HESI comp exam 1
A 6-year-old child is alert by quiet when brought the the ER with periorbital ecchymosis and
ecchymosis behind the ears. The nurse suspects potential child abuse and continues to assess
the child for additional manifestations of a basilar skull fracture. What assessment finding would
be consistent with a basilar skull fracture? - ANS-Rhinorrhoea or otorrhoea with Halo sign
Raccoon eyes (periorbital ecchymosis) and Battle's sign (ecchymosis behind the ears over
mastoid process) are both signs of a basilar skill fracture. Nurse should assess possible
meningeal tear that manifest as a Halo sign with CSF leakage from ears or nose.
A 9-year-old is hospitalized for neutropenia and is placed in reverse isolation. The child asks the
nurse, "Why do you have to wear a gown and mask when you are in my room?" How should the
nurse respond? - ANS-"To protect you because you can get an infection very easily"
Reverse isolation precaution implement measures to protect the client from exposure to
microorganism from others.
A 16-year-old male client is admitted to the hospital after falling off a bike and sustaining a
fractured bone. The HCP explains the surgery needed to immobilize the fracture. Which action
should be implemented to obtain a valid informed consent? - ANS-Obtain the permission of the
custodial parent for the surgery.
Pt is a minor and cannot legally sign his own consent unless he is an emancipated minor.
Consent should be obtained from the guardian, custodial parent.
A 56-year-old female client is receiving intracavitary radiation via a radium implant. Which nurse
should be assigned to care for this client? - ANS-A nurse with Marfan's syndrome who is
postmenopausal
Poses a radiation hazard while source is in place. Marfan's is not effected. 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
A 63-year-old female client whose husband died one month ago is seen in the psychiatric clinic.
Her daughter tells the nurse that her mother is eating poorly, sleeps very little at night, and
continues to set the table for her deceased husband. What nursing problem best describes this
problem? - ANS-Denial related to the loss of a loved one
Exhibits symptoms of anxiety and the pain is too great for her to acknowledge, so is denying the
situation. Using it as a defense mechanism
,A child is receiving maintainance intravenous (IV) fluids at the rate of 1000 mL for the first 10 kg
of body weight, plus 50 mL/kg per day for each kg between 10 and 20. How many mL/hour
should the nurse program the infusion pump for a child who weights 19.5 kg? - ANS-61
1-10 kg, 100 ml/kg/day; or 10-20 kg, 1000 ml for the first 10 kg plus's 50ml/kg/day for each kg
between 10 and 20. To determine hourly, divide mL/day by 24. 19.5 kg x 50 mg/kg = 475 ml +
1000 ml = 1475 ml / 24 hours = 61 ml/hour
A child with bacterial conjunctivitis receives a prescription for erythromycin eye drops. Which
information is most important for the nurse to include in the teaching plan? - ANS-Avoid sharing
towels and washcloths with siblings
avoids the spread of bacterial infection. Should also stay home from school for first 24 hours
after antibiotics start; take Tylenol for pain, sunglasses, warm compresses all true but not most
important
A child with Tetralogy of Fallot suffers a hypercyanotic episode. Which immediate action by the
nurse can lessen the symptoms of this " TET" spell? - ANS-Place child in knee-chest
compression
on back in knee-chest position to increase blood vessel resistance. It reduces the rush of blood
through the septal hole and improves blood circulation
A client assigned to a female practical nurse (PN) needs total morning care and sterile wound
packing with a wet to dry dressing. The PN tells the nurse that she has never performed a
wound packing. Which intervention should the charge nurse implement? - ANS-Demonstrate
the wound care procedure to the PN while the PN assists.
Within scope of practice; bets learning is through demonstration and return demo; allows best
opportunity to learn
A client is admitted to the hospital for alcohol dependency. What is the priority nursing
intervention during the first 48 hours following admission? - ANS-Monitor for increased blood
pressure and pulse
will experience withdrawal symptoms (elevated BP, pulse, temp). thiamine (B1) to prevent
korsakoff's is secondary
A client is admitted to the hospital with a diagnosis of Type 2 diabetes mellitus and influenza.
