HESI COMPREHENSIVE EXAM PRACTICE WITH
COMPLETE QUESTIONS AND WELL DETAILED
ANSWERS LATEST 2025
We have an expert-written solution to this problem!
The nurse is assessing a postpartum client who delivered in the car. Which finding should
the nurse identify as the earliest manifestation of a puerperal infection?
Dysuria and pyuria with each voiding.
White blood cells (WBC) greater than 12,000/mm3.
Increased vaginal bleeding with ambulation.
Temperature of 100.8 F 24 hours after delivery.
Temperature of 100.8 F 24 hours after delivery.
Rationale
Postpartum or puerperal infection is any clinical infection of the genital canal that occurs
within 28 days after miscarriage, induced abortion, or childbirth. The presence of a fever
of 38 C (100.4 F) 24 hours after birth is the first indicator. Although infection stimulates
leukocytosis, WBC counts after delivery are normal up to 15,000/mm3.
What nursing intervention should the nurse include in the plan of care for a client
following a bone marrow aspiration?
Use of a compression dressing for firm pressure to the site.
Proper positioning of the client in a prone position.
Follow-up hematological laboratory studies.
Application of warm, moist compresses to the puncture site.
Use of a compression dressing for firm pressure to the site.
Rationale
After the procedure, firm pressure using a compression dressing to the aspiration site
should be applied to control bleeding if organ puncture or coagulopathy is present.
Positioning the client prone is not necessary to control bleeding from the aspiration site.
Although hematological laboratory studies should be reviewed before and after the
procedure, the immediate risk is bleeding due to removal of bone marrow. Application of
ice, not warm moist compresses reduces the potential for bleeding.
The nurse instills an atropine ophthalmic solution into both eyes for a client who is having
a routine eye examination. Which side effects should the nurse tell the client to anticipate?
Blurred vision.
Halos around objects.
Inability to see at night.
Itching of the conjunctiva.
Blurred vision.
Rationale
,Atropine ophthalmic solution is used during eye examinations to dilate the pupil
(mydriasis) and paralyze the ciliary muscle (cycloplegic refraction), which prevents
accommodation and causes blurred vision.
The nurse-manager is planning to study a unit problem that engages the nursing staff in
evidence-based practice. What is the sequence of activities that the nurse-manager should
use? (Arrange in the order from first on top to last on the bottom.)
1. Identification of practice problem.
2. Review of published research.
3. Identify and develop plan for application of research findings.
4. Implementation of data gathering methods and data evaluation.
1. Identification of practice problem.
2. Review of published research.
3. Implementation of data gathering methods and data evaluation.
4. Identify and develop plan for application of research findings.
Rationale
The proper sequence in the research utilization process begins with the identification of a
practice problem, which in turn sets the stage for the step-by-step approach incorporating
critical thinking and decision making. Review of published research, implementation of
data gathering methods, analysis and evaluation of data, conclusion and plan for
application of findings to the practice problem should follow.
Which information is most important for the nurse to provide parents about long-term
care for their child with hydrocephalus and a ventriculoperitoneal (VP) shunt?
Physical contact sports may be restricted during childhood.
Shunt malfunction or infection requires immediate treatment.
Normal intellectual ability is expected with surgical diversion.
The use of a protective helmet is recommended during childhood.
Shunt malfunction or infection requires immediate treatment.
Rationale
A VP shunt is the standard procedure for hydrocephalus in neonates and young infants
which allows for excess tubing that minimizes the number of revisions needed as the child
grows. Parents should be taught about the immediacy for medical intervention of VP
complications, such as infection and functional or mechanical malfunction that cause the
accumulation of cerebrospinal fluid.
Which change in sleep patterns is most likely to occur in an older adult?
Becomes more difficult to arouse from sleep.
Takes less time to fall asleep.
Has a decline in stage 4 sleep.
Requires more sleep than a younger adult.
Has a decline in stage 4 sleep.
Rationale
With aging, a progressive decrease in the amount of non-rapid eye movement (NREM)
sleep occurs during stage 3 and 4, and some older adults have minimal amounts of stage 4,
or deep sleep. As people age, they do not become more difficult to arouse. An older adult
awakens more often during the night, and it may take more time for an older adult to fall
asleep. The older adult does not require more sleep than a younger adult.
