HESI Comprehensive Exit Exam 1 with Rationale.
The nurse is monitoring neurological vital signs for a male client who lost
consciousness after falling and hitting his head. Which assessment finding is the
earliest and most sensitive indication of altered cerebral function? a. Unequal
pupils.
b. Loss of central reflexes.
c. Inability to open the eyes.
d. Change in level of consciousness.: D
(Neurological vital signs include serial assessments of TPR, blood pressure, and
components of the Glasgow coma scale (GCS), which includes verbal,
musculoskeletal, and pupillary responses. A change in the client's level of
consciousness, as indicated by responses to commands during the GCS, is the
first and the most sensitive sign of change in cerebral function. The other
assessment data choices are late signs of altered cerebral function.)
A client is admitted to the hospital for alcohol dependency. What is the priority
nursing intervention during the first 48 hours following admission?
a. Administer thiamine (B1) to prevent Korsakoff's syndrome.
b. Monitor for increased blood pressure and pulse.
c. Administer a PRN benzodiazepine as needed for anxiety.
d. Encourage fluid intake of non-caffeinated beverages.: B
(Clients with alcohol dependency experience withdrawal symptoms, which include
elevated blood pressure, pulse, and temperature, so monitoring these physical
parameters has the highest priority. Administering thiamine will prevent Korsakoff's
syndrome (secondary dementia caused by thiamine deficiency, associated with
malnutrition secondary to excessive alcohol intake, but this intervention does not
have the priority of monitoring vital signs.)
,A client is brought into the emergency department following a sudden cardiac
arrest. A full code is started. Five minutes later the family arrives with a durable
power of attorney signed by the client requesting that no extraordinary measures
be taken, including intubation, to save the client's life. What action should the
nurse take?
a. Stop the code immediately.
b. Continue the code according to protocol.
c. Ask the legal department if the code should be continued.
d. Assess the family's support for the durable power of attorney.: A
(A durable power of attorney documents the client's wishes and supersedes the
wishes of the medical staff. The client's wishes are most important.)
A 16-year-old male client is admitted to the hospital after falling off a bike and
sustaining a fractured bone. The healthcare provider explains the surgery needed
to immobilize the fracture. Which action should be implemented to obtain a valid
informed consent?
a. Instruct the client sign the consent before giving medications.
b. Obtain the permission of the custodial parent for the surgery.
c. Obtain the signature of the client's stepfather for the surgery.
d. Notify the non-custodial parent to also sign a consent form.: B
(The client is a minor and cannot legally sign his own consent unless he is an
emancipated minor, so the consent should be obtained from the guardian for this
client, which is the custodial parent. The client is a minor so this is not a legal
option. A stepparent is not a legal guardian for a minor unless the child has been
adopted by the stepparent. The non-custodial parent does not need to co-sign this
form.)
,A primipara with a breech presentation is in the transition phase of labor. The
nurse visualizes the perineum and sees the umbilical cord extruding from the
introitus. In which position should the nurse place the client? a. Left supine with
thighs flexed on her abdomen.
b. Right lateral side with both legs flexed.
c. Semi-Fowler's with head of bed elevated 30 degrees.
d. Supine with the foot of the bed elevated.: D
(The supine position with the foot of the bed elevated (Trendelenburg) is one
position used to alleviate gravitational pressure by the fetus on the prolapsed
umbilical cord, The other listed positions do not alleviate pressure on the umbilical
cord.)
A 56-year-old female client is receiving intracavitary radiation via a radium implant.
Which nurse should be assigned to care for this client?
a. The nurse who is caring for another client receiving intracavitary radiation.
b. A nurse with Marfan's syndrome who is postmenopausal.
c. A nurse with oncology experience who may be pregnant.
d. The nurse who is caring for another client who has Clostridium difficile.: B
(A client receiving intracavity radiation poses a radiation hazard as long as the
intracavity radiation source is in place. A nurse's ability to care of this client is not
affected by Marfan's syndrome, which is a hereditary disorder of connective
tissues, bones, muscles, ligaments and skeletal structures. The goal is to limit any
one staff member's exposure to the calculated time span based on the half-life of
radium, such as the number of minutes at the bedside per day, so a nurse who is
already caring for a patient with radiation devices should not be assigned.
