitor blood pressure frequently
c. Evaluate neurological status
d. Maintain seizure precautions
Monitor blood pressure frequently
Rationale: A pheochromocytoma is a rare, catecholamine-secreting tumor that may precipitate life-
threatening hypertension
When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse elevates the
head of the bed 30 degrees. What is the reason for this intervention?
a. To reduce abdominal pressure on the diaphragm
b. to promote retraction of the intercostal accessory muscle of respiration
c. to promote bronchodilation and effective airway clearance
d. to decrease pressure on the medullary center which stimulates breathing
P a g e 4 | 214
Leadership HESI Exam Prep Test Bank 3
Rationales/ Hesi Leadership Exam Prep Test
Bank Latest (New!)| GUARANTEED PASS
1-Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment does the nurse
perform as a priority before administering the medication?
A. Checking the client's blood pressure
B. Checking the client's peripheral pulses
C. Checking the most recent potassium level
D. Checking the client's intake-and-output record for the last 24 hours
A. Checking the client's blood pressure
Checking the client's blood pressure
Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor used to treat hypertension. One
common side effect is postural hypotension. Therefore the nurse would check the client's blood
pressure immediately before administering each dose. Checking the client's peripheral pulses, the
results of the most recent potassium level, and the intake and output for the previous 24 hours are
not specifically associated with this mediation.
2-A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse provides
instructions to the client about the test. Which statement by the client indicates a need for further
P a g e 1 | 214
, HESI Exam Prep Test Bank P a g e | 2
instruction?
A. "The test will take about 30 minutes."
B. "I need to fast for 8 hours before the test."
C. "I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the
morning of the test."
D. "I need to take a laxative after the test is completed, because the liquid that I'll have to drink for the
test can be constipating."
C. "I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the
morning of the test."
An upper GI series involves visualization of the esophagus, duodenum, and upper jejunum by means of
the use of a contrast medium. It involves swallowing a contrast medium (usually barium), which is
administered in a flavored milkshake. Films are taken at intervals during the test, which takes about 30
minutes. No special preparation is necessary before a GI series, except that NPO status must be
maintained for 8 hours before the test. After an upper GI series, the client is prescribed a laxative to
hasten elimination of the barium. Barium that remains in the colon may become hard and difficult to
expel, leading to fecal impaction.
A female client reports that her hair is becoming coarse and breaking off, that the outer part of her
eyebrows have disappeared, and that her eyes are all puffy. Which follow-up question is best for the
nurse to ask?
a. "Is there a history of female baldness in your family?"
b. "Are you under any unusual stress at home or work?"
c. "Do you work with hazardous chemicals?"
d. "Have you noticed any changes in your fingernails?"
Have you noticed any changes in your fingernails?
Rationale: The pattern of reported manifestations is suggestive of hypothyroidism
After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and
malnutrition. The client is drowsy but responding to verbal stimuli and reports recently spitting up
blood. What assessment finding warrants immediate intervention by the nurse?
a. Bruises on arms and legs
b. Round and tight abdomen
c. Pitting edema in lower legs
d. Capillary refill of 8 seconds
Capillary refill of 8 seconds
P a g e 2 | 214
, HESI Exam Prep Test Bank P a g e | 3
Rationale: The client is bleeding and hypovolemia is likely. Capillary refill is greater than 3 to 5 seconds
indicates poor perfusion and requires immediate attention
After the nurse witnesses a preoperative client sign the surgical consent form, the nurse signs the
form as a witness. What are the legal implications of the nurse's signature on the client's surgical
consent form? (Select all that apply)
a. The client voluntarily grants permission for the procedure to be done
b. The surgeon has explained to the client why the surgery is necessary.
c. The client is competent to sign the consent without impairment of judgment
d. The client understands the risks and benefits associated with the procedure
e. After considering alternatives to surgery, the client elects to have the procedure.
a. The client voluntarily grants permission for the procedure to be done
c. The client is competent to sign the consent without impairment of judgment
d. The client understands the risks and benefits associated with the procedure
Rationale: Inform consent is required for any invasive procedure. The nurse's signature as a witness to
the client's signature on surgical consent indicates that the client voluntary gives consent for the
scheduled procedure. C is competent to give consent, and D and understand the risk and benefits of
the procedure.
Following surgery, a male client with antisocial personality disorder frequently requests that a specific
nurse be assigned to his care and is belligerent when another nurse is assigned. What action should
the charge nurse implement?
a. Ask the client to explain why he constantly request the nurse
b. Encourage the client to verbalize his feelings about the nurse
c. Reassure the client that his request will be met whenever possible.
d. Advise the client that assignments are not based on client requests
Advise the client that assignments are not based on clients requests
Rationale: Those with antisocial personality disorders are manipulative in order to meet their own
needs. The charge nurse must set limits on this behavior. The client's superficial charm and emotional
maturity prevent effective therapeutic communication and (A and B) will be used to the client's
advantage. C encourage further manipulative behavior.
A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant.
While providing care, the nurse finds the radiation implant in the bed. What action should the nurse
take?
a. Call the radiology department
P a g e 3 | 214
, HESI Exam Prep Test Bank P a g e | 4
b. Reinsert the implant into the vagina
c. Apply double gloves to retrieve the implant for disposal.
d. Place the implant in a lead container using long-handled forceps
Place the implant in a lead container using long-handled forceps
Rationale: Solid or sealed radiation sources, such as Cesium which is removed after treatment, are
inserted into an applicator or cervical implant to emit continuous, low energy radiation for adjacent
tumor tissues. If the radiation source or the applicator become dislodged long-handled forceps should
be used to retrieve the radiation implant to prevent injury due to direct handling. The applicator is then
placed in the lead container.
The client with which type of wound is most likely to need immediate intervention by the nurse?
a. Laceration
b. Abrasion
c. Contusion
d. Ulceration
Laceration
Rationale: A laceration is a wound that is produced by the tearing of soft body tissue. This type of
wound is often irregular and jagged. A laceration wound is often contaminated with bacteria and
debris from whatever object caused the cut
The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which
intervention has the highest priority for inclusion in this client's plan of care?
a. Record urine output every hour
b. Monitor blood pressure frequently
c. Evaluate neurological status
d. Maintain seizure precautions
Monitor blood pressure frequently
Rationale: A pheochromocytoma is a rare, catecholamine-secreting tumor that may precipitate life-
threatening hypertension
When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse elevates the
head of the bed 30 degrees. What is the reason for this intervention?
a. To reduce abdominal pressure on the diaphragm
b. to promote retraction of the intercostal accessory muscle of respiration
c. to promote bronchodilation and effective airway clearance
d. to decrease pressure on the medullary center which stimulates breathing
P a g e 4 | 214