,The nurse manager is explaining to a new nurse that the nursing units at the hospital are
managed by the nursing staff who control self-scheduling of shift work, implement unit
quality improvement program, and participate in unit recruitment-retention programs.
What type of management model is the nurse manager describing?
Operational shared governance.
Nursing staff unions.
Clinical career ladder program.
Centralized nursing division.
Operational shared governance.
Rationale
Shared governance is a model of organizational management where decision making is
decentralized in which staff nurses are empowered through autonomy and accountability
about the delivery of client care on the nursing unit. Unions in nursing represent a group of
employees in collective bargaining processes to negotiate decisions with an employing
organization’s management. Clinical career ladder programs are partnerships between
heath care agencies, nursing staff, and nursing schools for advancement in education and
promotion. A centralized organizational decision-making model in nursing is characterized
by a nurse executive who retains decision-making authority.
A client with advanced cirrhosis and hepatic encephalopathy is manifesting mounting
ascites and 4+ pitting edema of the feet and legs. The nurse identifies fluid leaking from his
skin when he is turned. Which intervention is most important for the nurse to include in
the client's plan of care?
Turn the client every 4 hours.
Restrict dietary protein intake.
Perform passive range of motion 4 times per day.
Apply a pressure-relieving mattress under the client.
Apply a pressure-relieving mattress under the client.
Rationale
The client's risk for impaired skin integrity requires meticulous skin care because the
edematous tissues are showing indications of breakdown. A pressure-relieving mattress
should be used to reduce the risk of skin tearing with manual turning.
A primiparous client has been in labor for 15 hours. Two hours ago, vaginal examination
revealed the cervix dilated to 5 cm, 100% effaced, and the presenting part at station 0. Five
minutes ago, the vaginal examination reveals no change in the cervix or decent of the fetus.
Which labor pattern should the nurse document to describe the client's progress?
Protracted descent.
Arrest of active phase.
Prolonged latent phase.
Protracted active phase.
Arrest of active phase.
Rationale
Arrest of active phase is indicated if there is no change in the dilation of the cervix for 2
hours or more in a primigravida. Prolonged latent phase is labor lasting longer than 20
hours in a primigravida. Protracted active phase occurs when dilatation of the cervix is less
than 1.2 cm/hour. Protracted descent occurs when the fetus decends less than 1 cm/hour
into the pelvis.
, We have an expert-written solution to this problem!
A client returns from surgery after undergoing an abdominal-perineal resection with a
sigmoid colostomy. The colostomy is dressed with petroleum jelly gauze and dry gauze
dressings. The perineal incision is partially closed with two drains attached to Jackson-
Pratt suction bulbs. During the early postoperative period, the nurse should give the
highest priority to which nursing action?
Provide a low-residue diet.
Monitor drainage from the colostomy stoma.
Maintain dry perineal dressings.
Encourage looking at the colostomy site.
Maintain dry perineal dressings.
Rationale
During the immediate postoperative period, the perineal dressing should be assessed,
reinforced, and changed frequently because profuse drainage during the first hours after
surgery macerates tissue and compromises incisional approximation and healing. The
priority action should include measures to promote healing and prevent infection.
We have an expert-written solution to this problem!
A client returns to the postoperative unit after a gastroduodenostomy (Billroth I) for
treatment of a perforated ulcer. The healthcare provider's prescriptions include morphine
with a patient-controlled analgesia (PCA), nasogastric tube (NGT) to low intermittent
nasogastric suction, and IV fluids and antibiotics. The client complains of increasing
abdominal pain 12 hours after returning to the surgical unit. The nurse determines the
client has no bowel sounds, and 200 ml of bright red nasogastric drainage is in the suction
canister in the past hour. What is the priority action the nurse should implement?
Notify the healthcare provider.
Irrigate the nasogastric tube per prescription.
Assess the client's use of the PCA device.
Splint the abdomen to relieve pressure on the incision.
Notify the healthcare provider.
Rationale
Although nasogastric aspirate can be bright red initially, the color should gradually darken
over the first 24 hours. A sudden increase in the volume of bright red gastric drainage
indicates bleeding, and the healthcare provider should be notified immediately. The client's
complaints of pain and signs of bleeding require immediate action to prevent hemorrhagic
shock.
We have an expert-written solution to this problem!
Which action should the hospice nurse implement to assist a client maintain self-worth
during the end-of-life process?
Arrange for a grief counselor to visit with the client.
