ANSWERS LATEST VERSION 2024 VERIFIED
RATIONALE GRADED A+
A child is brought to the emergency department by ambulance after swallowing several capsules of
acetaminophen. What statement by the nurse indicates a need for further information?
"We need to administer the antidote N-acetyl cysteine and dilute it in juice or soda."
"A loading dose of N-acetyl cysteine has to be followed by maintenance doses." Incorrect
"We need to give N-acetyl cysteine before we do gastric lavage with activated charcoal."
"If the child is unconscious, we must do gastric lavage with activated charcoal to decrease the absorption
of acetaminophen." - ans"We need to give N-acetyl cysteine before we do gastric lavage with activated
charcoal."
Rationale: There is a need for further information if the nurse states, "We need to give N-acetyl cysteine
before we do gastric lavage with activated charcoal." Activated charcoal with lavage is done if the child is
unconscious, but N-acetyl cysteine cannot be used because activated charcoal inactivates the antidote. If
given orally, it can be diluted in juice or soda, and a loading dose of N-acetyl cysteine must be followed
by maintenance doses.
A child who has just been found to have scoliosis will need to wear a thoracolumbosacral orthotic (TLSO)
brace, and the nurse provides information to the mother about the brace. Which statement by the
mother indicates a need for further information?
"My child will need to do exercises."
"My child needs to wear the brace 18 to 23 hours per day."
"Wearing the brace is really important in curing the scoliosis."
"I need to check my child's skin under the brace to be sure it doesn't break down." - ans"Wearing the
brace is really important in curing the scoliosis."
Rationale: Scoliosis is a lateral curvature of the spine. There is a need for further information when the
mother says, "Wearing the brace is really important in curing the scoliosis." Bracing is not curative of
scoliosis but may slow the progression of the curvature to allow skeletal growth and maturation. A brace
needs to be worn 18 to 23 hours a day, but it may be removed at night for sleep if this is prescribed. To
be more cosmetically acceptable, a brace is usually worn under loose-fitting clothing. Back exercises are
, HESI COMPREHENSIVE EXAM QUESTIONS AND
ANSWERS LATEST VERSION 2024 VERIFIED
RATIONALE GRADED A+
important in maintaining and strengthening the abdominal and spinal muscles. The child's skin must be
meticulously monitored for signs of breakdown.
A child with a diagnosis of Wilms' tumor is being admitted to the pediatric unit. The nurse prepares the
room for the child and places a sign at the child's bedside. What does this sign tell staff to avoid?
Palpating the abdomen
Taking temperatures rectally
Turning the child to the right side
Measuring blood pressure in the right arm - ansPalpating the abdomen
Rationale: The nurse would place a sign at the child's bedside warning against palpation of the child's
abdomen. Wilms' tumor, or nephroblastoma, is the most common renal tumor in children. Arising from
the renal parenchyma of the kidney, this tumor grows very rapidly. It may be unilateral and localized or
bilateral and sometimes involves metastasis to other organs. The tumor mass should not be palpated
because of the risk that the protective capsule will rupture. Excessive manipulation can result in seeding
of the tumor and the spread of cancerous cells. Taking temperatures rectally, turning the child to the
right side, and measuring blood pressure in the right arm are interventions that do not need to be
avoided.
A child with growth hormone deficiency will be receiving somatropin. The nurse provides information to
the mother about the medication. Which of the following laboratory values does the nurse tell the
mother will require monitoring?
Creatinine
Hemoglobin
Blood urea nitrogen (BUN)
Thyroid-stimulating hormone (TSH) - ansThyroid-stimulating hormone (TSH)
Rationale: TSH is the laboratory value the nurse tells the mother to monitor. Somatropin is a growth
hormone. One adverse reaction to somatropin is hypothyroidism. Thyroid function is assessed before
, HESI COMPREHENSIVE EXAM QUESTIONS AND
ANSWERS LATEST VERSION 2024 VERIFIED
RATIONALE GRADED A+
treatment and periodically thereafter. Creatinine and BUN are used to evaluate renal function, and
hemoglobin reflects hematologic activity.
A client arrives at the clinic for her first prenatal assessment. The client tells the nurse that the first day
of her last menstrual period (LMP) was September 25, 2017. Using Nagele's rule, what item of client
information is needed for the nurse to accurately determine estimated date of delivery (EDD)?
Client has never had an abortion
Client has regular 28-day menstrual cycle
Client was 14 years old when menses first started
Client's menstrual periods never last longer than 3 days - ansClient has regular 28-day menstrual cycle
Rationale: Accurate use of Nagele's rule is used to calculate the EDD. It requires that the woman have a
regular 28-day menstrual cycle.
A client arrives in the emergency department and tells the nurse that he/she is experiencing tingling in
both hands and is unable to move his/her fingers. The client states that he/she has been unable to work
because of the problem. During the psychosocial assessment, the client reports that 2 days earlier
his/her partner said he/she wanted a separation and that he/she would have to support self financially.
What problem does the nurse conclude that this client is exhibiting signs/symptoms compatible with?
Severe anxiety
Conversion disorder
Posttraumatic stress disorder (PTSD)
Obsessive-compulsive disorder - ansConversion disorder
Rationale: Conversion disorder is characterized by the presence of one or more signs/symptoms
suggesting a neurological problem that cannot be attributed to a medical disorder. Psychological factors
such as stress and conflict are associated with the onset or exacerbation of the sign/symptom. A person
with severe anxiety may focus on a particular detail or many scattered details. The person may have
difficulty noticing what is going on in the environment, even when it is pointed out by another. Learning
, HESI COMPREHENSIVE EXAM QUESTIONS AND
ANSWERS LATEST VERSION 2024 VERIFIED
RATIONALE GRADED A+
and problem-solving are not possible at this level of anxiety, and the client may be dazed and confused.
PTSD is characterized by repeated re-experiencing of a highly traumatic event that involved actual or
threatened death or serious injury to self or others to which the individual responded with intense fear,
helplessness, or horror. Obsessions are thoughts, impulses, or images that persist and recur so that they
cannot be dismissed from the mind. Compulsions are ritualistic behaviors that an individual feels driven
to perform in an attempt to reduce anxiety.
A client being seen in the clinic complains of fatigue and weakness. Laboratory studies are performed
because the primary health care provider suspects iron-deficiency anemia. After reviewing the
laboratory results, which finding indicative of this type of anemia does the nurse expect to note?.
An increased RBC count
An increased hematocrit level
An increased hemoglobin level
Microcytic red blood cells (RBCs) - ansMicrocytic red blood cells (RBCs)
Rationale: The nurse expects to note a low RBC count and microcytic (small) RBCs. In iron-deficiency
anemia, laboratory testing will reveal low hemoglobin and hematocrit levels. In iron-deficiency anemia,
iron stores are depleted first, followed by hemoglobin stores.
A client calls the emergency department and tells the nurse that he may have come in contact with
poison ivy while trimming bushes in his yard. What does the nurse tell the client to immediately do?
Contact the primary health care provider
Report to the emergency department for treatment
Get into the shower and rinse the skin for at least 15 minutes
Go to the drugstore, purchase an over-the-counter topical corticosteroid, and rub it into the exposed
skin - ansGet into the shower and rinse the skin for at least 15 minutes
Rationale: If contact with poison ivy is suspected, signs/symptoms may be averted by immediately
rinsing the skin for 15 minutes with running water to remove the resin before skin penetration occurs.