Which categories of illness should the nurse develop goals for the client's plan of care? -
ANS-One chronic and one acute illness
Adult onset DM is life-long chronic disease. Influenza is acute illness with short term duration.
, A client is admitted with a medical diagnosis of Addisonian crisis. When completing the
admission assessment, the nurse expects this client to exhibit which clinical manifestations? -
ANS-Hypotension, rapid weak pulse, and rapid respiratory rate.
often the manifestations of shock and at risk of circulatory collapse and shock.
A client is being admitted to the medical unit from the emergency department after having a
chest tube inserted. What equipment should be brought to this client's room? -
ANS-Rubber-tipped clamps
should be kept at the bedside for assessment of possible chest tube air leaks, with the
prescription of the healthcare provider.
A client is brought into the ED following a sudden cardiac arrest. A full code is started. 5 mins
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 next? - ANS-Stop the code immediately
it documents the clients wishes and supersedes wishes of medical staff -- client wishes are most
important
A client is receiving atenolol (Tenormin) 25 mg PO after a MI. The nurse determines the client's
apical pulse is 65 bpm. What action should the nurse implement next? - ANS-Administer the
medication
Apical pulse is >60 bpm
A client who has active TB is admitted to the medical unit. What action is most important for the
nurse to implement? - ANS-Assign the client to a negative air-flow room
active TB requires airborne precautions
A client who is one week postoperative after an aortic valve replacement suddenly develops
severe pain in the left leg. On assessment, the nurse determines that the client's leg is pale and
cool, and no pulses are palpable in the left leg. After notifying the healthcare provider, which
action should the nurse take? - ANS-Keep the client in bed in the supine position
common post-op complication (arterial occlusion from a clot) which requires anticoagulant
therapy to prevent further enlargement of the thrombus and reduce the risk of embolization
A client who is taking clonidine ( Catapres, Duraclon) reports drowsiness. Which additional
assessment should the nurse make? - ANS-How long has the client been taking the
medication?
A 6-year-old child is alert by quiet when brought the the ER with periorbital ecchymosis and
ecchymosis behind the ears. The nurse suspects potential child abuse and continues to assess
the child for additional manifestations of a basilar skull fracture. What assessment finding would
be consistent with a basilar skull fracture? - ANS-Rhinorrhoea or otorrhoea with Halo sign
Raccoon eyes (periorbital ecchymosis) and Battle's sign (ecchymosis behind the ears over
mastoid process) are both signs of a basilar skill fracture. Nurse should assess possible
meningeal tear that manifest as a Halo sign with CSF leakage from ears or nose.
A 9-year-old is hospitalized for neutropenia and is placed in reverse isolation. The child asks the
nurse, "Why do you have to wear a gown and mask when you are in my room?" How should the
nurse respond? - ANS-"To protect you because you can get an infection very easily"
Reverse isolation precaution implement measures to protect the client from exposure to
microorganism from others.
A 16-year-old male client is admitted to the hospital after falling off a bike and sustaining a
fractured bone. The HCP explains the surgery needed to immobilize the fracture. Which action
should be implemented to obtain a valid informed consent? - ANS-Obtain the permission of the
custodial parent for the surgery.
Pt is a minor and cannot legally sign his own consent unless he is an emancipated minor.
Consent should be obtained from the guardian, custodial parent.
A 56-year-old female client is receiving intracavitary radiation via a radium implant. Which nurse
should be assigned to care for this client? - ANS-A nurse with Marfan's syndrome who is
postmenopausal
Poses a radiation hazard while source is in place. Marfan's is not effected. 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
A 63-year-old female client whose husband died one month ago is seen in the psychiatric clinic.