Plan regular visits with the client throughout the day.
COMPLETE QUESTIONS AND WELL DETAILED
ANSWERS LATEST 2025
We have an expert-written solution to this problem!
The nurse is assessing a postpartum client who delivered in the car. Which finding should
the nurse identify as the earliest manifestation of a puerperal infection?
Dysuria and pyuria with each voiding.
White blood cells (WBC) greater than 12,000/mm3.
Increased vaginal bleeding with ambulation.
Temperature of 100.8 F 24 hours after delivery.
Temperature of 100.8 F 24 hours after delivery.
Rationale
Postpartum or puerperal infection is any clinical infection of the genital canal that occurs
within 28 days after miscarriage, induced abortion, or childbirth. The presence of a fever
of 38 C (100.4 F) 24 hours after birth is the first indicator. Although infection stimulates
leukocytosis, WBC counts after delivery are normal up to 15,000/mm3.
What nursing intervention should the nurse include in the plan of care for a client
following a bone marrow aspiration?
Use of a compression dressing for firm pressure to the site.
Proper positioning of the client in a prone position.
Follow-up hematological laboratory studies.
Application of warm, moist compresses to the puncture site.
Use of a compression dressing for firm pressure to the site.
Rationale
After the procedure, firm pressure using a compression dressing to the aspiration site
should be applied to control bleeding if organ puncture or coagulopathy is present.
Positioning the client prone is not necessary to control bleeding from the aspiration site.
Although hematological laboratory studies should be reviewed before and after the
procedure, the immediate risk is bleeding due to removal of bone marrow. Application of
ice, not warm moist compresses reduces the potential for bleeding.
The nurse instills an atropine ophthalmic solution into both eyes for a client who is having
a routine eye examination. Which side effects should the nurse tell the client to anticipate?
Blurred vision.
Halos around objects.
Inability to see at night.
Itching of the conjunctiva.
Blurred vision.
Rationale
,Atropine ophthalmic solution is used during eye examinations to dilate the pupil
(mydriasis) and paralyze the ciliary muscle (cycloplegic refraction), which prevents
accommodation and causes blurred vision.
The nurse-manager is planning to study a unit problem that engages the nursing staff in
evidence-based practice. What is the sequence of activities that the nurse-manager should
use? (Arrange in the order from first on top to last on the bottom.)
1. Identification of practice problem.
2. Review of published research.
3. Identify and develop plan for application of research findings.
4. Implementation of data gathering methods and data evaluation.
1. Identification of practice problem.
2. Review of published research.
3. Implementation of data gathering methods and data evaluation.
4. Identify and develop plan for application of research findings.
Rationale
The proper sequence in the research utilization process begins with the identification of a
practice problem, which in turn sets the stage for the step-by-step approach incorporating
critical thinking and decision making. Review of published research, implementation of
data gathering methods, analysis and evaluation of data, conclusion and plan for
application of findings to the practice problem should follow.
Which information is most important for the nurse to provide parents about long-term
care for their child with hydrocephalus and a ventriculoperitoneal (VP) shunt?
Physical contact sports may be restricted during childhood.
Shunt malfunction or infection requires immediate treatment.
Normal intellectual ability is expected with surgical diversion.
The use of a protective helmet is recommended during childhood.
Shunt malfunction or infection requires immediate treatment.
Rationale
A VP shunt is the standard procedure for hydrocephalus in neonates and young infants
which allows for excess tubing that minimizes the number of revisions needed as the child
grows. Parents should be taught about the immediacy for medical intervention of VP
complications, such as infection and functional or mechanical malfunction that cause the
accumulation of cerebrospinal fluid.
Which change in sleep patterns is most likely to occur in an older adult?
Becomes more difficult to arouse from sleep.
Takes less time to fall asleep.
Has a decline in stage 4 sleep.
Requires more sleep than a younger adult.
Has a decline in stage 4 sleep.
Rationale
With aging, a progressive decrease in the amount of non-rapid eye movement (NREM)
sleep occurs during stage 3 and 4, and some older adults have minimal amounts of stage 4,
or deep sleep. As people age, they do not become more difficult to arouse. An older adult
awakens more often during the night, and it may take more time for an older adult to fall
asleep. The older adult does not require more sleep than a younger adult.
,The nurse manager is explaining to a new nurse that the nursing units at the hospital are
managed by the nursing staff who control self-scheduling of shift work, implement unit
quality improvement program, and participate in unit recruitment-retention programs.
