COMPREHENSIVE HESI EXIT EXAM 2023 NEW
VERSION|ACCURATE ANSWERS|VERIFIED
ANSWERS|GUARANTEED PASS| LATEST
UPDATE.
The nurse is providing instructions to a pregnant client with genital herpes about the
measures that are needed to protect the fetus. Which instruction should the nurse
provide to the client?
1.
Total abstinence from sexual intercourse is necessary during the entire pregnancy.
2.
Sitz baths need to be taken every 4 hours while awake if vaginal lesions are present.
3.
Daily administration of acyclovir (Zovirax) is necessary during the entire pregnancy.
4.
A cesarean section will be necessary if vaginal lesions are present at the time of labor. -
Ans - 4.
A cesarean section will be necessary if vaginal lesions are present at the time of labor.
Rationale:
For women with active lesions, either recurrent or primary at the time of labor, delivery
should be by cesarean section to prevent the fetus from being in contact with the genital
herpes. The safety of acyclovir has not been established during pregnancy, and it
should be used only when a life-threatening infection is present. Clients should be
advised to abstain from sexual contact while the lesions are present. If this is an initial
infection, clients should continue to abstain until they become culture-negative because
prolonged viral shedding may occur in such cases. Keeping the genital area clean and
dry promotes healing.
The nurse is reviewing the record of a client who has just been told that a pregnancy
test is positive. The health care provider has documented the presence of Goodell's
sign. This finding is most closely associated with which characteristic?
1.
A softening of the cervix
,2.
The presence of fetal movement
3.
The presence of human chorionic gonadotropin in the urine
4.
A soft blowing sound that corresponds to the maternal pulse during auscultation of the
uterus - Ans - 1.
A softening of the cervix
Rationale:
At the beginning of the second month of gestation, the cervix becomes softer as a result
of increased vascularity and hyperplasia, which cause Goodell's sign. Cervical softening
is noted by the examiner during pelvic examination. Goodell's sign does not indicate the
presence of fetal movement. Human chorionic gonadotropin noted in maternal urine is a
probable sign of pregnancy. A soft blowing sound that corresponds to the maternal
pulse may be auscultated over the uterus and is caused by blood circulating through the
placenta.
The health care provider (HCP) is assessing the client for the presence of ballottement.
To make this determination, the HCP should take which action?
1.
Auscultate for fetal heart sounds.
2.
Assess the cervix for compressibility.
3.
Palpate the abdomen for fetal movement.
4.
Initiate a gentle upward tap on the cervix. - Ans - 4.
Initiate a gentle upward tap on the cervix.
Rationale:
Ballottement is a technique of palpating a floating structure by bouncing it gently and
feeling it rebound. In the technique used to palpate the fetus, the examiner places a
finger in the vagina and taps gently upward, causing the fetus to rise. The fetus then
sinks, and the examiner feels a gentle tap on the finger. Options 1, 2, and 3 are not
assessment techniques to check for ballottement. Option 2 is related to Hegar's sign.
Options 1 and 3 are a part of fetal assessment.
,A pregnant client asks the nurse in the clinic when she will be able to begin to feel the
fetus move. The nurse responds by telling the mother that fetal movements will be
noted between which weeks of gestation?
1.
6 and 8
2.
8 and 10
3.
10 and 12
4.
14 and 18 - Ans - 4.
14 and 18
Rationale:
Quickening is fetal movement that is felt by the mother. In the multiparous woman this
may occur as early as the fourteenth to sixteenth weeks. The nulliparous woman may
not notice these sensations until the eighteenth week or later. Options 1, 2, and 3 are
incorrect time frames because quickening does not occur this early during pregnancy.
The nurse is providing instructions to a pregnant client who is scheduled for an
amniocentesis. What instruction should the nurse provide?
1.
Strict bed rest is required after the procedure.
2.
Hospitalization is necessary for 24 hours after the procedure.
3.
An informed consent needs to be signed before the procedure.
4.
A fever is expected after the procedure because of the trauma to the abdomen. - Ans -
3.
