ALL HESI EXIT SET 3 UPDATED ACTUAL
QUESTIONS AND CORRECT ANSWERS
◉ A client comes to the obstetric clinic for her first prenatal visit and
complains of feeling nauseated every morning. The client tells the
nurse, "I'm having second thoughts about wanting to have this baby."
Which response is best for the nurse to make?
A."It's normal to feel ambivalent about a pregnancy when you are
not feeling well."
B."I think you should discuss these feelings with your health care
provider."
C."How does the father of your child feel about your having this
baby?"
D."Tell me about these second thoughts you are having about this
pregnancy.". Answer: D
Rationale:
Although ambivalence is normal during the first trimester, (D) is the
best nursing response at this time. It is reflective and keeps the lines
of communication open. (A) is not the best response because it
offers false reassurance. (B) dismisses the client's feelings. The
nurse should use communication skills that encourage this type of
discussion, not shift responsibility to the care provider. (C) may
eventually be discussed, but it is not the most important information
to obtain at this time.
,◉ A nurse performs an initial admission assessment of a 56-year-old
client. Which factor(s) would indicate that the client is at risk for
metabolic syndrome? (Select all that apply.)
A.Abdominal obesity
B.Sedentary lifestyle
C.History of hypoglycemia
D.Hispanic or Asian ethnicity
E.Increased triglycerides. Answer: A,B,D,E
Rationale:
Metabolic syndrome is a name for a group of risk factors that
increase the risk for coronary artery disease, type 2 diabetes, and
stroke (A, B, D, and E). Hypoglycemia is not a risk factor for
metabolic syndrome (C).
◉ The nurse administers regular insulin (human), 8 units
subcutaneously, to a client at 8:00 am, 30 minutes before breakfast.
At what time is the client most at risk for a hypoglycemic reaction?
A.9:30 am
B.10:30 am
C.12:00 pm
D.3:00 pm. Answer: B
Rationale:
,Regular insulin is short-acting and peaks between 2 and 3 hours
after administration (B). The client is most at risk for a hypoglycemic
reaction during the peak times. (A, C, and D) are not high-risk times
for the client to experience hypoglycemia because they do not fall
within the peak time.
◉ Which intervention is most important when caring for a client
immediately after electroconvulsive therapy (ECT)?A.Reorient the
client to surroundings.
B.Assess blood pressure every 15 minutes.
C.Determine if muscle soreness is present.
D.Maintain a patent airway.. Answer: D
Rationale:
The client is typically unconscious immediately following ECT, and
nausea is a common side effect. The nurse should take measures to
prevent aspiration and maintain a patent airway (D). Patients may
be confused after ECT (A), but reorientation is not as high a priority
as the airway. Although vital signs should be assessed, the airway is
a higher priority (B). Muscle soreness is an expected finding after
ECT (C).
◉ The nurse prepares to administer ophthalmic drops to a client
prior to cataract surgery. List the steps in the order that they should
be implemented from first step to final step.
A. Drop prescribed number of drops into conjunctival sac.
, B. Wash hands and apply clean gloves.
C. Place dominant hand on the client's forehead.
D. Ask the client to close the eye gently.
A. C, B, A, D
B. B, C, A, D
C. A, B, D, C
D. A, C, B, D. Answer: B
Rationale:
Washing hands and applying gloves prior to procedure initiation
prevents the spread of infection (B). Placing the dominant hand on
the client's forehead (C) stabilizes the hand so the nurse can hold
the dropper 1 to 2 cm above the conjunctival sac and drop the
prescribed number of drops (A); asking the client to close the eye
gently helps distribute the medication (D).
◉ A client with bipolar disorder is seen in the mental health clinic
for evaluation of a new medication regimen that includes
risperidone (Risperdal). The nurse notes that the client has gained
30 lb in the past 3 months. Which assessment is most important for
the nurse to obtain?
