HESI Comprehensive Exit Exam 1 (And Rati vg vg vg vg vg vg
onale)
1. The nurse is monitoring neurological vital signs for a male clie
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nt who lost consciousness after falling and hitting his head. Whic
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h assessment finding is the earliest and most sensitive indication
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of altered cerebral function?
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a. Unequal pupils. vg
b. Loss of central reflexes. vg vg vg
c. Inability to open the eyes. vg vg vg vg
d. Change in level of consciousness.: D vg vg vg vg vg
(Neurological vital signs include serial assessments of TPR, blood pressure, and components of the G
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lasgow coma scale (GCS), which includes verbal, musculoskeletal, and pupillary responses. A change
vg vg vg vg vg vg vg vg vg vg vg vg vg
in the client's level of consciousness, as indicated by responses to commands during the GCS, is th
vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg
e first and the most sensitive sign of change in cerebral function. The other assessment data choic
vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg
es are late signs of altered cerebral function.)
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2. A nurse is planning to teach self-
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care measures to a female client about prevention of yeast infe
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ctions. Which instructions should the nurse provide?
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a. Use a douche preparation no more than once a month.
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b. Increase daily intake of fiber and leafy green vegetables.
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c. Select nylon underwear that is loose-
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fitting, white, and comfortable. v g v g v g
d. Avoid tight-fitting clothing and do not use bubble-
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bath or bath salts.: D vg vg vg vg
(A common genital tract infection in females is candidiasis, which is an overgrowth of the normal vaginal
vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg
flora of Candida albicans that thrives in an environment that is warm and moist and is perpetuated
vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg
by tight-
vg
fitting clothing, underwear, or pantyhose made of nonabsorbent materials. The client should wear clot
vg vg vg vg vg vg vg vg vg vg vg vg vg
hing that is loose fitting and absorbent, such as cotton underwear, and avoid using bubble-
vg vg vg vg vg vg vg vg vg vg vg vg vg vg
bath or bath salts which further irritate sensitive genital tissue. Douching is not recommended becau
vg vg vg vg vg vg vg vg vg vg vg vg vg vg
se it can irritate vaginal tissue, alter pH, and contribute to fungal growth. While increasing dietary fi
vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg
ber intake encourages healthy, nutritional guidelines, it is not the focus of the teaching. Cotton, not
vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg
vgnylon undergarments, provide absorbancy and reduce moisture in the perineal area.)
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1vg/
vg103
, HESI Comprehensive Exit Exam 1 (And Rati
vg vg vg vg vg vg
onale)
3. A client who has active tuberculosis (TB) is admitted to the med
vg vg vg vg vg vg vg vg vg vg vg
ical unit. What action is most important for the nurse to imple
vg vg vg vg vg vg vg vg vg vg vg
ment?
a. Place an isolation cart in the hallway.
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b. Fit the client with a respirator mask.
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c. Don a clean gown for client care.
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2vg/
vg103
, HESI Comprehensive Exit Exam 1 (And Rati vg vg vg vg vg vg
onale)
d. Assign the client to a negative air-flow room.: Dvg vg vg vg vg vg vg vg
(Active tuberculosis requires implementation of airborne precautions, so the client should be assigned t
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o a negative pressure air-
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flow room. Although isolation gowns and isolation carts should be implemented for clients in isolation
vg vg vg vg vg vg vg vg vg vg vg vg vg vg
with contact precautions, it is most important that air flow from the room is minimized when the client h
vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg
as TB. The respirator mask should be implemented when the client leaves the isolation environment
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.)
4. The nurse is planning to conduct nutritional assessments and di
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et teaching to clients at a family health clinic. Which individual ha
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s the greatest nutritional and energy demands?
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a. A pregnant woman. v g v g
b. A teenager beginning puberty.
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c. A 3-month-old infant.
v g v g
d. A school-aged child.: A
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A pregnant woman's metabolic demands are 20 to 24% more than the basic metabolic rate. The other
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clients require only 15 to 20% more than the basic metabolic rate.
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5. What nursing delivery of care provides the nurse to plan and di
vg vg vg vg vg vg vg vg vg vg vg
rect care of a group of clients over a 24-hour period?
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a. Team nursing. vg
b. Primary nursing. v g
c. Case management. vg
d. Functional nursing.: B v g v g
(Primary nursing is a model of delivery of care where a nurse is accountable for planning care for clie
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nts around the clock. Functional nursing is a care delivery model that provides client care by assign
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ment of functions or tasks. Team nursing is a care delivery model where assignments to a group of
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clients are provided by a mixed-
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statt team. Case management is the delivery of care that uses a collaborative process of assessment
vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg
, planning, facilitation, and advocacy for options and services to meet an individual's health needs an
vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg
d promote quality cost-ettective outcomes.)
vg vg vg vg
3vg/
vg103
, HESI Comprehensive Exit Exam 1 (And Rati
vg vg vg vg vg vg
onale)
6. Which approach should the nurse use when preparing a toddler
vg vg vg vg vg vg vg vg vg
for a proce- dure?