Her daughter tells the nurse that her mother is eating poorly, sleeps very little at night, and
continues to set the table for her deceased husband. What nursing problem best describes this
problem? - ANS-Denial related to the loss of a loved one
Exhibits symptoms of anxiety and the pain is too great for her to acknowledge, so is denying the
situation. Using it as a defense mechanism
,A child is receiving maintainance intravenous (IV) fluids at the rate of 1000 mL for the first 10 kg
of body weight, plus 50 mL/kg per day for each kg between 10 and 20. How many mL/hour
should the nurse program the infusion pump for a child who weights 19.5 kg? - ANS-61
1-10 kg, 100 ml/kg/day; or 10-20 kg, 1000 ml for the first 10 kg plus's 50ml/kg/day for each kg
between 10 and 20. To determine hourly, divide mL/day by 24. 19.5 kg x 50 mg/kg = 475 ml +
1000 ml = 1475 ml / 24 hours = 61 ml/hour
A child with bacterial conjunctivitis receives a prescription for erythromycin eye drops. Which
information is most important for the nurse to include in the teaching plan? - ANS-Avoid sharing
towels and washcloths with siblings
avoids the spread of bacterial infection. Should also stay home from school for first 24 hours
after antibiotics start; take Tylenol for pain, sunglasses, warm compresses all true but not most
important
A child with Tetralogy of Fallot suffers a hypercyanotic episode. Which immediate action by the
nurse can lessen the symptoms of this " TET" spell? - ANS-Place child in knee-chest
compression
on back in knee-chest position to increase blood vessel resistance. It reduces the rush of blood
through the septal hole and improves blood circulation
A client assigned to a female practical nurse (PN) needs total morning care and sterile wound
packing with a wet to dry dressing. The PN tells the nurse that she has never performed a
wound packing. Which intervention should the charge nurse implement? - ANS-Demonstrate
the wound care procedure to the PN while the PN assists.
Within scope of practice; bets learning is through demonstration and return demo; allows best
opportunity to learn
A client is admitted to the hospital for alcohol dependency. What is the priority nursing
intervention during the first 48 hours following admission? - ANS-Monitor for increased blood
pressure and pulse
will experience withdrawal symptoms (elevated BP, pulse, temp). thiamine (B1) to prevent
korsakoff's is secondary
A client is admitted to the hospital with a diagnosis of Type 2 diabetes mellitus and influenza.
Which categories of illness should the nurse develop goals for the client's plan of care? -
ANS-One chronic and one acute illness
Adult onset DM is life-long chronic disease. Influenza is acute illness with short term duration.
, A client is admitted with a medical diagnosis of Addisonian crisis. When completing the
admission assessment, the nurse expects this client to exhibit which clinical manifestations? -
ANS-Hypotension, rapid weak pulse, and rapid respiratory rate.
often the manifestations of shock and at risk of circulatory collapse and shock.
A client is being admitted to the medical unit from the emergency department after having a
chest tube inserted. What equipment should be brought to this client's room? -
ANS-Rubber-tipped clamps
should be kept at the bedside for assessment of possible chest tube air leaks, with the
prescription of the healthcare provider.
A client is brought into the ED following a sudden cardiac arrest. A full code is started. 5 mins
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 next? - ANS-Stop the code immediately
it documents the clients wishes and supersedes wishes of medical staff -- client wishes are most
important
A client is receiving atenolol (Tenormin) 25 mg PO after a MI. The nurse determines the client's
apical pulse is 65 bpm. What action should the nurse implement next? - ANS-Administer the
medication
Apical pulse is >60 bpm
A client who has active TB is admitted to the medical unit. What action is most important for the
nurse to implement? - ANS-Assign the client to a negative air-flow room
active TB requires airborne precautions
A client who is one week postoperative after an aortic valve replacement suddenly develops
severe pain in the left leg. On assessment, the nurse determines that the client's leg is pale and
cool, and no pulses are palpable in the left leg. After notifying the healthcare provider, which
action should the nurse take? - ANS-Keep the client in bed in the supine position
common post-op complication (arterial occlusion from a clot) which requires anticoagulant
therapy to prevent further enlargement of the thrombus and reduce the risk of embolization
A client who is taking clonidine ( Catapres, Duraclon) reports drowsiness. Which additional
assessment should the nurse make? - ANS-How long has the client been taking the
medication?
