COMPREHENSIVE HESI EXAM 2022 NEW
LATEST VERSION UPDATE 2024-2025 BEST
STUDYING MATERIAL WITH VERIFIED
ANSWERS.
While changing the tapes on a tracheostomy tube, the client coughs and the tube is
dislodged. Which is the initial nursing action?
.
Call the health care provider to reinsert the tube.
2.
Grasp the retention sutures to spread the opening.
3.
Call the respiratory therapy department to reinsert the tracheotomy.
4.
Cover the tracheostomy site with a sterile dressing to prevent infection. - Ans - 2.
Grasp the retention sutures to spread the opening.
Rationale:
If the tube is dislodged accidentally, the initial nursing action is to grasp the retention
sutures and spread the opening. If agency policy permits, the nurse then attempts
immediately to replace the tube. Calling ancillary services or the HCP will delay
treatment in this emergency situation. Covering the tracheostomy site will block the
airway.
The nurse is assisting a health care provider with the removal of a chest tube. The
nurse should instruct the client to take which action?
1.
Exhale slowly.
2.
Stay very still.
3.
Inhale and exhale quickly.
4.
Perform the Valsalva maneuver. - Ans - 4.
,Perform the Valsalva maneuver.
Rationale:
When the chest tube is removed, the client is asked to perform the Valsalva maneuver
(take a deep breath, exhale, and bear down). The tube is quickly withdrawn, and an
airtight dressing is taped in place. An alternative instruction is to ask the client to take a
deep breath and hold the breath while the tube is removed.
The nurse is assessing the functioning of a chest tube drainage system in a client who
has just returned from the recovery room following a thoracotomy with wedge resection.
Which are the expected assessment findings? Select all that apply.
1.
Excessive bubbling in the water seal chamber
2.
Vigorous bubbling in the suction control chamber
3.
Drainage system maintained below the client's chest
4.
50 mL of drainage in the drainage collection chamber
5.
Occlusive dressing in place over the chest tube insertion site
6.
Fluctuation of water in the tube in the water seal chamber during inhalation and
exhalation - Ans - 3,4,5,6
Rationale:
The bubbling of water in the water seal chamber indicates air drainage from the client
and usually is seen when intrathoracic pressure is higher than atmospheric pressure,
and may occur during exhalation, coughing, or sneezing. Excessive bubbling in the
water seal chamber may indicate an air leak, an unexpected finding. Fluctuation of
water in the tube in the water seal chamber during inhalation and exhalation is
expected. An absence of fluctuation may indicate that the chest tube is obstructed or
that the lung has reexpanded and that no more air is leaking into the pleural space.
Gentle (not vigorous) bubbling should be noted in the suction control chamber. A total of
50 mL of drainage is not excessive in a client returning to the nursing unit from the
recovery room. Drainage that is more than 70 to 100 mL/hour is considered excessive
and requires health care provider notification. The chest tube insertion site is covered
with an occlusive (airtight) dressing to prevent air from entering the pleural space.
,Positioning the drainage system below the client's chest allows gravity to drain the
pleural space.
The nurse is caring for a client immediately after removal of the endotracheal tube. The
nurse should report which sign immediately if experienced by the client?
1.
Stridor
2.
Occasional pink-tinged sputum
3.
Respiratory rate of 24 breaths/minute
4.
A few basilar lung crackles on the right - Ans - 1.
Stridor
Rationale:
Following removal of the endotracheal tube the nurse monitors the client for respiratory
distress. The nurse reports stridor to the health care provider (HCP) immediately. This is
a high-pitched, coarse sound that is heard with the stethoscope over the trachea.
Stridor indicates airway edema and places the client at risk for airway obstruction.
Although the findings identified in the remaining options require monitoring, they do not
require immediate notification of the health care provider.
The nurse caring for a client with a pneumothorax and who has had a chest tube
inserted notes continuous gentle bubbling in the suction control chamber. What action is
most appropriate?
