HESI comp exam 1
A 6-year-old child is alert by quiet Rhinorrhoea or otorrhoea with Halo sign
when brought the the ER with
periorbital ecchymosis and Raccoon eyes (periorbital ecchymosis) and Battle's sign (ecchymosis
ecchymosis behind the ears. The behind the ears over mastoid process) are both signs of a basilar skill
nurse suspects potential child fracture. Nurse should assess possible meningeal tear that manifest as
abuse and continues to assess the a Halo sign with CSF leakage from ears or nose.
child for additional manifestations
of a basilar skull fracture. What
assessment finding would be
consistent with a basilar skull
fracture?
A 9-year-old is hospitalized for "To protect you because you can get an infection very easily"
neutropenia and is placed in
reverse isolation. The child asks the Reverse isolation precaution implement measures to protect the client
nurse, "Why do you have to wear a from exposure to microorganism from others.
gown and mask when you are in my
room?" How should the nurse
respond?
Page 1
, HESI comp exam 1
A 16-year-old male client is Obtain the permission of the custodial parent for the surgery.
admitted to the hospital after falling
off a bike and sustaining a fractured Pt is a minor and cannot legally sign his own consent unless he is an
bone. The HCP explains the surgery emancipated minor. Consent should be obtained from the guardian,
needed to immobilize the fracture. custodial parent.
Which action should be
implemented to obtain a valid
informed consent?
A nurse with Marfan's syndrome who is postmenopausal
A 56-year-old female client is
receiving intracavitary radiation via
Poses a radiation hazard while source is in place. Marfan's is not
a radium implant. Which nurse
effected. Goal is to limit any one staff member's exposure to the
should be assigned to care for this
calculated time span based on the half-life of radium, such as the
client?
number of minutes at the bedside per day
A 63-year-old female client whose Denial related to the loss of a loved one
husband died one month ago is
seen in the psychiatric clinic. Her Exhibits symptoms of anxiety and the pain is too great for her to
daughter tells the nurse that her acknowledge, so is denying the situation. Using it as a defense
mother is eating poorly, sleeps very mechanism
little at night, and continues to set
the table for her deceased
husband. What nursing problem
best describes this problem?
Page 2
, HESI comp exam 1
An 80-year old client is given Tricyclic antidepressants
morphine sulfate for post-op pain.
Which concomitant med should the Drugs with anticholinergic properties can exacerbate urinary retention
nurse question that poses a associated with opioids in the older client.
potential development of urinary
retention in this geriatric client?
After 1 month of short-term Erythrocyte sedimentation rate
corticosteroid therapy, a client with
an acute exacerbation of ESR is indicative of active inflammation, so the RN should determine if
rheumatoid arthritis returns to the it has normalized.
clinic for a follow-up visit. Which
laboratory finding should the nurse
review for a therapeutic response?
Close your eyelids
After eye drops are instilled, which
instruction should the nurse
Gently closing eyelids without blinking allows med to spread over the
provide to the client?
eye. Pt can tilt head back during admin
After receiving report, the nurse The client who has a new onset of difficulty breathing
prioritizes the client care
assignment. Which client should the Maslow's hierarchy of needs (ABC's - airway, breathing, circulation)
nurse assess first?
Page 3
, HESI comp exam 1
A child is receiving maintainance 61
intravenous (IV) fluids at the rate of
1000 mL for the first 10 kg of body 1-10 kg, 100 ml/kg/day; or 10-20 kg, 1000 ml for the first 10 kg plus's
weight, plus 50 mL/kg per day for 50ml/kg/day for each kg between 10 and 20. To determine hourly,
each kg between 10 and 20. How divide mL/day by 24. 19.5 kg x 50 mg/kg = 475 ml + 1000 ml = 1475 ml /
many mL/hour should the nurse 24 hours = 61 ml/hour
program the infusion pump for a
child who weights 19.5 kg?
A child with bacterial conjunctivitis Avoid sharing towels and washcloths with siblings
receives a prescription for
erythromycin eye drops. Which avoids the spread of bacterial infection. Should also stay home from
information is most important for school for first 24 hours after antibiotics start; take Tylenol for pain,
the nurse to include in the teaching sunglasses, warm compresses all true but not most important
plan?
A child with Tetralogy of Fallot Place child in knee-chest compression
suffers a hypercyanotic episode.
