am
Comprehensive HESI am am
Exam Review Q&A for Nursing
am am am am am
Students Complete Study Outline
amam am am am
& Essential Testing Concepts
am am am
100% Guaranteed Pass
am am
, lOMoARcPSD|61098961
am
1.ID: 383711499 am
Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment does the nurse
am am am am am am am am am am am am am
perform as a priority before administering the medicaton?
am am am am am am am
Checking the client's blood pressure Correct am am am am am
Checking the client's peripheral pulses am am am am
Checking the most recent potassium level am am am am am
Checking the client's intake-and-output record for the last 24 hoursam am am am am am am am am
Ratonale: Enalapril maleate is an angiotensin-convertng enzyme (ACE) inhibitor used to treat
am am am am am am am am am am am
hypertension. One common side effect is postural hypotension. Therefore the nurse would check the
am am am am am am am am am am am am am
client’s blood pressure immediately before administering each dose. Checking the client’s peripheral
am am am am am am am am am am am
pulses, the results of the most recent potassium level, and the intake and output for the previous 24
am am am am am am am am am am am am am am am am am
hours are not specifically associated with this mediaton.
am am am am am am am
2.ID: 383744011 am
A client is scheduled to undergo an upper gastrointestnal (GI) series, and the nurse provides
am am am am am am am am am am am am am am
instructons to the client about the test. Which statement by the client indicates a need for further
am am am am am am am am am am am am am am am am
instructon?
"The test will take about 30 minutes."
am am am am am am
"I need to fast for 8 hours before the test."
am am am am am am am am am
"I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the
am am am am am am am am am am am am am am am am am am am
morning of the test." Correct am am am am
"I need to take a laxatve aſter the test is completed, because the liquid that I’ll have to drink for the
am am am am am am am am am am am am am am am am am am am am
test can be constpatng."
am am am
Ratonale: An upper GI series involves visualizaton of the esophagus, duodenum, and upper jejunum by
am am am am am am am am am am am am am am
means of the use of a contrast medium. It involves swallowing a contrast medium (usually barium),
am am am am am am am am am am am am am am am
which is administered in a flavored milkshake. Films are taken at intervals during the test, which takes
am am am am am am am am am am am am am am am am
about 30 minutes. No special preparaton is necessary before a GI series, except that NPO status must
am am am am am am am am am am am am am am am am
be maintained for 8 hours before the test. Aſter an upper GI series, the client is prescribed a laxatve to
am am am am am am am am am am am am am am am am am am am
hasten eliminaton of the barium. Barium that remains in the colon may become hard and difficult to
am am am am am am am am am am am am am am am am
expel, leading to fecal impacton.
am am am am
3.ID: 383705015 am
A nurse on the evening shiſt checks a physician's prescriptons and notes that the dose of a prescribed
am am am am am am am am am am am am am am am am am
medicaton is higher than the normal dose. The nurse calls the physician's answering service and is told
am am am am am am am am am am am am am am am am
that the physician is off for the night and will be available in the morning. The nurse should:
am am am am am am am am am am am am am am am am am
Call the nursing supervisor
am am am
Ask the answering service to contact the on-call physician Correct
am am am am am am am am am
Withhold the medicaton untl the physician can be reached in the morning
am am am am am am am am am am am
Administer the medicaton but consult the physician when he becomes available
am am am am am am am am am am
,am
lOMoARcPSD|61098961
Ratonale: The nurse has a duty to protect the client from harm. A nurse who believes that a physician’s
am am am am am am am am am am am am am am am am am am
prescripton may be in error is responsible for clarifying the prescripton before carrying it out. Therefore
am am am am am am am am am am am am am am am
the nurse would not administer the medicaton; instead, the nurse would withhold the medicaton untl
am am am am am am am am am am am am am am
the dose can be clarified. The nurse would not wait untl the next morning to obtain clarificaton. It is
am am am am am am am am am am am am am am am am am am
premature to call the nursing supervisor. am am am am am
4.ID: 383708500 am
An emergency department (ED) nurse is monitoring a client with suspected acute myocardial infarcton
am am am am am am am am am am am am am
(MI) who is awaitng transfer to the coronary intensive care unit. The nurse notes the sudden onset of
am am am am am am am am am am am am am am am am am
premature ventricular contractons (PVCs) on the monitor, checks the client's carotd pulse, and
am am am am am am am am am am am am
determines that the PVCs are not resultng in perfusion. The appropriate acton by the nurse is:
am am am am am am am am am am am am am am am
Documentng the findings am am
Asking the ED physician to check the client Correct
am am am am am am am am
Contnuing to monitor the client's cardiac status am am am am am am
Informing the client that PVCs are expected aſter an MI am am am am am am am am am
Ratonale: PVCs are a result of increased irritability of ventricular cells. Peripheral pulses may be absent
am am am am am am am am am am am am am am am
or diminished with the PVCs themselves because the decreased stroke volume of the premature beats
am am am am am am am am am am am am am am
may in turn decrease peripheral perfusion. Because other rhythms also cause widened QRS complexes,
am am am am am am am am am am am am am
it is essental that the nurse determine whether the premature beats are resultng in perfusion of the
am am am am am am am am am am am am am am am am
extremites. This is done by palpatng the carotd, brachial, or femoral artery while observing the
am am am am am am am am am am am am am am
monitor for widened complexes or by auscultatng for apical heart sounds. In the situaton of acute MI,
am am am am am am am am am am am am am am am am
PVCs may be considered warning dysrhythmias, possibly heralding the onset of ventricular tachycardia
am am am am am am am am am am am am
or ventricular fibrillaton. Therefore the nurse would not tell the client that the PVCs are expected.