What type of management model is the nurse manager describing?
Operational shared governance.
Nursing staff unions.
Clinical career ladder program.
Centralized nursing division.
Operational shared governance.
Rationale
Shared governance is a model of organizational management where decision making is
decentralized in which staff nurses are empowered through autonomy and accountability
about the delivery of client care on the nursing unit. Unions in nursing represent a group of
employees in collective bargaining processes to negotiate decisions with an employing
organization’s management. Clinical career ladder programs are partnerships between
heath care agencies, nursing staff, and nursing schools for advancement in education and
promotion. A centralized organizational decision-making model in nursing is characterized
by a nurse executive who retains decision-making authority.
A client with advanced cirrhosis and hepatic encephalopathy is manifesting mounting
ascites and 4+ pitting edema of the feet and legs. The nurse identifies fluid leaking from his
skin when he is turned. Which intervention is most important for the nurse to include in
the client's plan of care?
Turn the client every 4 hours.
Restrict dietary protein intake.
Perform passive range of motion 4 times per day.
Apply a pressure-relieving mattress under the client.
Apply a pressure-relieving mattress under the client.
Rationale
The client's risk for impaired skin integrity requires meticulous skin care because the
edematous tissues are showing indications of breakdown. A pressure-relieving mattress
should be used to reduce the risk of skin tearing with manual turning.
A primiparous client has been in labor for 15 hours. Two hours ago, vaginal examination
revealed the cervix dilated to 5 cm, 100% effaced, and the presenting part at station 0. Five
minutes ago, the vaginal examination reveals no change in the cervix or decent of the fetus.
Which labor pattern should the nurse document to describe the client's progress?
Protracted descent.
Arrest of active phase.
Prolonged latent phase.
Protracted active phase.
Arrest of active phase.
Rationale
Arrest of active phase is indicated if there is no change in the dilation of the cervix for 2
hours or more in a primigravida. Prolonged latent phase is labor lasting longer than 20
hours in a primigravida. Protracted active phase occurs when dilatation of the cervix is less
than 1.2 cm/hour. Protracted descent occurs when the fetus decends less than 1 cm/hour
into the pelvis.
, We have an expert-written solution to this problem!
A client returns from surgery after undergoing an abdominal-perineal resection with a
sigmoid colostomy. The colostomy is dressed with petroleum jelly gauze and dry gauze
dressings. The perineal incision is partially closed with two drains attached to Jackson-
Pratt suction bulbs. During the early postoperative period, the nurse should give the
highest priority to which nursing action?
Provide a low-residue diet.
Monitor drainage from the colostomy stoma.
Maintain dry perineal dressings.
Encourage looking at the colostomy site.
Maintain dry perineal dressings.
Rationale
During the immediate postoperative period, the perineal dressing should be assessed,
reinforced, and changed frequently because profuse drainage during the first hours after
surgery macerates tissue and compromises incisional approximation and healing. The
priority action should include measures to promote healing and prevent infection.
We have an expert-written solution to this problem!
A client returns to the postoperative unit after a gastroduodenostomy (Billroth I) for
treatment of a perforated ulcer. The healthcare provider's prescriptions include morphine
with a patient-controlled analgesia (PCA), nasogastric tube (NGT) to low intermittent
nasogastric suction, and IV fluids and antibiotics. The client complains of increasing
abdominal pain 12 hours after returning to the surgical unit. The nurse determines the
client has no bowel sounds, and 200 ml of bright red nasogastric drainage is in the suction
canister in the past hour. What is the priority action the nurse should implement?
Notify the healthcare provider.
Irrigate the nasogastric tube per prescription.
Assess the client's use of the PCA device.
Splint the abdomen to relieve pressure on the incision.
Notify the healthcare provider.
Rationale
Although nasogastric aspirate can be bright red initially, the color should gradually darken
over the first 24 hours. A sudden increase in the volume of bright red gastric drainage
indicates bleeding, and the healthcare provider should be notified immediately. The client's
complaints of pain and signs of bleeding require immediate action to prevent hemorrhagic
shock.
We have an expert-written solution to this problem!
Which action should the hospice nurse implement to assist a client maintain self-worth
during the end-of-life process?
Arrange for a grief counselor to visit with the client.
Plan regular visits with the client throughout the day.
