HESI Comprehensive Exam A Practice QUESTIONS AND ANSWERS

ESI Comprehensive Exam A Practice 1 . A 2-day postpartum mother who is breastfeeding asks, "Why do I feel this tingling in my breasts after the baby sucks for a few minutes?" Which information should the nurse provide? A. This feeling occurs during feeding with a breast infection. B. This sensation occurs as breast milk moves to the nipple. C. The baby does not have good latch-on. D. The infant is not positioned correctly. B. This sensation occurs as breast milk moves to the nipple. Rationale: When the mother's milk comes in, usually 2 to 3 days after delivery, women often report they feel a tingling sensation in their nipples (B) when letdown occurs. (A, C, and D) provide inaccurate information. 2 . A 40-year-old office worker who is at 36 weeks' gestation presents to the occupational health clinic complaining of a pounding headache, blurry vision, and swollen ankles. Which intervention should the nurse implement first? A. Check the client's blood pressure. B. Teach her to elevate her feet when sitting. C. Obtain a 24-hour diet history to evaluate for the intake of salty foods. D. Assess the fetal heart rate. A. Check the client's blood pressure. Rationale: The blood pressure (A) should be assessed first. Preeclampsia is a multisystem disorder, and women older than 35 years and have chronic hypertension are at increased risk. Classic signs include headache, visual changes, edema, recent rapid weight gain, and elevated blood pressure. (B, C, and D) can be done if the blood pressure is normal. 3 . A 50-year-old man arrives at the clinic with complaints of pain on ejaculation. Which action should the nurse implement? A. Teach the client testicular selfexamination (TSE). B. Assess for the presence of blood C. Ask about scrotal pain or blood in the semen. Rationale: Orchitis is an acute testicular inflammation resulting from recurrent urinary tract infection, recurrent sexually transmitted disease (STD), or in the urine. C. Ask about scrotal pain or blood in the semen. D. Inquire about a history of kidney stones. an indwelling urethral urinary catheter causing pain on ejaculation, scrotal pain, blood in the semen, and penile discharge, so the nurse should determine the presence of other symptoms (C). Although all men should practice TSE, the client's symptoms are suggestive of an inflammatory syndrome rather than testicular cancer (A). Although hematuria (B) is associated with renal disease or calculi (D), the client's pain is associated with ejaculate, not urine. 4 . A 77-year-old female client states that she has never been so large around the waist and that she has frequent periods of constipation. Colon disease has been ruled out with a flexible sigmoidoscopy. Which information should the nurse provide to this client? A. As women age, they often become rounder in the middle because they do not exercise properly. B. Further assessment is indicated because loss of abdominal muscle tone and constipation do not occur with aging. C. With age, more fatty tissue develops in the abdomen and decreased intestinal movement can cause constipation. D. Because there is no evidence of a diseased colon, there is no need to worry about abdominal size. C. With age, more fatty tissue develops in the abdomen and decreased intestinal movement can cause constipation. Rationale: With aging, the abdominal muscles weaken as fatty tissue is deposited around the trunk and waist. Slowing peristalsis also affects the emptying of the colon, resulting in constipation (C). (A) is not the primary reason for the changes in body structure. (B) is not indicated because loss of muscle tone and constipation are age-related changes. (D) dismisses the client's concerns and does not help her understand the changes that she is experiencing. 5 . According to Erikson, which client should the nurse identify as having difficulty completing the developmental stage of older adults? D. A 75-year-old woman who wishes her friends were still alive so she could change some of the choices she made over the years A. A 60-year-old man who tells the nurse that he is feeling fine and really does not need any help from anyone B. A 78-year-old widower who has come to the mental health clinic for counseling after the recent death of his wife C. An 81-year-old woman who states that she enjoys having her grandchildren visit but is usually glad when they go home D. A 75-year-old woman who wishes her friends were still alive so she could change some of the choices she made over the years Rationale: The older woman who wishes she could change the choices she has made in her lifetime is expressing despair and is still searching for integrity (D). The nurse uses Erikson stages of development over the life span to assess an older client's adjustment to aging and plans teaching strategies to assist the clients attain integrity versus despair. (A, B, and C) are normal developmental tasks of older adults. 6 . After administration of an 0730 dose of Humalog 50/50 insulin to a client with diabetes mellitus, which nursing action has the highest priority? A. Ensure that the client receives breakfast within 30 minutes. B. Remind the client to have a midmorning snack at 1000. C. Discuss the importance of a midafternoon snack with the client. D. Explain that the client's capillary glucose will be checked at 1130. A. Ensure that the client receives breakfast within 30 minutes. Rationale: Insulin 50/50 contains 50% regular and 50% NPH insulin. Therefore, the onset of action is within 30 minutes and the nurse's priority action is to ensure that the client receives a breakfast tray to avoid a hypoglycemic reaction (A). (B, C, and D) are also important nursing actions but are of less immediacy than (A). 