am am am am am am am am am am am am am am am
Although the nurse will contnue to monitor the client and document the findings, these are not the
am am am am am am am am am am am am am am am am
most appropriate actons of those provided. The most appropriate acton would be to ask the ED
am am am am am am am am am am am am am am am
physician to check the client. am am am am
5.ID: 383704545 am
NPO status is imposed 8 hours before the procedure on a client scheduled to undergo electroconvulsive
am am am am am am am am am am am am am am am
therapy (ECT) at 1 p.m. On the morning of the procedure, the nurse checks the client's record and notes
am am am am am am am am am am am am am am am am am am
that the client routnely takes an oral anthypertensive medicaton each morning. The nurse should:
am am am am am am am am am am am am am
Administer the anthypertensive with a small sip of water Correct am am am am am am am am am
Withhold the anthypertensive and administer it at bedtme am am am am am am am
Administer the medicaton by way of the intravenous (IV) route am am am am am am am am am
Hold the anthypertensive and resume its administraton on the day aſter the ECT
am am am am am am am am am am am am
Ratonale: General anesthesia is required for ECT, so NPO status is imposed for 6 to 8 hours before
am am am am am am am am am am am am am am am am am
treatment to help prevent aspiraton. Exceptons include clients who routnely receive cardiac
am am am am am am am am am am am
medicatons, anthypertensive agents, or histamine (H2) blockers, which should be administered several
am am am am am am am am am am am
hours before treatment with a small sip of water. Withholding the anthypertensive and administering it
am am am am am am am am am am am am am am
at bedtme and withholding the anthypertensive and resuming administraton on the day aſter the ECT
am am am am am am am am am am am am am am
are incorrect actons, because anthypertensives must be administered on tme; otherwise, the risk for
am am am am am am am am am am am am am
,am
lOMoARcPSD|61098961
rebound hypertension exists. The nurse would not administer a medicaton by way of a route that has
am am am am am am am am am am am am am am am am
not been prescribed.
am am
6.ID: 383706660 am
A client who recently underwent coronary artery bypass graſt surgery comes to the physician's office for
am am am am am am am am am am am am am am am
a follow-up visit. On assessment, the client tells the nurse that he is feeling depressed. Which response
am am am am am am am am am am am am am am am am
by the nurse is therapeutc?
am am am am
"Tell me more about what you’re feeling." Correct
am am am am am am am
"That’s a normal response aſter this type of surgery."
am am am am am am am am
"It will take tme, but, I promise you, you will get over this depression."
am am am am am am am am am am am am am
"Every client who has this surgery feels the same way for about a month."
am am am am am am am am am am am am am
Ratonale: When a client expresses feelings of depression, it is extremely important for the nurse to
am am am am am am am am am am am am am am am
further explore these feelings with the client. In statng, "This is a normal response aſter this type of
am am am am am am am am am am am am am am am am am
surgery" the nurse provides false reassurance and avoids addressing the client’s feelings. "It will take
am am am am am am am am am am am am am am
tme, but, I promise you, you will get over the depression" is also a false reassurance, and it does not
am am am am am am am am am am am am am am am am am am am
encourage the expression of feelings. "Every client who has this surgery feels the same way for about a
am am am am am am am am am am am am am am am am am
month" is a generalizaton that avoids the client’s feelings.
