HESI-RN COMPREHENSIVE
EXAM (A\B) ACTUAL EXAM
2024-2025 QUESTIONS AND
ANSWERS GRADED A+
Which of the following cardiac rhythms is represented in the image?
A.
Normal sinus rhythm
B.
Sinus tachycardia
C.
Ventricular fibrillation
D.
Atrial fibrillation
- CORRECT ANSWERS - C
Rationale:Ventricular fibrillation is a life-threatening arrhythmia characterized
by irregular undulations of varying amplitudes. Options A, B, and D are not
represented in the image.
A client in the psychiatric setting with an anxiety disorder reports chest pain.
Which action should the nurse take first?
A.
Administer an antianxiety medication PRN.
B.
,Assess the client's vital signs.
C.
Notify the primary health care provider.
D.
Determine coping mechanisms used in the past.
- CORRECT ANSWERS - B
Rationale:Although increased heart rate, palpitations, and chest pain may be
caused by anxiety, it is important that the nurse assess the client and rule out
physiologic causes. Nonpharmacologic measures should be taken first. Options
C and D may be considered but are not as high priority as the initial physiologic
assessment.
The nurse is providing care to a newborn in the labor, delivery, recovery and
postpartum unit. Which vaccinations should the nurse include in the newborns
plan of care? (Select all that apply.)
A.
Hepatitis B
B.
Human papilloma virus (HPV)
C.
Varicella
D.
Meningococcal vaccine
E.
Vitamin K
- CORRECT ANSWERS - A, E
Rationale:The hepatitis B vaccination should be given to all newborns before
hospital discharge. Vitamin K is administered shortly after birth as the newborn
has no clotting mechanisms. HPV is not recommended until adolescence.
,Varicella immunization begins at 12 months. Meningococcal vaccine is
administered beginning at 2 years.
A 78-year-old client is preparing for transfer from the hospital to a skilled
facility to rehabilitate after a surgical repair of a broken hip. The client's spouse
indicates to the nurse at the skilled facility that the client seems to be more
confused since the surgery. What will the receiving nurse include in the client's
plan of care? (Select all that apply.)
A.
Place the client close to the nurse's station.
B.
Place pictures of the family on the client's bedside table.
C.
Administer prn sleep aids every evening at 1900.
D.
Place a calendar on the wall opposite the clients' head of the bed.
E.
Apply restraints when the nurse is not in the room.
F.
Withhold fluids to decrease the risk of spilling.
- CORRECT ANSWERS - A, B, D
Rationale:Increased confusion can occur after surgery secondary to anesthesia.
This is generally reversible and the client will return to baseline. During the
period of confusion, the client will need to be monitored closely. The nurse
needs to keep the client oriented and place familiar objects in the surroundings.
There is no indication the client needs a sleep aid and they can increase levels of
confusion. Restraints are a last resort; the nurse needs to attempt alternatives to
restraints first. There is no indication in the stem that the client is at risk, and
restraints are needed. Not all confused clients' needs restraints. There is no
indication that the client is on a fluid restriction. Maintain toileting routine
instead of restricting fluids.
, The nurse administers atropine sulfate ophthalmic drops preoperatively to the
right eye of a client scheduled for cataract surgery. Which response by the client
indicates that the drug was effective?
A.
The pupils become equal and reactive to light.
B.
The client reports an inability to tolerate light.
C.
Bilateral visual accommodation is restored.
D.
The right pupil dilates after drop instillation.`
- CORRECT ANSWERS - D
Rationale:Atropine is a mydriatic drug which causes pupil dilation and paralysis
in preparation for surgery or examination. Options A and C do not describe the
therapeutic effects of atropine sulfate ophthalmic drops prior to cataract surgery.
Light intolerance is an outcome of pupil dilation.
When assessing a normal newborn, which findings should the nurse expect?
(Select all that apply.)
A.
Umbilical cord contains one vein and two arteries
B.
Slightly edematous labia in the female newborn
C.
Absence of Babinski reflex
D.