1.
Do nothing, because this is an expected finding.
2.
Check for an air leak because the bubbling should be intermittent.
3.
Increase the suction pressure so that the bubbling becomes vigorous.
4.
Immediately clamp the chest tube and notify the health care provider. - Ans - 1.
Do nothing, because this is an expected finding.
Rationale:
, Continuous gentle bubbling should be noted in the suction control chamber. Bubbling
should be continuous in the suction control chamber and not intermittent. Increasing the
suction pressure only increases the rate of evaporation of water in the drainage system;
in addition, increasing the suction can be harmful and is not done without a specific
prescription to do so. Chest tubes should only be clamped to check for an air leak or
when changing drainage devices (according to agency policy).
The nurse is providing instructions regarding treatment of hemorrhoids to a client who is
in the second trimester of pregnancy. Which statement by the client indicates a need for
further instruction?
1.
"I should avoid straining during bowel movements."
2.
"I can gently replace the hemorrhoids into the rectum."
3.
"I can apply ice packs to the hemorrhoids to reduce the swelling."
4.
"I should apply heat packs to the hemorrhoids to help the hemorrhoids shrink." - Ans - 4.
"I should apply heat packs to the hemorrhoids to help the hemorrhoids shrink."
Rationale:
Measures that provide relief from hemorrhoids include avoiding constipation and
straining during bowel movements; applying ice packs to reduce the hemorrhoidal
swelling; gently replacing the hemorrhoids into the rectum; using stool softeners,
ointments, or sprays as prescribed; and assuming certain positions to relieve pressure
on the hemorrhoids. Heat packs increase the blood flow to the area and worsen the
discomfort from hemorrhoids.
The nurse is providing instructions to a client in the first trimester of pregnancy
regarding measures to assist in reducing breast tenderness. Which instruction should
the nurse provide?
1.
Avoid wearing a bra.
2.
Wash the breasts with warm water and keep them dry.
3.
Wear tight-fitting blouses or dresses to provide support.
LATEST VERSION UPDATE 2024-2025 BEST
STUDYING MATERIAL WITH VERIFIED
ANSWERS.
While changing the tapes on a tracheostomy tube, the client coughs and the tube is
dislodged. Which is the initial nursing action?
.
Call the health care provider to reinsert the tube.
2.
Grasp the retention sutures to spread the opening.
3.
Call the respiratory therapy department to reinsert the tracheotomy.
4.
Cover the tracheostomy site with a sterile dressing to prevent infection. - Ans - 2.
Grasp the retention sutures to spread the opening.
Rationale:
If the tube is dislodged accidentally, the initial nursing action is to grasp the retention
sutures and spread the opening. If agency policy permits, the nurse then attempts
immediately to replace the tube. Calling ancillary services or the HCP will delay
treatment in this emergency situation. Covering the tracheostomy site will block the
airway.
The nurse is assisting a health care provider with the removal of a chest tube. The
nurse should instruct the client to take which action?
1.
Exhale slowly.
2.
Stay very still.
3.
Inhale and exhale quickly.
4.
Perform the Valsalva maneuver. - Ans - 4.
,Perform the Valsalva maneuver.
Rationale:
When the chest tube is removed, the client is asked to perform the Valsalva maneuver
(take a deep breath, exhale, and bear down). The tube is quickly withdrawn, and an
airtight dressing is taped in place. An alternative instruction is to ask the client to take a
deep breath and hold the breath while the tube is removed.
The nurse is assessing the functioning of a chest tube drainage system in a client who
has just returned from the recovery room following a thoracotomy with wedge resection.
Which are the expected assessment findings? Select all that apply.
1.
Excessive bubbling in the water seal chamber
2.
Vigorous bubbling in the suction control chamber
3.
Drainage system maintained below the client's chest
4.
50 mL of drainage in the drainage collection chamber
5.
Occlusive dressing in place over the chest tube insertion site
6.