Which immediate action by the on back in knee-chest position to increase blood vessel resistance. It
nurse can lessen the symptoms of reduces the rush of blood through the septal hole and improves blood
this " TET" spell? circulation
Page 4
A 6-year-old child is alert by quiet Rhinorrhoea or otorrhoea with Halo sign
when brought the the ER with
periorbital ecchymosis and Raccoon eyes (periorbital ecchymosis) and Battle's sign (ecchymosis
ecchymosis behind the ears. The behind the ears over mastoid process) are both signs of a basilar skill
nurse suspects potential child fracture. Nurse should assess possible meningeal tear that manifest as
abuse and continues to assess the a Halo sign with CSF leakage from ears or nose.
child for additional manifestations
of a basilar skull fracture. What
assessment finding would be
consistent with a basilar skull
fracture?
A 9-year-old is hospitalized for "To protect you because you can get an infection very easily"
neutropenia and is placed in
reverse isolation. The child asks the Reverse isolation precaution implement measures to protect the client
nurse, "Why do you have to wear a from exposure to microorganism from others.
gown and mask when you are in my
room?" How should the nurse
respond?
Page 1
, HESI comp exam 1
A 16-year-old male client is Obtain the permission of the custodial parent for the surgery.
admitted to the hospital after falling
off a bike and sustaining a fractured Pt is a minor and cannot legally sign his own consent unless he is an
bone. The HCP explains the surgery emancipated minor. Consent should be obtained from the guardian,
needed to immobilize the fracture. custodial parent.
Which action should be
implemented to obtain a valid
informed consent?
A nurse with Marfan's syndrome who is postmenopausal
A 56-year-old female client is
receiving intracavitary radiation via
Poses a radiation hazard while source is in place. Marfan's is not
a radium implant. Which nurse
effected. Goal is to limit any one staff member's exposure to the
should be assigned to care for this
calculated time span based on the half-life of radium, such as the
client?
number of minutes at the bedside per day
A 63-year-old female client whose Denial related to the loss of a loved one
husband died one month ago is
seen in the psychiatric clinic. Her Exhibits symptoms of anxiety and the pain is too great for her to
daughter tells the nurse that her acknowledge, so is denying the situation. Using it as a defense
mother is eating poorly, sleeps very mechanism
little at night, and continues to set
the table for her deceased
husband. What nursing problem
best describes this problem?
Page 2
, HESI comp exam 1
An 80-year old client is given Tricyclic antidepressants
morphine sulfate for post-op pain.
Which concomitant med should the Drugs with anticholinergic properties can exacerbate urinary retention
nurse question that poses a associated with opioids in the older client.
potential development of urinary
retention in this geriatric client?
After 1 month of short-term Erythrocyte sedimentation rate
corticosteroid therapy, a client with
an acute exacerbation of ESR is indicative of active inflammation, so the RN should determine if
rheumatoid arthritis returns to the it has normalized.
clinic for a follow-up visit. Which
laboratory finding should the nurse
review for a therapeutic response?
Close your eyelids
After eye drops are instilled, which
instruction should the nurse
Gently closing eyelids without blinking allows med to spread over the
provide to the client?
eye. Pt can tilt head back during admin
After receiving report, the nurse The client who has a new onset of difficulty breathing
prioritizes the client care
assignment. Which client should the Maslow's hierarchy of needs (ABC's - airway, breathing, circulation)
nurse assess first?
Page 3
, HESI comp exam 1
A child is receiving maintainance 61
intravenous (IV) fluids at the rate of
1000 mL for the first 10 kg of body 1-10 kg, 100 ml/kg/day; or 10-20 kg, 1000 ml for the first 10 kg plus's
weight, plus 50 mL/kg per day for 50ml/kg/day for each kg between 10 and 20. To determine hourly,
each kg between 10 and 20. How divide mL/day by 24. 19.5 kg x 50 mg/kg = 475 ml + 1000 ml = 1475 ml /
many mL/hour should the nurse 24 hours = 61 ml/hour
program the infusion pump for a
child who weights 19.5 kg?
A child with bacterial conjunctivitis Avoid sharing towels and washcloths with siblings
receives a prescription for
erythromycin eye drops. Which avoids the spread of bacterial infection. Should also stay home from
information is most important for school for first 24 hours after antibiotics start; take Tylenol for pain,
the nurse to include in the teaching sunglasses, warm compresses all true but not most important
plan?
A child with Tetralogy of Fallot Place child in knee-chest compression
suffers a hypercyanotic episode.
Which immediate action by the on back in knee-chest position to increase blood vessel resistance. It
nurse can lessen the symptoms of reduces the rush of blood through the septal hole and improves blood
this " TET" spell? circulation
Page 4