Pregnant employees should not be exposed to the radiation due to the possible
effect on the fetus. A radiation exposure decreases the immune response in the
client who should not be exposed to the potential inadvertent transmission of an
infectious organism like C. Diff.)
, Which information should the nurse provide a client who has undergone
cryosurgery for Stage 1A cervical cancer?
a. Notify the healthcare provider if heavy vaginal discharge occurs.
b. Use condoms for sexual intercourse during the next week.
c. Flat subclinical mucosal lesions are a common harmless side effect.
d. Use a sanitary napkin instead of a tampon.: D
(Clients should avoid the use of tampons for 3 to 6 weeks after the procedure to
reduce the risk of infection. A heavy, watery vaginal discharge is expected during
this time, so the healthcare provider notification is not necessary. Sexual
intercourse should be avoided for up to 6 weeks. Mucosal lesions are not a side
effect of the procedure but may indicate human papillomavirus or a cancerous
lesion and should be reported.)
A nurse is planning to teach self-care measures to a female client about
prevention of yeast infections. Which instructions should the nurse provide? a.
Use a douche preparation no more than once a month.
b. Increase daily intake of fiber and leafy green vegetables.
c. Select nylon underwear that is loose-fitting, white, and comfortable.
d. Avoid tight-fitting clothing and do not use bubble-bath or bath salts.: D
(A common genital tract infection in females is candidiasis, which is an overgrowth
of the normal vaginal flora of Candida albicans that thrives in an environment that
is warm and moist and is perpetuated by tight-fitting clothing, underwear, or
pantyhose made of nonabsorbent materials. The client should wear clothing that is
loose fitting and absorbent, such as cotton underwear, and avoid using bubble-
bath or bath salts which further irritate sensitive genital tissue. Douching is not
recommended because it can irritate vaginal tissue, alter pH, and contribute to
fungal growth. While increasing dietary fiber intake encourages healthy, nutritional
guidelines, it is not the focus of the teaching. Cotton, not nylon undergarments,
provide absorbancy and reduce moisture in the perineal area.)
The nurse is monitoring neurological vital signs for a male client who lost
consciousness after falling and hitting his head. Which assessment finding is the
earliest and most sensitive indication of altered cerebral function? a. Unequal
pupils.
b. Loss of central reflexes.
c. Inability to open the eyes.
d. Change in level of consciousness.: D
(Neurological vital signs include serial assessments of TPR, blood pressure, and
components of the Glasgow coma scale (GCS), which includes verbal,
musculoskeletal, and pupillary responses. A change in the client's level of
consciousness, as indicated by responses to commands during the GCS, is the
first and the most sensitive sign of change in cerebral function. The other
assessment data choices are late signs of altered cerebral function.)
A client is admitted to the hospital for alcohol dependency. What is the priority
nursing intervention during the first 48 hours following admission?
a. Administer thiamine (B1) to prevent Korsakoff's syndrome.
b. Monitor for increased blood pressure and pulse.
c. Administer a PRN benzodiazepine as needed for anxiety.
d. Encourage fluid intake of non-caffeinated beverages.: B
(Clients with alcohol dependency experience withdrawal symptoms, which include
elevated blood pressure, pulse, and temperature, so monitoring these physical
parameters has the highest priority. Administering thiamine will prevent Korsakoff's
syndrome (secondary dementia caused by thiamine deficiency, associated with
malnutrition secondary to excessive alcohol intake, but this intervention does not
have the priority of monitoring vital signs.)
,A client is brought into the emergency department following a sudden cardiac
arrest. A full code is started. Five minutes later the family arrives with a durable
power of attorney signed by the client requesting that no extraordinary measures
be taken, including intubation, to save the client's life. What action should the
nurse take?
a. Stop the code immediately.
b. Continue the code according to protocol.
c. Ask the legal department if the code should be continued.
d. Assess the family's support for the durable power of attorney.: A
(A durable power of attorney documents the client's wishes and supersedes the
wishes of the medical staff. The client's wishes are most important.)