am am am am am am am am
7.ID: 383705009 am
A client in labor experiences spontaneous rupture of the membranes. The nurse immediately counts the
am am am am am am am am am am am am am am
fetal heart rate (FHR) for 1 full minute and then checks the amniotc fluid. The nurse notes that the fluid
am am am am am am am am am am am am am am am am am am am
is yellow and has a strong odor. Which of the following actons should be the nurse’s priority?
am am am am am am am am am am am am am am am am
Contactng the physician Correct am am am
Documentng the findings am am
Checking the fluid for protein am am am am
Contnuing to monitor the client and the FHR am am am am am am am
Ratonale: The FHR is assessed for at least 1 minute when the membranes rupture. The nurse also
am am am am am am am am am am am am am am am am
checks the quantty, color, and odor of the amniotc fluid. The fluid should be clear (oſten with bits of
am am am am am am am am am am am am am am am am am am
vernix) and have a mild odor. Fluid with a foul or strong odor, cloudy appearance, or yellow coloraton
am am am am am am am am am am am am am am am am am
suggests chorioamnionits and warrants notfying the physician. A large amount of vernix in the fluid
am am am am am am am am am am am am am am
suggests that the fetus is preterm. Greenish, meconium-stained fluid may be seen in cases of posterm
am am am am am am am am am am am am am am am
gestaton or placental insufficiency. Checking the fluid for protein is not associated with the data in the
am am am am am am am am am am am am am am am am
queston. Although the nurse would contnue to monitor the client and the FHR and would document
am am am am am am am am am am am am am am am
the findings, contactng the physician is the priority.
am am am am am am am
8.ID: 383705011 am
A nurse has assisted a physician in insertng a central venous access device into a client with a diagnosis
am am am am am am am am am am am am am am am am am am
of severe malnutriton who will be receiving parenteral nutriton (PN). Aſter inserton of the catheter,
am am am am am am am am am am am am am am
the nurse immediately plans to:
am am am am
Call the radiography department to obtain a chest x-ray Correct
am am am am am am am am am
Check the client's blood glucose level to serve as a baseline measurement
am am am am am am am am am am am
Downloaded by Lexiz Gichbuoy () am am am am
Comprehensive HESI am am
Exam Review Q&A for Nursing
am am am am am
Students Complete Study Outline
amam am am am
& Essential Testing Concepts
am am am
100% Guaranteed Pass
am am
, lOMoARcPSD|61098961
am
1.ID: 383711499 am
Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment does the nurse
am am am am am am am am am am am am am
perform as a priority before administering the medicaton?
am am am am am am am
Checking the client's blood pressure Correct am am am am am
Checking the client's peripheral pulses am am am am
Checking the most recent potassium level am am am am am
Checking the client's intake-and-output record for the last 24 hoursam am am am am am am am am
Ratonale: Enalapril maleate is an angiotensin-convertng enzyme (ACE) inhibitor used to treat
am am am am am am am am am am am
hypertension. One common side effect is postural hypotension. Therefore the nurse would check the
am am am am am am am am am am am am am
client’s blood pressure immediately before administering each dose. Checking the client’s peripheral
am am am am am am am am am am am
pulses, the results of the most recent potassium level, and the intake and output for the previous 24
am am am am am am am am am am am am am am am am am
hours are not specifically associated with this mediaton.
am am am am am am am
2.ID: 383744011 am
A client is scheduled to undergo an upper gastrointestnal (GI) series, and the nurse provides
am am am am am am am am am am am am am am
instructons to the client about the test. Which statement by the client indicates a need for further
am am am am am am am am am am am am am am am am
instructon?
"The test will take about 30 minutes."
am am am am am am
"I need to fast for 8 hours before the test."
am am am am am am am am am
"I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the
am am am am am am am am am am am am am am am am am am am
morning of the test." Correct am am am am
"I need to take a laxatve aſter the test is completed, because the liquid that I’ll have to drink for the
am am am am am am am am am am am am am am am am am am am am
test can be constpatng."
am am am
Ratonale: An upper GI series involves visualizaton of the esophagus, duodenum, and upper jejunum by
am am am am am am am am am am am am am am
means of the use of a contrast medium. It involves swallowing a contrast medium (usually barium),
am am am am am am am am am am am am am am am
which is administered in a flavored milkshake. Films are taken at intervals during the test, which takes
am am am am am am am am am am am am am am am am
about 30 minutes. No special preparaton is necessary before a GI series, except that NPO status must
am am am am am am am am am am am am am am am am
be maintained for 8 hours before the test. Aſter an upper GI series, the client is prescribed a laxatve to
am am am am am am am am am am am am am am am am am am am
hasten eliminaton of the barium. Barium that remains in the colon may become hard and difficult to
am am am am am am am am am am am am am am am am
expel, leading to fecal impacton.
