HESI COMPREHENSIVE A,
COMPREHENSIVE EXAM B, 2020 EXIT V 2
WITH QUESTIONS AND CORRECT
ANSWERS WITH DETAILED RATIONALES
GRADED A+
A nurse is interviewing a mother during a well-child visit. Which
finding would alert the nurse to continue further assessment of the
infant?
A.Two-month-old who is unable to roll from back to abdomen
B.Ten-month-old who cannot sit without support
C.Nine-month-old who cries when his mother leaves the room
D.Eight-month-old who has not yet begun to speak words Correct
Answer B
Rationale:
As a developmental milestone, infants should sit
unsupported by 8 months (B). The milestone of rolling over
is achieved at 5 to 6 months for most infants (A). Stranger
anxiety is common from 7 to 9 months (C). Speaking a few
words is expected at about 12 months (D).
Which intervention should be included in the plan of care for a
client admitted to the hospital with ulcerative colitis?
,A.Administer stool softeners.
B.Place the client on fluid restriction.
C.Provide a low-residue diet.
D.Add a milk product to each meal. Correct Answer C
Rationale:
A low-residue diet (C) will help decrease symptoms of
diarrhea, which are clinical manifestations of ulcerative
colitis. (A, B, and D) are contraindicated and could worsen
the condition.
The nurse is caring for a client with deep vein thrombosis who is
on a continuous IV heparin infusion. The activated partial
prothrombin time (aPTT) is 120 seconds. Which action should the
nurse take?
A.Increase the rate of the heparin infusion using a nomogram.
B.Decrease the heparin infusion rate and give vitamin K IM.
C.Continue the heparin infusion at the current prescribed rate.
D.Stop the heparin drip and prepare to administer protamine
sulfate. Correct Answer D
Rationale:
An aPTT more than 100 seconds is a critically high value;
therefore, the heparin should be stopped. The antidote for heparin
is protamine sulfate (D). Increasing the rate would increase the
risk for hemorrhage (A). The infusion should be stopped, and
vitamin K is the antidote for warfarin (Coumadin) (B). Keeping the
,infusion at the current rate would increase the risk for hemorrhage
(C).
While assessing a client with recurring chest pain, the unit
secretary notifies the nurse that the client's health care provider is
on the telephone. What action should the nurse instruct the unit
secretary to implement?
A.Transfer the call into the room of the client.
B.Instruct the secretary to explain reason for the call.
C.Ask another nurse to take the phone call.
D.Ask the health care provider to see the client on the unit.
Correct Answer C
Rationale:
Another nurse should be asked to take the phone call (C), which
allows the nurse to stay at the bedside to complete the
assessment of the client's chest pain. (A and B) should not be
done during an acute change in the client's condition. Requesting
the health care provider (D) to come to the unit is premature until
the nurse completes assessment of the client's status.
Which instruction(s) should the nurse include in the discharge
teaching plan of a male client who has had a myocardial infarction
and who has a new prescription for nitroglycerin (NTG)? (Select
all that apply.)
A.Keep the medication in your pocket so that it can be accessed
quickly.
, B.Call 911 if chest pain is not relieved after one nitroglycerin.
C.Store the medication in its original container and protect it from
light.
D.Activate the emergency medical system after three doses of
medication.
E.Do not use within 1 hour of taking sildenafil citrate (Viagra).
Correct Answer B,C
Rationale:
Emergency action should be taken if chest pain is not relieved
after one nitroglycerin tablet (B). The medication should be kept in
the original container to protect from light (C). Keeping the
medication in the shirt pocket provides an environment that is too
warm (A). The newest guidelines recommend calling 911 after
one nitroglycerin tablet if chest pain is not relieved (D).
Nitroglycerin and other nitrates should never be taken with Viagra
(E).
The nurse prepares to administer 3 units of regular insulin and 20
units of NPH insulin subcutaneously to a client with an elevated
blood glucose level. Which procedure is correct?
A.Using one syringe, first insert air into the regular vial and then
insert air into the NPH vial.
B.Using one syringe, add the regular insulin into the syringe and
then add the NPH insulin.
C.Avoid combining the two insulins because incompatibility could
cause an adverse reaction.