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a. Demonstrate the procedure using a doll.
v g v g v g v g v g
4vg/
vg103
onale)
1. The nurse is monitoring neurological vital signs for a male clie
vg vg vg vg vg vg vg vg vg vg
nt who lost consciousness after falling and hitting his head. Whic
vg vg vg vg vg vg vg vg vg vg
h assessment finding is the earliest and most sensitive indication
vg vg vg vg vg vg vg vg vg
of altered cerebral function?
vg vg vg vg
a. Unequal pupils. vg
b. Loss of central reflexes. vg vg vg
c. Inability to open the eyes. vg vg vg vg
d. Change in level of consciousness.: D vg vg vg vg vg
(Neurological vital signs include serial assessments of TPR, blood pressure, and components of the G
vg vg vg vg vg vg vg vg vg vg vg vg vg vg
lasgow coma scale (GCS), which includes verbal, musculoskeletal, and pupillary responses. A change
vg vg vg vg vg vg vg vg vg vg vg vg vg
in the client's level of consciousness, as indicated by responses to commands during the GCS, is th
vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg
e first and the most sensitive sign of change in cerebral function. The other assessment data choic
vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg
es are late signs of altered cerebral function.)
vg vg vg vg vg vg vg
2. A nurse is planning to teach self-
vg vg vg vg vg vg
care measures to a female client about prevention of yeast infe
vg vg vg vg vg vg vg vg vg vg
ctions. Which instructions should the nurse provide?
vg vg vg vg vg vg
a. Use a douche preparation no more than once a month.
vg vg vg vg vg vg vg vg vg
b. Increase daily intake of fiber and leafy green vegetables.
vg vg vg vg vg vg vg vg
c. Select nylon underwear that is loose-
v g v g v g v g v g
fitting, white, and comfortable. v g v g v g
d. Avoid tight-fitting clothing and do not use bubble-
vg vg vg vg vg vg vg
bath or bath salts.: D vg vg vg vg
(A common genital tract infection in females is candidiasis, which is an overgrowth of the normal vaginal
vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg
flora of Candida albicans that thrives in an environment that is warm and moist and is perpetuated
vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg
by tight-
vg
fitting clothing, underwear, or pantyhose made of nonabsorbent materials. The client should wear clot
vg vg vg vg vg vg vg vg vg vg vg vg vg
hing that is loose fitting and absorbent, such as cotton underwear, and avoid using bubble-
vg vg vg vg vg vg vg vg vg vg vg vg vg vg
bath or bath salts which further irritate sensitive genital tissue. Douching is not recommended becau
vg vg vg vg vg vg vg vg vg vg vg vg vg vg
se it can irritate vaginal tissue, alter pH, and contribute to fungal growth. While increasing dietary fi
vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg
ber intake encourages healthy, nutritional guidelines, it is not the focus of the teaching. Cotton, not
vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg
vgnylon undergarments, provide absorbancy and reduce moisture in the perineal area.)
vg vg vg vg vg vg vg vg vg vg
1vg/
vg103
, HESI Comprehensive Exit Exam 1 (And Rati
vg vg vg vg vg vg
onale)
3. A client who has active tuberculosis (TB) is admitted to the med
vg vg vg vg vg vg vg vg vg vg vg
ical unit. What action is most important for the nurse to imple
vg vg vg vg vg vg vg vg vg vg vg
ment?
a. Place an isolation cart in the hallway.
vg vg vg vg vg vg
b. Fit the client with a respirator mask.
vg vg vg vg vg vg
c. Don a clean gown for client care.
vg vg vg vg vg vg
2vg/
vg103
, HESI Comprehensive Exit Exam 1 (And Rati vg vg vg vg vg vg
onale)
d. Assign the client to a negative air-flow room.: Dvg vg vg vg vg vg vg vg
(Active tuberculosis requires implementation of airborne precautions, so the client should be assigned t
vg vg vg vg vg vg vg vg vg vg vg vg vg
o a negative pressure air-
vg vg vg vg
flow room. Although isolation gowns and isolation carts should be implemented for clients in isolation
vg vg vg vg vg vg vg vg vg vg vg vg vg vg
with contact precautions, it is most important that air flow from the room is minimized when the client h
vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg
as TB. The respirator mask should be implemented when the client leaves the isolation environment
vg vg vg vg vg vg vg vg vg vg vg vg vg vg
.)
4. The nurse is planning to conduct nutritional assessments and di
vg vg vg vg vg vg vg vg vg
et teaching to clients at a family health clinic. Which individual ha
vg vg vg vg vg vg vg vg vg vg vg
s the greatest nutritional and energy demands?
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a. A pregnant woman. v g v g
b. A teenager beginning puberty.
vg vg vg
c. A 3-month-old infant.
v g v g
d. A school-aged child.: A
vg vg vg
A pregnant woman's metabolic demands are 20 to 24% more than the basic metabolic rate. The other
vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg
clients require only 15 to 20% more than the basic metabolic rate.
vg vg vg vg vg vg vg vg vg vg vg
5. What nursing delivery of care provides the nurse to plan and di
vg vg vg vg vg vg vg vg vg vg vg
rect care of a group of clients over a 24-hour period?
vg vg vg vg vg vg vg vg vg vg
a. Team nursing. vg
b. Primary nursing. v g
c. Case management. vg
d. Functional nursing.: B v g v g
(Primary nursing is a model of delivery of care where a nurse is accountable for planning care for clie
vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg
nts around the clock. Functional nursing is a care delivery model that provides client care by assign
vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg
ment of functions or tasks. Team nursing is a care delivery model where assignments to a group of
vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg v
clients are provided by a mixed-
g vg vg vg vg vg
statt team. Case management is the delivery of care that uses a collaborative process of assessment
vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg
, planning, facilitation, and advocacy for options and services to meet an individual's health needs an
vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg
d promote quality cost-ettective outcomes.)
vg vg vg vg
3vg/
vg103
, HESI Comprehensive Exit Exam 1 (And Rati
vg vg vg vg vg vg
onale)
6. Which approach should the nurse use when preparing a toddler
vg vg vg vg vg vg vg vg vg
for a proce- dure?
vg vg vg vg
a. Demonstrate the procedure using a doll.
v g v g v g v g v g
4vg/
vg103