am am am am
3.ID: 383705015 am
A nurse on the evening shiſt checks a physician's prescriptons and notes that the dose of a prescribed
am am am am am am am am am am am am am am am am am
medicaton is higher than the normal dose. The nurse calls the physician's answering service and is told
am am am am am am am am am am am am am am am am
that the physician is off for the night and will be available in the morning. The nurse should:
am am am am am am am am am am am am am am am am am
Call the nursing supervisor
am am am
Ask the answering service to contact the on-call physician Correct
am am am am am am am am am
Withhold the medicaton untl the physician can be reached in the morning
am am am am am am am am am am am
Administer the medicaton but consult the physician when he becomes available
am am am am am am am am am am
,am
lOMoARcPSD|61098961
Ratonale: The nurse has a duty to protect the client from harm. A nurse who believes that a physician’s
am am am am am am am am am am am am am am am am am am
prescripton may be in error is responsible for clarifying the prescripton before carrying it out. Therefore
am am am am am am am am am am am am am am am
the nurse would not administer the medicaton; instead, the nurse would withhold the medicaton untl
am am am am am am am am am am am am am am
the dose can be clarified. The nurse would not wait untl the next morning to obtain clarificaton. It is
am am am am am am am am am am am am am am am am am am
premature to call the nursing supervisor. am am am am am
4.ID: 383708500 am
An emergency department (ED) nurse is monitoring a client with suspected acute myocardial infarcton
am am am am am am am am am am am am am
(MI) who is awaitng transfer to the coronary intensive care unit. The nurse notes the sudden onset of
am am am am am am am am am am am am am am am am am
premature ventricular contractons (PVCs) on the monitor, checks the client's carotd pulse, and
am am am am am am am am am am am am
determines that the PVCs are not resultng in perfusion. The appropriate acton by the nurse is:
am am am am am am am am am am am am am am am
Documentng the findings am am
Asking the ED physician to check the client Correct
am am am am am am am am
Contnuing to monitor the client's cardiac status am am am am am am
Informing the client that PVCs are expected aſter an MI am am am am am am am am am
Ratonale: PVCs are a result of increased irritability of ventricular cells. Peripheral pulses may be absent
am am am am am am am am am am am am am am am
or diminished with the PVCs themselves because the decreased stroke volume of the premature beats
am am am am am am am am am am am am am am
may in turn decrease peripheral perfusion. Because other rhythms also cause widened QRS complexes,
am am am am am am am am am am am am am
it is essental that the nurse determine whether the premature beats are resultng in perfusion of the
am am am am am am am am am am am am am am am am
extremites. This is done by palpatng the carotd, brachial, or femoral artery while observing the
am am am am am am am am am am am am am am
monitor for widened complexes or by auscultatng for apical heart sounds. In the situaton of acute MI,
am am am am am am am am am am am am am am am am
PVCs may be considered warning dysrhythmias, possibly heralding the onset of ventricular tachycardia
am am am am am am am am am am am am
or ventricular fibrillaton. Therefore the nurse would not tell the client that the PVCs are expected.
am am am am am am am am am am am am am am am
Although the nurse will contnue to monitor the client and document the findings, these are not the
am am am am am am am am am am am am am am am am
most appropriate actons of those provided. The most appropriate acton would be to ask the ED
am am am am am am am am am am am am am am am
physician to check the client. am am am am
5.ID: 383704545 am
NPO status is imposed 8 hours before the procedure on a client scheduled to undergo electroconvulsive
am am am am am am am am am am am am am am am
therapy (ECT) at 1 p.m. On the morning of the procedure, the nurse checks the client's record and notes
am am am am am am am am am am am am am am am am am am
that the client routnely takes an oral anthypertensive medicaton each morning. The nurse should:
am am am am am am am am am am am am am
Administer the anthypertensive with a small sip of water Correct am am am am am am am am am
Withhold the anthypertensive and administer it at bedtme am am am am am am am
Administer the medicaton by way of the intravenous (IV) route am am am am am am am am am
Hold the anthypertensive and resume its administraton on the day aſter the ECT
am am am am am am am am am am am am
Ratonale: General anesthesia is required for ECT, so NPO status is imposed for 6 to 8 hours before
am am am am am am am am am am am am am am am am am
treatment to help prevent aspiraton. Exceptons include clients who routnely receive cardiac
am am am am am am am am am am am
medicatons, anthypertensive agents, or histamine (H2) blockers, which should be administered several
am am am am am am am am am am am
hours before treatment with a small sip of water. Withholding the anthypertensive and administering it
am am am am am am am am am am am am am am
at bedtme and withholding the anthypertensive and resuming administraton on the day aſter the ECT
am am am am am am am am am am am am am am
are incorrect actons, because anthypertensives must be administered on tme; otherwise, the risk for
am am am am am am am am am am am am am
,am
lOMoARcPSD|61098961
rebound hypertension exists. The nurse would not administer a medicaton by way of a route that has
am am am am am am am am am am am am am am am am
not been prescribed.
