EXIT HESI COMPREHENSIVE B
COMPREHENSIVE STUDY GUIDE WITH
SOLUTIONS
◉ The nurse is caring for a client with heart failure who develops
respiratory distress and coughs up pink frothy sputum. Which action
should the nurse take first?
A.Draw arterial blood gases.
B.Notify the primary health care provider.
C.Position in a high Fowler's position with the legs down.
D.Obtain a chest X-ray.
Answer: C
Rationale:
Positioning the patient in a high Fowler's position with dangling feet
will decrease further venous return to the left ventricle (C). The
other actions should be performed after the change in position (A, B,
and D).
◉ A client who is prescribed chlorpromazine HCl (Thorazine) for
schizophrenia develops rigidity, a shuffling gait, and tremors. Which
action by the nurse is most important?A.Administer a dose of
benztropine mesylate (Cogentin) PRN.
B.Determine if the client has increased photosensitivity.
,C.Provide comfort measures for sore muscles.
D.Assess the client for visual and auditory hallucinations..
Answer: A
Rationale:
Rigidity, shuffling gait, pill-rolling hand movements, tremors,
dyskinesia, and masklike face are extrapyramidal side effects
associated with Thorazine. It is most important for the nurse to
administer an anticholinergic such as Cogentin to reverse these
effects (A). The others (B, C, D) may be appropriate interventions
but are not as urgent as (A).
◉ A nurse is interviewing a mother during a well-child visit. Which
finding would alert the nurse to continue further assessment of the
infant?
A.Two-month-old who is unable to roll from back to abdomen
B.Ten-month-old who cannot sit without support
C.Nine-month-old who cries when his mother leaves the room
D.Eight-month-old who has not yet begun to speak words.
Answer: B
Rationale:
As a developmental milestone, infants should sit unsupported by 8
months (B). The milestone of rolling over is achieved at 5 to 6
months for most infants (A). Stranger anxiety is common from 7 to 9
months (C). Speaking a few words is expected at about 12 months
(D).
,◉ Which intervention should be included in the plan of care for a
client admitted to the hospital with ulcerative colitis?
A.Administer stool softeners.
B.Place the client on fluid restriction.
C.Provide a low-residue diet.
D.Add a milk product to each meal..
Answer: C
Rationale:
A low-residue diet (C) will help decrease symptoms of diarrhea,
which are clinical manifestations of ulcerative colitis. (A, B, and D)
are contraindicated and could worsen the condition.
◉ The nurse is caring for a client with deep vein thrombosis who is
on a continuous IV heparin infusion. The activated partial
prothrombin time (aPTT) is 120 seconds. Which action should the
nurse take?
A.Increase the rate of the heparin infusion using a nomogram.
B.Decrease the heparin infusion rate and give vitamin K IM.
C.Continue the heparin infusion at the current prescribed rate.
D.Stop the heparin drip and prepare to administer protamine
sulfate..
Answer: D
Rationale:
, An aPTT more than 100 seconds is a critically high value; therefore,
the heparin should be stopped. The antidote for heparin is
protamine sulfate (D). Increasing the rate would increase the risk for
hemorrhage (A). The infusion should be stopped, and vitamin K is
the antidote for warfarin (Coumadin) (B). Keeping the infusion at
the current rate would increase the risk for hemorrhage (C).
◉ While assessing a client with recurring chest pain, the unit
secretary notifies the nurse that the client's health care provider is
on the telephone. What action should the nurse instruct the unit
secretary to implement?
A.Transfer the call into the room of the client.
B.Instruct the secretary to explain reason for the call.
C.Ask another nurse to take the phone call.
D.Ask the health care provider to see the client on the unit..
Answer: C
Rationale:
Another nurse should be asked to take the phone call (C), which
allows the nurse to stay at the bedside to complete the assessment
of the client's chest pain. (A and B) should not be done during an
acute change in the client's condition. Requesting the health care
provider (D) to come to the unit is premature until the nurse
completes assessment of the client's status.
