EVOLVE COMPREHENSIVE EXAM HESI ACTUAL
TEST PAPER WITH CORRECT ANSWERS
◉ A client is receiving atonal (tenormin) 25 mg PO after a
myocardial infraction. The nurse determines the clinents apical
pulse is 65 beats per minute. What action should the nurse
implement next?
Answer: Administer the medication
Atenolol, a beta-blocker, blocks the beta receptors of the sinoatrial
node to reduce the heart rate, so the medication should be
administered (C) because the client's apical pulse is greater than 60.
(A, B, and D) are not indicated at this time.
◉ A 6 year old child is alert but quiet when brought to the
emergency center with periobital ecchymosis and ecchymosis
behind the ears. The nurse suspects potential child abuse and
continues to assess the child for additional manifestations of a
basilar skull fracture. What assessment finding would be consistent
with the basilar skull fracture?
Answer: Rhinorrhoea or otorrhoea with halo sign
Raccoon eyes (periorbital ecchymosis) and Battle's sign (ecchymosis
behind the ear over the mastoid process) are both signs of a basilar
,skull fracture, so the nurse should assess for possible meningeal
tears that manifest as a Halo sign with CSF leakage from the ears or
nose (D). (A) is consistent with orbital fractures. (B) occurs with
wrenching traumas of the shoulder or arm fractures. (C) occurs with
blunt abdominal injuries.
◉ The nurse is assessing a client who complains of weight loss,
racing heart rate and difficulty sleeping. The nurse determines the
client has moist skin with fine hair, prominent eyes, lid retrace, and a
staring expression. These findings are consistent with which
disorder?
Answer: Graves disease
This client is exhibiting symptoms associated with hyperthyroidism
or Grave's disease (A), which is an autoimmune condition affecting
the thyroid. (B, C, and D) are not associated with these symptoms.
◉ The nurse is assessing an older adult client and determines that
the client's left upper eyelid droops, covering more of the iris than
the right eyelid. Which description should the nurse use to
document this finding?
Answer: Ptosis on the left eyelid
Ptosis is the term to describe an eyelid droop that covers a large
portion of the iris (A), which may result from oculomotor nerve or
eyelid muscle disorder. (B) is characterized by rapid, rhythmic
,movement of both eyes. (C) is a distortion of the lens of the eye,
causing decreased visual acuity. (D) is a term used to describe a
protrusion of the eyeballs that occurs with hyperthyroidism.
◉ The nurse obtains the pluse rate of 89 beats/min for an infant
before administering digoxin (Lanoxin) which action should the
nurse take?
Answer: Withhold the medication and contact the healthcare
provider
Bradycardia is an early sign of digoxin toxicity, so if the infant's pulse
rate is less than 100 beats/minute, digoxin should be withheld and
the healthcare provider should be notified (D). Assessing the
respiratory rate (A) is not indicated before administering Lanoxin.
(B and C) place the infant at further risk for digoxin toxicity.
◉ The nurse is developing a teaching plan for an adolescent with a
milwaukee brace. Which instruction should the nurse include?
Answer: Wear the brace over a T-shirt 23 hours a day.
Idiopathic scoliosis is an abnormal lateral curvature of the spine in
adolescent females. Early treatment uses a Milwaukee brace that
places pressure against the lateral spinal curvature, under the neck,
and against the iliac crest, so it should be worn for 23 hours per day
over a T-shirt (D) which reduces friction and chafing of the skin. (A,
B, and C) reduce the effectiveness of the brace.
, ◉ A 9 year old is hospitalized for the neutropenia and is placed in
reverse isolation. The child asks the nurse " why do you have to wear
a gown and mask when you are in my room?" How should the nurse
respond?
Answer: " To protect you because you can get an infection very easily
Reverse isolation precaution implement measures to protect the
client from exposure to microorganisms from others (B). Although
microbes are prevalent in all environments, (A) does not adequately
answer the child's question. Reverse isolation should be
implemented until the client's white blood cell increases (C).
Neutropenia in this child does not place others (D) at risk for
infection.
◉ A male client who had abdominal surgery has a nasogastric tube
to suction, oxygen per nasal cannula, and complains of dry mouth.
Which action should the nurse implement?
Answer: Apply a water soluble lubricant to the lips, oral mucosa and
nares.