COMPREHENSIVE EXAM B, 2020 EXIT V 2
WITH QUESTIONS AND CORRECT
ANSWERS WITH DETAILED RATIONALES
GRADED A+
A nurse is interviewing a mother during a well-child visit. Which
finding would alert the nurse to continue further assessment of the
infant?
A.Two-month-old who is unable to roll from back to abdomen
B.Ten-month-old who cannot sit without support
C.Nine-month-old who cries when his mother leaves the room
D.Eight-month-old who has not yet begun to speak words Correct
Answer B
Rationale:
As a developmental milestone, infants should sit
unsupported by 8 months (B). The milestone of rolling over
is achieved at 5 to 6 months for most infants (A). Stranger
anxiety is common from 7 to 9 months (C). Speaking a few
words is expected at about 12 months (D).
Which intervention should be included in the plan of care for a
client admitted to the hospital with ulcerative colitis?
,A.Administer stool softeners.
B.Place the client on fluid restriction.
C.Provide a low-residue diet.
D.Add a milk product to each meal. Correct Answer C
Rationale:
A low-residue diet (C) will help decrease symptoms of
diarrhea, which are clinical manifestations of ulcerative
colitis. (A, B, and D) are contraindicated and could worsen
the condition.
The nurse is caring for a client with deep vein thrombosis who is
on a continuous IV heparin infusion. The activated partial
prothrombin time (aPTT) is 120 seconds. Which action should the
nurse take?
A.Increase the rate of the heparin infusion using a nomogram.
B.Decrease the heparin infusion rate and give vitamin K IM.
C.Continue the heparin infusion at the current prescribed rate.
D.Stop the heparin drip and prepare to administer protamine
sulfate. Correct Answer D
Rationale:
An aPTT more than 100 seconds is a critically high value;
therefore, the heparin should be stopped. The antidote for heparin
is protamine sulfate (D). Increasing the rate would increase the
risk for hemorrhage (A). The infusion should be stopped, and
vitamin K is the antidote for warfarin (Coumadin) (B). Keeping the
,infusion at the current rate would increase the risk for hemorrhage
(C).
While assessing a client with recurring chest pain, the unit
secretary notifies the nurse that the client's health care provider is
on the telephone. What action should the nurse instruct the unit
secretary to implement?
A.Transfer the call into the room of the client.
B.Instruct the secretary to explain reason for the call.
C.Ask another nurse to take the phone call.
D.Ask the health care provider to see the client on the unit.
Correct Answer C
Rationale:
Another nurse should be asked to take the phone call (C), which
allows the nurse to stay at the bedside to complete the
assessment of the client's chest pain. (A and B) should not be
done during an acute change in the client's condition. Requesting
the health care provider (D) to come to the unit is premature until
the nurse completes assessment of the client's status.
Which instruction(s) should the nurse include in the discharge
teaching plan of a male client who has had a myocardial infarction
and who has a new prescription for nitroglycerin (NTG)? (Select
all that apply.)
A.Keep the medication in your pocket so that it can be accessed
quickly.
, B.Call 911 if chest pain is not relieved after one nitroglycerin.
C.Store the medication in its original container and protect it from
light.
D.Activate the emergency medical system after three doses of
medication.
E.Do not use within 1 hour of taking sildenafil citrate (Viagra).
Correct Answer B,C
Rationale:
Emergency action should be taken if chest pain is not relieved
after one nitroglycerin tablet (B). The medication should be kept in
the original container to protect from light (C). Keeping the
medication in the shirt pocket provides an environment that is too
warm (A). The newest guidelines recommend calling 911 after
one nitroglycerin tablet if chest pain is not relieved (D).
Nitroglycerin and other nitrates should never be taken with Viagra
(E).
The nurse prepares to administer 3 units of regular insulin and 20
units of NPH insulin subcutaneously to a client with an elevated
blood glucose level. Which procedure is correct?
A.Using one syringe, first insert air into the regular vial and then
insert air into the NPH vial.
B.Using one syringe, add the regular insulin into the syringe and
then add the NPH insulin.
C.Avoid combining the two insulins because incompatibility could
cause an adverse reaction.