7 . The antigout medication allopurinol (Zyloprim) is prescribed for a client newly diagnosed with gout. Which comment by the client warrants intervention by the nurse? A. "I take aspirin for my pain." B. "I frequently eat fruit and drink fruit juices." C. "I drink a great deal of water, so I have to get up at night to urinate." A. "I take aspirin for my pain." Rationale: The client should be taught to avoid aspirin (A) because the ingestion of aspirin or diuretics can precipitate an attack of gout. (B, C, and D) are all appropriate for the treatment of gout. The client's urinary pH can be increased by the intake D. "I observe my skin daily to see if I have an allergic rash to the medication." of alkaline ash foods, such as citrus fruits and juices, which will help reduce stone formation (B). Increasing fluids helps prevent urinary calculi (stone) formation and should be encouraged, even if the client must get up at night to urinate (C). Allopurinol has a rare but potentially fatal hypersensitivity syndrome, which is characterized by a rash and fever. The medication should be discontinued immediately if this occurs (D). 8 . Because of census overload, the charge nurse of an acute care medical unit must select a client who can be transferred back to a residential facility. The client with which symptomology is the most stable? A. A stage 3 sacral pressure ulcer, with colonized methicillin-resistant Staphylococcus aureus (MRSA) B. Pneumonia, with a sputum culture of gram-negative bacteria C. Urinary tract infection, with positive blood cultures D. Culture of a diabetic foot ulcer shows gram-positive cocci A. A stage 3 sacral pressure ulcer, with colonized methicillin-resistant Staphylococcus aureus (MRSA) Rationale: The client with colonized MRSA (A) is the most stable client, because colonization does not cause symptomatic disease. The gram-negative organisms causing pneumonia are typically resistant to drug therapy (B), which makes recovery very difficult. Positive blood cultures (C) indicate a systemic infection. Poor circulation places the diabetic with an infected ulcer (D) at high risk for poor healing and bone infection. 9 . The charge nurse of a 16-bed medical unit is making 0700 to 1900 shift assignments. The team consists of two RNs, two PNs, B. Assign the UAPs to take vital signs and obtain daily weights. and two UAP. Which assignment is the most effective use of the available team members? A. Assign the PNs to perform am care and assist with feeding the clients. B. Assign the UAPs to take vital signs and obtain daily weights. C. Assign the RNs to answer the call lights and administer all medications. D. Assign the PNs to assist health care providers on rounds and perform glucometer checks. Rationale: A UAP can take vital signs and daily weights on stable clients (B). UAPs can perform am care and feed clients, which is a better use of personnel than assigning the task to the PN (A). All team members can answer call lights and PNs can administer some of the medications, so assigning the RN (C) these tasks is not an effective use of the available personnel. The RN is the best team member to assist on rounds (D), and the UAP can perform glucometer checks, so assigning the PN these tasks is not an effective use of available personnel. 10. The charge nurse of a medical surgical unit is alerted to an impending disaster requiring implementation of the hospital's disaster plan. Specific facts about the nature of this disaster are not yet known. Which instruction should the charge nurse give to the other staff members at this time? A. Prepare to evacuate the unit, starting with the bedridden clients. B. UAPs should report to the emergency center to handle transports. C. The licensed staff should D. Continue with current assignments until more instructions are received. Rationale: When faced with an impending disaster, hospital personnel may be alerted but should continue with current client care assignments until further instructions are received (D). Evacuation is typically a response of last resort that begins with clients who are most able to ambulate (A). (B) is premature and is likely to increase the chaos if incoming casualties are anticipated. (C) is poor begin counting wheelchairs and IV poles on the unit. D. Continue with current assignments until more instructions are received. utilization of personnel. 11. The charge nurse overhears a staff member asking for a doughnut from a client's meal tray. Which action should the charge nurse implement? A. Advise the client that food from the meal tray should not be shared with others. B. Leave the room and discuss the incident privately with the staff member. C. Objectively document the situation as observed on a variance report. D. Call the nurse-manager to the client's room immediately. B. Leave the room and discuss the incident privately with the staff member. Rationale: Discussing the incident privately (B) promotes open communication between the charge nurse and staff member. The client is free to share unwanted food (A) with family or friends, but the employee should not ask for the client's food. (C) is not necessary, and the charge nurse can respond to this situation without implementing (D). 12. The charge nurse working in the surgical department is making shift assignments. The shift personnel include an RN with 12 years of nursing experience, an RN with 2 years of nursing experience, and an RN with 3 months of nursing experience. Which client should the charge nurse assign to the RN with 3 months of experience? A. A client who is 2 days postoperative with a right total knee replacement B. A client who is scheduled for a sigmoid colostomy A. A client who is 2 days postoperative with a right total knee replacement Rationale: (A) is the least critical client and should be assigned to the RN with the least experience. A client with a knee replacement is probably ambulating and able to perform self-care, and a physical therapist is likely to be assisting with the client's care. (B) will require a high level of nursing care when returned from surgery. (C) means that there is a surgery today C. A client who has a surgical abdominal wound with dehiscence D. A client who is 1 day postoperative following a right-sided mastectomy separation or rupture of the wound, which requires an experienced nurse to provide care. (D) requires extensive teaching and should be assigned to a more experienced nurse. 