A.Compliance with medication regimen
B.Current thyroid-stimulating hormone (TSH) level
C.Occurrence of mania or depression
QUESTIONS AND CORRECT ANSWERS
◉ A client comes to the obstetric clinic for her first prenatal visit and
complains of feeling nauseated every morning. The client tells the
nurse, "I'm having second thoughts about wanting to have this baby."
Which response is best for the nurse to make?
A."It's normal to feel ambivalent about a pregnancy when you are
not feeling well."
B."I think you should discuss these feelings with your health care
provider."
C."How does the father of your child feel about your having this
baby?"
D."Tell me about these second thoughts you are having about this
pregnancy.". Answer: D
Rationale:
Although ambivalence is normal during the first trimester, (D) is the
best nursing response at this time. It is reflective and keeps the lines
of communication open. (A) is not the best response because it
offers false reassurance. (B) dismisses the client's feelings. The
nurse should use communication skills that encourage this type of
discussion, not shift responsibility to the care provider. (C) may
eventually be discussed, but it is not the most important information
to obtain at this time.
,◉ A nurse performs an initial admission assessment of a 56-year-old
client. Which factor(s) would indicate that the client is at risk for
metabolic syndrome? (Select all that apply.)
A.Abdominal obesity
B.Sedentary lifestyle
C.History of hypoglycemia
D.Hispanic or Asian ethnicity
E.Increased triglycerides. Answer: A,B,D,E
Rationale:
Metabolic syndrome is a name for a group of risk factors that
increase the risk for coronary artery disease, type 2 diabetes, and
stroke (A, B, D, and E). Hypoglycemia is not a risk factor for
metabolic syndrome (C).
◉ The nurse administers regular insulin (human), 8 units
subcutaneously, to a client at 8:00 am, 30 minutes before breakfast.
At what time is the client most at risk for a hypoglycemic reaction?
A.9:30 am
B.10:30 am
C.12:00 pm
D.3:00 pm. Answer: B
Rationale:
,Regular insulin is short-acting and peaks between 2 and 3 hours
after administration (B). The client is most at risk for a hypoglycemic
reaction during the peak times. (A, C, and D) are not high-risk times
for the client to experience hypoglycemia because they do not fall
within the peak time.
◉ Which intervention is most important when caring for a client
immediately after electroconvulsive therapy (ECT)?A.Reorient the
client to surroundings.
B.Assess blood pressure every 15 minutes.
C.Determine if muscle soreness is present.
D.Maintain a patent airway.. Answer: D
Rationale:
The client is typically unconscious immediately following ECT, and
nausea is a common side effect. The nurse should take measures to
prevent aspiration and maintain a patent airway (D). Patients may
be confused after ECT (A), but reorientation is not as high a priority
as the airway. Although vital signs should be assessed, the airway is
a higher priority (B). Muscle soreness is an expected finding after
ECT (C).
◉ The nurse prepares to administer ophthalmic drops to a client
prior to cataract surgery. List the steps in the order that they should
be implemented from first step to final step.
A. Drop prescribed number of drops into conjunctival sac.
, B. Wash hands and apply clean gloves.
C. Place dominant hand on the client's forehead.
D. Ask the client to close the eye gently.
A. C, B, A, D
B. B, C, A, D
C. A, B, D, C
D. A, C, B, D. Answer: B
Rationale:
Washing hands and applying gloves prior to procedure initiation
prevents the spread of infection (B). Placing the dominant hand on
the client's forehead (C) stabilizes the hand so the nurse can hold
the dropper 1 to 2 cm above the conjunctival sac and drop the
prescribed number of drops (A); asking the client to close the eye
gently helps distribute the medication (D).
◉ A client with bipolar disorder is seen in the mental health clinic
for evaluation of a new medication regimen that includes
risperidone (Risperdal). The nurse notes that the client has gained
30 lb in the past 3 months. Which assessment is most important for
the nurse to obtain?
A.Compliance with medication regimen
B.Current thyroid-stimulating hormone (TSH) level
C.Occurrence of mania or depression