A 16-year-old male client is admitted to the hospital after falling off a bike and
sustaining a fractured bone. The healthcare provider explains the surgery needed
to immobilize the fracture. Which action should be implemented to obtain a valid
informed consent?
a. Instruct the client sign the consent before giving medications.
b. Obtain the permission of the custodial parent for the surgery.
c. Obtain the signature of the client's stepfather for the surgery.
d. Notify the non-custodial parent to also sign a consent form.: B
(The client is a minor and cannot legally sign his own consent unless he is an
emancipated minor, so the consent should be obtained from the guardian for this
client, which is the custodial parent. The client is a minor so this is not a legal
option. A stepparent is not a legal guardian for a minor unless the child has been
adopted by the stepparent. The non-custodial parent does not need to co-sign this
form.)
,A primipara with a breech presentation is in the transition phase of labor. The
nurse visualizes the perineum and sees the umbilical cord extruding from the
introitus. In which position should the nurse place the client? a. Left supine with
thighs flexed on her abdomen.
b. Right lateral side with both legs flexed.
c. Semi-Fowler's with head of bed elevated 30 degrees.
d. Supine with the foot of the bed elevated.: D
(The supine position with the foot of the bed elevated (Trendelenburg) is one
position used to alleviate gravitational pressure by the fetus on the prolapsed
umbilical cord, The other listed positions do not alleviate pressure on the umbilical
cord.)
A 56-year-old female client is receiving intracavitary radiation via a radium implant.
Which nurse should be assigned to care for this client?
a. The nurse who is caring for another client receiving intracavitary radiation.
b. A nurse with Marfan's syndrome who is postmenopausal.
c. A nurse with oncology experience who may be pregnant.
d. The nurse who is caring for another client who has Clostridium difficile.: B
(A client receiving intracavity radiation poses a radiation hazard as long as the
intracavity radiation source is in place. A nurse's ability to care of this client is not
affected by Marfan's syndrome, which is a hereditary disorder of connective
tissues, bones, muscles, ligaments and skeletal structures. The goal is to limit any
one staff member's exposure to the calculated time span based on the half-life of
radium, such as the number of minutes at the bedside per day, so a nurse who is
already caring for a patient with radiation devices should not be assigned.
Pregnant employees should not be exposed to the radiation due to the possible
effect on the fetus. A radiation exposure decreases the immune response in the
client who should not be exposed to the potential inadvertent transmission of an
infectious organism like C. Diff.)
, Which information should the nurse provide a client who has undergone
cryosurgery for Stage 1A cervical cancer?
a. Notify the healthcare provider if heavy vaginal discharge occurs.
b. Use condoms for sexual intercourse during the next week.
c. Flat subclinical mucosal lesions are a common harmless side effect.
d. Use a sanitary napkin instead of a tampon.: D
(Clients should avoid the use of tampons for 3 to 6 weeks after the procedure to
reduce the risk of infection. A heavy, watery vaginal discharge is expected during
this time, so the healthcare provider notification is not necessary. Sexual
intercourse should be avoided for up to 6 weeks. Mucosal lesions are not a side
effect of the procedure but may indicate human papillomavirus or a cancerous
lesion and should be reported.)
A nurse is planning to teach self-care measures to a female client about
prevention of yeast infections. Which instructions should the nurse provide? a.
Use a douche preparation no more than once a month.
b. Increase daily intake of fiber and leafy green vegetables.
c. Select nylon underwear that is loose-fitting, white, and comfortable.
d. Avoid tight-fitting clothing and do not use bubble-bath or bath salts.: D
(A common genital tract infection in females is candidiasis, which is an overgrowth
of the normal vaginal flora of Candida albicans that thrives in an environment that
is warm and moist and is perpetuated by tight-fitting clothing, underwear, or
pantyhose made of nonabsorbent materials. The client should wear clothing that is
loose fitting and absorbent, such as cotton underwear, and avoid using bubble-
bath or bath salts which further irritate sensitive genital tissue. Douching is not
recommended because it can irritate vaginal tissue, alter pH, and contribute to
fungal growth. While increasing dietary fiber intake encourages healthy, nutritional
guidelines, it is not the focus of the teaching. Cotton, not nylon undergarments,
provide absorbancy and reduce moisture in the perineal area.)