Fluctuation of water in the tube in the water seal chamber during inhalation and
exhalation - Ans - 3,4,5,6
Rationale:
The bubbling of water in the water seal chamber indicates air drainage from the client
and usually is seen when intrathoracic pressure is higher than atmospheric pressure,
and may occur during exhalation, coughing, or sneezing. Excessive bubbling in the
water seal chamber may indicate an air leak, an unexpected finding. Fluctuation of
water in the tube in the water seal chamber during inhalation and exhalation is
expected. An absence of fluctuation may indicate that the chest tube is obstructed or
that the lung has reexpanded and that no more air is leaking into the pleural space.
Gentle (not vigorous) bubbling should be noted in the suction control chamber. A total of
50 mL of drainage is not excessive in a client returning to the nursing unit from the
recovery room. Drainage that is more than 70 to 100 mL/hour is considered excessive
and requires health care provider notification. The chest tube insertion site is covered
with an occlusive (airtight) dressing to prevent air from entering the pleural space.
,Positioning the drainage system below the client's chest allows gravity to drain the
pleural space.
The nurse is caring for a client immediately after removal of the endotracheal tube. The
nurse should report which sign immediately if experienced by the client?
1.
Stridor
2.
Occasional pink-tinged sputum
3.
Respiratory rate of 24 breaths/minute
4.
A few basilar lung crackles on the right - Ans - 1.
Stridor
Rationale:
Following removal of the endotracheal tube the nurse monitors the client for respiratory
distress. The nurse reports stridor to the health care provider (HCP) immediately. This is
a high-pitched, coarse sound that is heard with the stethoscope over the trachea.
Stridor indicates airway edema and places the client at risk for airway obstruction.
Although the findings identified in the remaining options require monitoring, they do not
require immediate notification of the health care provider.
The nurse caring for a client with a pneumothorax and who has had a chest tube
inserted notes continuous gentle bubbling in the suction control chamber. What action is
most appropriate?
1.
Do nothing, because this is an expected finding.
2.
Check for an air leak because the bubbling should be intermittent.
3.
Increase the suction pressure so that the bubbling becomes vigorous.
4.
Immediately clamp the chest tube and notify the health care provider. - Ans - 1.
Do nothing, because this is an expected finding.
Rationale:
, Continuous gentle bubbling should be noted in the suction control chamber. Bubbling
should be continuous in the suction control chamber and not intermittent. Increasing the
suction pressure only increases the rate of evaporation of water in the drainage system;
in addition, increasing the suction can be harmful and is not done without a specific
prescription to do so. Chest tubes should only be clamped to check for an air leak or
when changing drainage devices (according to agency policy).
The nurse is providing instructions regarding treatment of hemorrhoids to a client who is
in the second trimester of pregnancy. Which statement by the client indicates a need for
further instruction?
1.
"I should avoid straining during bowel movements."
2.
"I can gently replace the hemorrhoids into the rectum."
3.
"I can apply ice packs to the hemorrhoids to reduce the swelling."
4.
"I should apply heat packs to the hemorrhoids to help the hemorrhoids shrink." - Ans - 4.
"I should apply heat packs to the hemorrhoids to help the hemorrhoids shrink."
Rationale:
Measures that provide relief from hemorrhoids include avoiding constipation and
straining during bowel movements; applying ice packs to reduce the hemorrhoidal
swelling; gently replacing the hemorrhoids into the rectum; using stool softeners,
ointments, or sprays as prescribed; and assuming certain positions to relieve pressure
on the hemorrhoids. Heat packs increase the blood flow to the area and worsen the
discomfort from hemorrhoids.
The nurse is providing instructions to a client in the first trimester of pregnancy
regarding measures to assist in reducing breast tenderness. Which instruction should
the nurse provide?
1.
Avoid wearing a bra.
2.
Wash the breasts with warm water and keep them dry.
3.
Wear tight-fitting blouses or dresses to provide support.