am am
6.ID: 383706660 am
A client who recently underwent coronary artery bypass graſt surgery comes to the physician's office for
am am am am am am am am am am am am am am am
a follow-up visit. On assessment, the client tells the nurse that he is feeling depressed. Which response
am am am am am am am am am am am am am am am am
by the nurse is therapeutc?
am am am am
"Tell me more about what you’re feeling." Correct
am am am am am am am
"That’s a normal response aſter this type of surgery."
am am am am am am am am
"It will take tme, but, I promise you, you will get over this depression."
am am am am am am am am am am am am am
"Every client who has this surgery feels the same way for about a month."
am am am am am am am am am am am am am
Ratonale: When a client expresses feelings of depression, it is extremely important for the nurse to
am am am am am am am am am am am am am am am
further explore these feelings with the client. In statng, "This is a normal response aſter this type of
am am am am am am am am am am am am am am am am am
surgery" the nurse provides false reassurance and avoids addressing the client’s feelings. "It will take
am am am am am am am am am am am am am am
tme, but, I promise you, you will get over the depression" is also a false reassurance, and it does not
am am am am am am am am am am am am am am am am am am am
encourage the expression of feelings. "Every client who has this surgery feels the same way for about a
am am am am am am am am am am am am am am am am am
month" is a generalizaton that avoids the client’s feelings.
am am am am am am am am
7.ID: 383705009 am
A client in labor experiences spontaneous rupture of the membranes. The nurse immediately counts the
am am am am am am am am am am am am am am
fetal heart rate (FHR) for 1 full minute and then checks the amniotc fluid. The nurse notes that the fluid
am am am am am am am am am am am am am am am am am am am
is yellow and has a strong odor. Which of the following actons should be the nurse’s priority?
am am am am am am am am am am am am am am am am
Contactng the physician Correct am am am
Documentng the findings am am
Checking the fluid for protein am am am am
Contnuing to monitor the client and the FHR am am am am am am am
Ratonale: The FHR is assessed for at least 1 minute when the membranes rupture. The nurse also
am am am am am am am am am am am am am am am am
checks the quantty, color, and odor of the amniotc fluid. The fluid should be clear (oſten with bits of
am am am am am am am am am am am am am am am am am am
vernix) and have a mild odor. Fluid with a foul or strong odor, cloudy appearance, or yellow coloraton
am am am am am am am am am am am am am am am am am
suggests chorioamnionits and warrants notfying the physician. A large amount of vernix in the fluid
am am am am am am am am am am am am am am
suggests that the fetus is preterm. Greenish, meconium-stained fluid may be seen in cases of posterm
am am am am am am am am am am am am am am am
gestaton or placental insufficiency. Checking the fluid for protein is not associated with the data in the
am am am am am am am am am am am am am am am am
queston. Although the nurse would contnue to monitor the client and the FHR and would document
am am am am am am am am am am am am am am am
the findings, contactng the physician is the priority.
am am am am am am am
8.ID: 383705011 am
A nurse has assisted a physician in insertng a central venous access device into a client with a diagnosis
am am am am am am am am am am am am am am am am am am
of severe malnutriton who will be receiving parenteral nutriton (PN). Aſter inserton of the catheter,
am am am am am am am am am am am am am am
the nurse immediately plans to:
am am am am
Call the radiography department to obtain a chest x-ray Correct
am am am am am am am am am
Check the client's blood glucose level to serve as a baseline measurement
am am am am am am am am am am am
Downloaded by Lexiz Gichbuoy () am am am am