An informed consent needs to be signed before the procedure.
Rationale:
Because amniocentesis is an invasive procedure, informed consent needs to be
obtained before the procedure. After the procedure, the client is instructed to rest, but
may resume light activity after the cramping subsides. The client is instructed to keep
, the puncture site clean and to report any complications, such as chills, fever, bleeding,
leakage of fluid at the needle insertion site, decreased fetal movement, uterine
contractions, or cramping. Amniocentesis is an outpatient procedure and may be done
in a health care provider's private office or in a special prenatal testing unit.
Hospitalization is not necessary after the procedure.
A client with the recent diagnosis of myocardial infarction and impaired renal function is
recuperating on the step-down cardiac unit. The client's blood pressure has been
borderline low and intravenous (IV) fluids have been infusing at 100 mL/hour via a
central line catheter in the right internal jugular for approximately 24 hours to increase
renal output and maintain the blood pressure. Upon entering the client's room, the nurse
notes that the client is breathing rapidly and is coughing. The nurse determines that the
client is most likely experiencing which complication of IV therapy?
1.
Hematoma
2.
Air embolism
3.
Systemic infection
4.
Circulatory overload - Ans - 4.
Circulatory overload
Rationale:
Circulatory (fluid) overload is a complication of intravenous therapy. Signs include rapid
breathing, dyspnea, a moist cough, and crackles. When circulatory overload is present,
the client's blood pressure also increases. Hematoma is characterized by ecchymosis,
swelling, and leakage at the IV insertion site, as well as hard and painful lumps at the
site. Air embolism is characterized by tachycardia, dyspnea, hypotension, cyanosis, and
decreased level of consciousness. Systemic infection is characterized by chills, fever,
malaise, headache, nausea, vomiting, backache, and tachycardia.
Packed red blood cells have been prescribed for a client with low hemoglobin and
hematocrit levels. The nurse takes the client's temperature before hanging the blood
transfusion and records 100.6° F orally. Which action should the nurse take?
1.
Begin the transfusion as prescribed.
2.
Administer an antihistamine and begin the transfusion.
VERSION|ACCURATE ANSWERS|VERIFIED
ANSWERS|GUARANTEED PASS| LATEST
UPDATE.
The nurse is providing instructions to a pregnant client with genital herpes about the
measures that are needed to protect the fetus. Which instruction should the nurse
provide to the client?
1.
Total abstinence from sexual intercourse is necessary during the entire pregnancy.
2.
Sitz baths need to be taken every 4 hours while awake if vaginal lesions are present.
3.
Daily administration of acyclovir (Zovirax) is necessary during the entire pregnancy.
4.
A cesarean section will be necessary if vaginal lesions are present at the time of labor. -
Ans - 4.
A cesarean section will be necessary if vaginal lesions are present at the time of labor.
Rationale:
For women with active lesions, either recurrent or primary at the time of labor, delivery
should be by cesarean section to prevent the fetus from being in contact with the genital
herpes. The safety of acyclovir has not been established during pregnancy, and it
should be used only when a life-threatening infection is present. Clients should be
advised to abstain from sexual contact while the lesions are present. If this is an initial
infection, clients should continue to abstain until they become culture-negative because
prolonged viral shedding may occur in such cases. Keeping the genital area clean and
dry promotes healing.
The nurse is reviewing the record of a client who has just been told that a pregnancy
test is positive. The health care provider has documented the presence of Goodell's
sign. This finding is most closely associated with which characteristic?
1.
A softening of the cervix
,2.
The presence of fetal movement
3.
The presence of human chorionic gonadotropin in the urine
4.
A soft blowing sound that corresponds to the maternal pulse during auscultation of the
uterus - Ans - 1.
A softening of the cervix
Rationale:
At the beginning of the second month of gestation, the cervix becomes softer as a result
of increased vascularity and hyperplasia, which cause Goodell's sign. Cervical softening
is noted by the examiner during pelvic examination. Goodell's sign does not indicate the
presence of fetal movement. Human chorionic gonadotropin noted in maternal urine is a
probable sign of pregnancy. A soft blowing sound that corresponds to the maternal
pulse may be auscultated over the uterus and is caused by blood circulating through the
placenta.