Presence of white plaques on the cheeks and tongue
EXAM (A\B) ACTUAL EXAM
2024-2025 QUESTIONS AND
ANSWERS GRADED A+
Which of the following cardiac rhythms is represented in the image?
A.
Normal sinus rhythm
B.
Sinus tachycardia
C.
Ventricular fibrillation
D.
Atrial fibrillation
- CORRECT ANSWERS - C
Rationale:Ventricular fibrillation is a life-threatening arrhythmia characterized
by irregular undulations of varying amplitudes. Options A, B, and D are not
represented in the image.
A client in the psychiatric setting with an anxiety disorder reports chest pain.
Which action should the nurse take first?
A.
Administer an antianxiety medication PRN.
B.
,Assess the client's vital signs.
C.
Notify the primary health care provider.
D.
Determine coping mechanisms used in the past.
- CORRECT ANSWERS - B
Rationale:Although increased heart rate, palpitations, and chest pain may be
caused by anxiety, it is important that the nurse assess the client and rule out
physiologic causes. Nonpharmacologic measures should be taken first. Options
C and D may be considered but are not as high priority as the initial physiologic
assessment.
The nurse is providing care to a newborn in the labor, delivery, recovery and
postpartum unit. Which vaccinations should the nurse include in the newborns
plan of care? (Select all that apply.)
A.
Hepatitis B
B.
Human papilloma virus (HPV)
C.
Varicella
D.
Meningococcal vaccine
E.
Vitamin K
- CORRECT ANSWERS - A, E
Rationale:The hepatitis B vaccination should be given to all newborns before
hospital discharge. Vitamin K is administered shortly after birth as the newborn
has no clotting mechanisms. HPV is not recommended until adolescence.
,Varicella immunization begins at 12 months. Meningococcal vaccine is
administered beginning at 2 years.
A 78-year-old client is preparing for transfer from the hospital to a skilled
facility to rehabilitate after a surgical repair of a broken hip. The client's spouse
indicates to the nurse at the skilled facility that the client seems to be more
confused since the surgery. What will the receiving nurse include in the client's
plan of care? (Select all that apply.)
A.
Place the client close to the nurse's station.
B.
Place pictures of the family on the client's bedside table.
C.
Administer prn sleep aids every evening at 1900.
D.
Place a calendar on the wall opposite the clients' head of the bed.
E.
Apply restraints when the nurse is not in the room.
F.
Withhold fluids to decrease the risk of spilling.
- CORRECT ANSWERS - A, B, D
Rationale:Increased confusion can occur after surgery secondary to anesthesia.
This is generally reversible and the client will return to baseline. During the
period of confusion, the client will need to be monitored closely. The nurse
needs to keep the client oriented and place familiar objects in the surroundings.
There is no indication the client needs a sleep aid and they can increase levels of
confusion. Restraints are a last resort; the nurse needs to attempt alternatives to
restraints first. There is no indication in the stem that the client is at risk, and
restraints are needed. Not all confused clients' needs restraints. There is no
indication that the client is on a fluid restriction. Maintain toileting routine
instead of restricting fluids.
, The nurse administers atropine sulfate ophthalmic drops preoperatively to the
right eye of a client scheduled for cataract surgery. Which response by the client
indicates that the drug was effective?
A.
The pupils become equal and reactive to light.
B.
The client reports an inability to tolerate light.
C.
Bilateral visual accommodation is restored.
D.
The right pupil dilates after drop instillation.`
- CORRECT ANSWERS - D
Rationale:Atropine is a mydriatic drug which causes pupil dilation and paralysis
in preparation for surgery or examination. Options A and C do not describe the
therapeutic effects of atropine sulfate ophthalmic drops prior to cataract surgery.
Light intolerance is an outcome of pupil dilation.
When assessing a normal newborn, which findings should the nurse expect?
(Select all that apply.)
A.
Umbilical cord contains one vein and two arteries
B.
Slightly edematous labia in the female newborn
C.
Absence of Babinski reflex
D.
Presence of white plaques on the cheeks and tongue