COMPREHENSIVE STUDY GUIDE WITH
SOLUTIONS
◉ The nurse is caring for a client with heart failure who develops
respiratory distress and coughs up pink frothy sputum. Which action
should the nurse take first?
A.Draw arterial blood gases.
B.Notify the primary health care provider.
C.Position in a high Fowler's position with the legs down.
D.Obtain a chest X-ray.
Answer: C
Rationale:
Positioning the patient in a high Fowler's position with dangling feet
will decrease further venous return to the left ventricle (C). The
other actions should be performed after the change in position (A, B,
and D).
◉ A client who is prescribed chlorpromazine HCl (Thorazine) for
schizophrenia develops rigidity, a shuffling gait, and tremors. Which
action by the nurse is most important?A.Administer a dose of
benztropine mesylate (Cogentin) PRN.
B.Determine if the client has increased photosensitivity.
,C.Provide comfort measures for sore muscles.
D.Assess the client for visual and auditory hallucinations..
Answer: A
Rationale:
Rigidity, shuffling gait, pill-rolling hand movements, tremors,
dyskinesia, and masklike face are extrapyramidal side effects
associated with Thorazine. It is most important for the nurse to
administer an anticholinergic such as Cogentin to reverse these
effects (A). The others (B, C, D) may be appropriate interventions
but are not as urgent as (A).
◉ A nurse is interviewing a mother during a well-child visit. Which
finding would alert the nurse to continue further assessment of the
infant?
A.Two-month-old who is unable to roll from back to abdomen
B.Ten-month-old who cannot sit without support
C.Nine-month-old who cries when his mother leaves the room
D.Eight-month-old who has not yet begun to speak words.
Answer: B
Rationale:
As a developmental milestone, infants should sit unsupported by 8
months (B). The milestone of rolling over is achieved at 5 to 6
months for most infants (A). Stranger anxiety is common from 7 to 9
months (C). Speaking a few words is expected at about 12 months
(D).
,◉ Which intervention should be included in the plan of care for a
client admitted to the hospital with ulcerative colitis?
A.Administer stool softeners.
B.Place the client on fluid restriction.
C.Provide a low-residue diet.
D.Add a milk product to each meal..
Answer: C
Rationale:
A low-residue diet (C) will help decrease symptoms of diarrhea,
which are clinical manifestations of ulcerative colitis. (A, B, and D)
are contraindicated and could worsen the condition.
◉ The nurse is caring for a client with deep vein thrombosis who is
on a continuous IV heparin infusion. The activated partial
prothrombin time (aPTT) is 120 seconds. Which action should the
nurse take?
A.Increase the rate of the heparin infusion using a nomogram.
B.Decrease the heparin infusion rate and give vitamin K IM.
C.Continue the heparin infusion at the current prescribed rate.
D.Stop the heparin drip and prepare to administer protamine
sulfate..
Answer: D
Rationale:
, An aPTT more than 100 seconds is a critically high value; therefore,
the heparin should be stopped. The antidote for heparin is
protamine sulfate (D). Increasing the rate would increase the risk for
hemorrhage (A). The infusion should be stopped, and vitamin K is
the antidote for warfarin (Coumadin) (B). Keeping the infusion at
the current rate would increase the risk for hemorrhage (C).
◉ While assessing a client with recurring chest pain, the unit
secretary notifies the nurse that the client's health care provider is
on the telephone. What action should the nurse instruct the unit
secretary to implement?
A.Transfer the call into the room of the client.
B.Instruct the secretary to explain reason for the call.
C.Ask another nurse to take the phone call.
D.Ask the health care provider to see the client on the unit..
Answer: C
Rationale:
Another nurse should be asked to take the phone call (C), which
allows the nurse to stay at the bedside to complete the assessment
of the client's chest pain. (A and B) should not be done during an
acute change in the client's condition. Requesting the health care
provider (D) to come to the unit is premature until the nurse
completes assessment of the client's status.