The health care provider (HCP) is assessing the client for the presence of ballottement.
To make this determination, the HCP should take which action?
1.
Auscultate for fetal heart sounds.
2.
Assess the cervix for compressibility.
3.
Palpate the abdomen for fetal movement.
4.
Initiate a gentle upward tap on the cervix. - Ans - 4.
Initiate a gentle upward tap on the cervix.
Rationale:
Ballottement is a technique of palpating a floating structure by bouncing it gently and
feeling it rebound. In the technique used to palpate the fetus, the examiner places a
finger in the vagina and taps gently upward, causing the fetus to rise. The fetus then
sinks, and the examiner feels a gentle tap on the finger. Options 1, 2, and 3 are not
assessment techniques to check for ballottement. Option 2 is related to Hegar's sign.
Options 1 and 3 are a part of fetal assessment.
,A pregnant client asks the nurse in the clinic when she will be able to begin to feel the
fetus move. The nurse responds by telling the mother that fetal movements will be
noted between which weeks of gestation?
1.
6 and 8
2.
8 and 10
3.
10 and 12
4.
14 and 18 - Ans - 4.
14 and 18
Rationale:
Quickening is fetal movement that is felt by the mother. In the multiparous woman this
may occur as early as the fourteenth to sixteenth weeks. The nulliparous woman may
not notice these sensations until the eighteenth week or later. Options 1, 2, and 3 are
incorrect time frames because quickening does not occur this early during pregnancy.
The nurse is providing instructions to a pregnant client who is scheduled for an
amniocentesis. What instruction should the nurse provide?
1.
Strict bed rest is required after the procedure.
2.
Hospitalization is necessary for 24 hours after the procedure.
3.
An informed consent needs to be signed before the procedure.
4.
A fever is expected after the procedure because of the trauma to the abdomen. - Ans -
3.
An informed consent needs to be signed before the procedure.
Rationale:
Because amniocentesis is an invasive procedure, informed consent needs to be
obtained before the procedure. After the procedure, the client is instructed to rest, but
may resume light activity after the cramping subsides. The client is instructed to keep
, the puncture site clean and to report any complications, such as chills, fever, bleeding,
leakage of fluid at the needle insertion site, decreased fetal movement, uterine
contractions, or cramping. Amniocentesis is an outpatient procedure and may be done
in a health care provider's private office or in a special prenatal testing unit.
Hospitalization is not necessary after the procedure.
A client with the recent diagnosis of myocardial infarction and impaired renal function is
recuperating on the step-down cardiac unit. The client's blood pressure has been
borderline low and intravenous (IV) fluids have been infusing at 100 mL/hour via a
central line catheter in the right internal jugular for approximately 24 hours to increase
renal output and maintain the blood pressure. Upon entering the client's room, the nurse
notes that the client is breathing rapidly and is coughing. The nurse determines that the
client is most likely experiencing which complication of IV therapy?
1.
Hematoma
2.
Air embolism
3.
Systemic infection
4.
Circulatory overload - Ans - 4.
Circulatory overload
Rationale:
Circulatory (fluid) overload is a complication of intravenous therapy. Signs include rapid
breathing, dyspnea, a moist cough, and crackles. When circulatory overload is present,
the client's blood pressure also increases. Hematoma is characterized by ecchymosis,
swelling, and leakage at the IV insertion site, as well as hard and painful lumps at the
site. Air embolism is characterized by tachycardia, dyspnea, hypotension, cyanosis, and
decreased level of consciousness. Systemic infection is characterized by chills, fever,
malaise, headache, nausea, vomiting, backache, and tachycardia.
Packed red blood cells have been prescribed for a client with low hemoglobin and
hematocrit levels. The nurse takes the client's temperature before hanging the blood
transfusion and records 100.6° F orally. Which action should the nurse take?
1.
Begin the transfusion as prescribed.
2.
Administer an antihistamine and begin the transfusion.