13. A child is having a generalized tonic-clonic seizure. Which action should the nurse take? A. Move objects out of the child's immediate area. B. Quickly slip soft restraints on the child's wrists. C. Insert a padded tongue blade between the teeth. D. Place in the recovery position before going for help. A. Move objects out of the child's immediate area. Rationale: The first priority during a seizure is to provide a safe environment, so the nurse should clear the area (A) to reduce the risk of trauma. The child should not be restrained (B) because this may cause more trauma. Objects should not be placed in the child's mouth (C) because it may pose a choking hazard. Although (D) should be implemented after the seizure, the nurse should not leave the child during a seizure to get help. 14 . A child with nephrotic syndrome is receiving prednisone (Deltasone). Which choice of breakfast foods at a fast food restaurant indicates that the mother understands the dietary guidelines necessary for her child? A. French toast sticks and orange juice B. Sausage egg muffin and grape juice C. Canadian bacon slices and hot chocolate D. Toasted oat cereal and low-fat D. Toasted oat cereal and low-fat milk A child receiving a corticosteroid for nephrotic syndrome should follow a low-sodium, low-fat, and low-sugar diet. Based on these guidelines, the best breakfast choice is (D). (A) is high in fat and sugar. (B and C) are high in fat and sodium. milk 15 . A client has been on a mechanical ventilator for several days. What should the nurse use to document and record this client's respirations? A. The respiratory settings on the ventilator B. Only the client's spontaneous respirations C. The ventilator-assisted respirations minus the client's independent breaths D. The ventilator setting for respiratory rate and the clientinitiated respirations D. The ventilator setting for respiratory rate and the clientinitiated respirations Rationale: The nurse should count the client's respirations, and document both the respiratory rate set by the ventilator and the client's independent respiratory rate (D). Never rely strictly on (A). Although the client's spontaneous breaths will be shallow and machine-assisted breaths will be deep, it is important to record machine-assisted breaths as well as the client's spontaneous breaths to get an overall respiratory picture of the client (B and C) 16 . A client has been receiving levofloxacin (Levaquin), 500 mg IV piggyback q24h for 7 days. The UAP reports to the nurse that the client has had three loose foul-smelling stools this morning. Which intervention is most important for the nurse to implement? A. Perform a digital evaluation for fecal impaction. B. Administer a PRN dose of psyllium (Metamucil). C. Obtain a stool specimen for culture and sensitivity. D. Instruct the UAP to obtain incontinent pads for the client. C. Obtain a stool specimen for culture and sensitivity Rationale: Long-term use of levofloxacin (Levaquin) can cause foul-smelling diarrhea because of Clostridium difficile infection or associated colitis, so it is most important to obtain a stool specimen (C). Impaction is unlikely, so (A) is of less priority and may not be necessary. (B) is a bulk-forming agent that may be used for constipation or diarrhea. Treatment of the diarrhea and client comfort (D) are important interventions but of less priority than determining the cause of the client's diarrhea. 17 . A client hospitalized for meningitis is demonstrating nuchal rigidity. C. Inability to flex the chin to the chest Which symptom is this client likely to be exhibiting? A. Hyperexcitability of reflexes B. Hyperextension of the head and back C. Inability to flex the chin to the chest D. Lateral facial paralysis Rationale: Nuchal rigidity (neck stiffness) is a characteristic of meningeal irritation and is elicited by attempting to flex the neck and place the chin to the chest (C). Although (A, B, and D) may occur in meningitis, (A) describes exaggerated spinal nerve reflex responses, (B) describes opisthotonus, and (D) may be related to cranial nerve pathology of the trigeminal nerve. 18 . A client is admitted to the mental health unit with a chief complaint of crying, depressed mood, and sleeping difficulties. While talking about the death of a friend, the client states, "I can't believe this happened." Which statement by the nurse is most therapeutic? A. "It sounds like you're feeling very sad." B. "Tell me more about how you're feeling." C. "How often do you have crying spells?" D. "Do you want to talk about these feelings?" B. "Tell me more about how you're feeling." Rationale: It is most therapeutic to ask an openended question and encourage the client to explore his or her feelings (B). (A) is a leading response, and the client may not be feeling sad. (C and D) are close-ended questions that do not facilitate communication. 19 . A client reports experiencing dysuria and urinary frequency. Which client teaching should the nurse provide? A. Save the next urine sample. B. Restrict oral fluid intake. C. Strain all voided urine. D. Reduce physical activity. A. Save the next urine sample. Rationale: The nurse should instruct the client to save the next urine sample (A) for observation of its appearance and for possible urinalysis. The client is reporting symptoms that may indicate the onset of a urinary tract infection. Increased fluid intake should be encouraged, unless contraindicated (B). (C) is only necessary if a calculus (stone) is suspected. (D) is not indicated by this client's symptoms.