To ease the client's discomfort, a water soluble lubricant to the lips
and nares assists to keep the mucous membranes moist (D). (A) is a
petroleum-based product and should not be used because it is
flammable. (B and C) should not be given to the client with a
TEST PAPER WITH CORRECT ANSWERS
◉ A client is receiving atonal (tenormin) 25 mg PO after a
myocardial infraction. The nurse determines the clinents apical
pulse is 65 beats per minute. What action should the nurse
implement next?
Answer: Administer the medication
Atenolol, a beta-blocker, blocks the beta receptors of the sinoatrial
node to reduce the heart rate, so the medication should be
administered (C) because the client's apical pulse is greater than 60.
(A, B, and D) are not indicated at this time.
◉ A 6 year old child is alert but quiet when brought to the
emergency center with periobital ecchymosis and ecchymosis
behind the ears. The nurse suspects potential child abuse and
continues to assess the child for additional manifestations of a
basilar skull fracture. What assessment finding would be consistent
with the basilar skull fracture?
Answer: Rhinorrhoea or otorrhoea with halo sign
Raccoon eyes (periorbital ecchymosis) and Battle's sign (ecchymosis
behind the ear over the mastoid process) are both signs of a basilar
,skull fracture, so the nurse should assess for possible meningeal
tears that manifest as a Halo sign with CSF leakage from the ears or
nose (D). (A) is consistent with orbital fractures. (B) occurs with
wrenching traumas of the shoulder or arm fractures. (C) occurs with
blunt abdominal injuries.
◉ The nurse is assessing a client who complains of weight loss,
racing heart rate and difficulty sleeping. The nurse determines the
client has moist skin with fine hair, prominent eyes, lid retrace, and a
staring expression. These findings are consistent with which
disorder?
Answer: Graves disease
This client is exhibiting symptoms associated with hyperthyroidism
or Grave's disease (A), which is an autoimmune condition affecting
the thyroid. (B, C, and D) are not associated with these symptoms.
◉ The nurse is assessing an older adult client and determines that
the client's left upper eyelid droops, covering more of the iris than
the right eyelid. Which description should the nurse use to
document this finding?
Answer: Ptosis on the left eyelid
Ptosis is the term to describe an eyelid droop that covers a large
portion of the iris (A), which may result from oculomotor nerve or
eyelid muscle disorder. (B) is characterized by rapid, rhythmic
,movement of both eyes. (C) is a distortion of the lens of the eye,
causing decreased visual acuity. (D) is a term used to describe a
protrusion of the eyeballs that occurs with hyperthyroidism.
◉ The nurse obtains the pluse rate of 89 beats/min for an infant
before administering digoxin (Lanoxin) which action should the
nurse take?
Answer: Withhold the medication and contact the healthcare
provider
Bradycardia is an early sign of digoxin toxicity, so if the infant's pulse
rate is less than 100 beats/minute, digoxin should be withheld and
the healthcare provider should be notified (D). Assessing the
respiratory rate (A) is not indicated before administering Lanoxin.
(B and C) place the infant at further risk for digoxin toxicity.
◉ The nurse is developing a teaching plan for an adolescent with a
milwaukee brace. Which instruction should the nurse include?
Answer: Wear the brace over a T-shirt 23 hours a day.
Idiopathic scoliosis is an abnormal lateral curvature of the spine in
adolescent females. Early treatment uses a Milwaukee brace that
places pressure against the lateral spinal curvature, under the neck,
and against the iliac crest, so it should be worn for 23 hours per day
over a T-shirt (D) which reduces friction and chafing of the skin. (A,
B, and C) reduce the effectiveness of the brace.
, ◉ A 9 year old is hospitalized for the neutropenia and is placed in
reverse isolation. The child asks the nurse " why do you have to wear
a gown and mask when you are in my room?" How should the nurse
respond?
Answer: " To protect you because you can get an infection very easily
Reverse isolation precaution implement measures to protect the
client from exposure to microorganisms from others (B). Although
microbes are prevalent in all environments, (A) does not adequately
answer the child's question. Reverse isolation should be
implemented until the client's white blood cell increases (C).
Neutropenia in this child does not place others (D) at risk for
infection.
◉ A male client who had abdominal surgery has a nasogastric tube
to suction, oxygen per nasal cannula, and complains of dry mouth.
Which action should the nurse implement?
Answer: Apply a water soluble lubricant to the lips, oral mucosa and
nares.
To ease the client's discomfort, a water soluble lubricant to the lips
and nares assists to keep the mucous membranes moist (D). (A) is a
petroleum-based product and should not be used because it is
flammable. (B and C) should not be given to the client with a
