EXIT HESI COMPREHENSIVE B EVOLVE
ACTUAL SCRIPT WITH 100 PERCENT
CORRECT ANSWERS
◉ Which intervention is most important when caring for a client
immediately after electroconvulsive therapy (ECT)?A.Reorient the
client to surroundings.
B.Assess blood pressure every 15 minutes.
C.Determine if muscle soreness is present.
D.Maintain a patent airway.
Answer: D
Rationale:
The client is typically unconscious immediately following ECT, and
nausea is a common side effect. The nurse should take measures
to prevent aspiration and maintain a patent airway (D). Patients
may be confused after ECT (A), but reorientation is not as high a
priority as the airway. Although vital signs should be assessed, the
airway is a higher priority (B). Muscle soreness is an expected
finding after ECT (C).
◉ The nurse prepares to administer ophthalmic drops to a client
prior to cataract surgery. List the steps in the order that they
should be implemented from first step to final step.
A. Drop prescribed number of drops into conjunctival sac.
B. Wash hands and apply clean gloves.
,C. Place dominant hand on the client's forehead.
D. Ask the client to close the eye gently.
A. C, B, A, D
B. B, C, A, D
C. A, B, D, C
D. A, C, B, D
Answer: B
Rationale:
Washing hands and applying gloves prior to procedure initiation
prevents the spread of infection (B). Placing the dominant hand
on the client's forehead (C) stabilizes the hand so the nurse can
hold the dropper 1 to 2 cm above the conjunctival sac and drop
the prescribed number of drops (A); asking the client to close the
eye gently helps distribute the medication (D).
◉ A client with bipolar disorder is seen in the mental health clinic
for evaluation of a new medication regimen that includes
risperidone (Risperdal). The nurse notes that the client has
gained 30 lb in the past 3 months. Which assessment is most
important for the nurse to obtain?
A.Compliance with medication regimen
B.Current thyroid-stimulating hormone (TSH) level
C.Occurrence of mania or depression
D.A 24-hour diet and exercise recall
Answer: A
,Rationale:
Medication compliance (A) is most important for the treatment of
psychotic disorders and, because Risperdal is associated with
weight gain, it is probable that the client is complying with the
treatment plan. The TSH level (B) indicates thyroid function,
which regulates basal metabolic rate and influences weight. It is
important to obtain information about occurrences of mania and
depression (C) since the last visit, but if the client is compliant
with the medication regimen, these symptoms are likely to have
been controlled. Diet and exercise (D) should also be assessed, but
weight gain is a likely indicator of medication compliance.
◉ The nurse is caring for a client with chronic renal failure (CRF)
who is receiving dialysis therapy. Which nursing intervention has
the greatest priority when planning this client's care?
A.Palpate for pitting edema.
B.Provide meticulous skin care.
C.Administer phosphate binders.
D.Monitor serum potassium levels.
Answer: D
Rationale:
Clients with CRF are at risk for electrolyte imbalances, and
imbalances in potassium can be life threatening (D). One sign of
fluid retention is pitting edema (A), but it is an expected symptom
of renal failure and is not as high a priority as (D). (B and C) are
common nursing interventions for CRF but not as high a priority
as (D).
, ◉ A client is admitted with a diagnosis of leukemia. This condition
is manifested by which of the following?
A.Fever, elevated white blood count, elevated platelets
B.Fatigue, weight loss and anorexia, elevated red blood cells
C.Hyperplasia of the gums, elevated white blood count, weakness
D.Hypocellular bone marrow aspirate, fever, decreased
hemoglobin level
Answer: C
Rationale:
Hyperplastic gums, weakness, and elevated white blood count are
classic signs of leukemia (C). (A, B, and D) state incorrect
information for symptoms of leukemia.
◉ Which monitored pattern of fetal heart rate alerts the nurse to
seek immediate intervention by the health care provider?
A.Accelerations in response to fetal movement
B.Early decelerations in the second stage of labor
C.Fetal heart rate of 130 beats/min between contractions
D.Late decelerations with absent variability and tachycardia
Answer: D
Rationale:
Late decelerations indicate uteroplacental insufficiency and can
be indicative of complications. When occurring with absent
variability and tachycardia, the situation is ominous (D). 130
beats/min is an expected heart rate (C). The others are not as
critical (A and B).
ACTUAL SCRIPT WITH 100 PERCENT
CORRECT ANSWERS
◉ Which intervention is most important when caring for a client
immediately after electroconvulsive therapy (ECT)?A.Reorient the
client to surroundings.
B.Assess blood pressure every 15 minutes.
C.Determine if muscle soreness is present.
D.Maintain a patent airway.
Answer: D
Rationale:
The client is typically unconscious immediately following ECT, and
nausea is a common side effect. The nurse should take measures
to prevent aspiration and maintain a patent airway (D). Patients
may be confused after ECT (A), but reorientation is not as high a
priority as the airway. Although vital signs should be assessed, the
airway is a higher priority (B). Muscle soreness is an expected
finding after ECT (C).
◉ The nurse prepares to administer ophthalmic drops to a client
prior to cataract surgery. List the steps in the order that they
should be implemented from first step to final step.
A. Drop prescribed number of drops into conjunctival sac.
B. Wash hands and apply clean gloves.
,C. Place dominant hand on the client's forehead.
D. Ask the client to close the eye gently.
A. C, B, A, D
B. B, C, A, D
C. A, B, D, C
D. A, C, B, D
Answer: B
Rationale:
Washing hands and applying gloves prior to procedure initiation
prevents the spread of infection (B). Placing the dominant hand
on the client's forehead (C) stabilizes the hand so the nurse can
hold the dropper 1 to 2 cm above the conjunctival sac and drop
the prescribed number of drops (A); asking the client to close the
eye gently helps distribute the medication (D).
◉ A client with bipolar disorder is seen in the mental health clinic
for evaluation of a new medication regimen that includes
risperidone (Risperdal). The nurse notes that the client has
gained 30 lb in the past 3 months. Which assessment is most
important for the nurse to obtain?
A.Compliance with medication regimen
B.Current thyroid-stimulating hormone (TSH) level
C.Occurrence of mania or depression
D.A 24-hour diet and exercise recall
Answer: A
,Rationale:
Medication compliance (A) is most important for the treatment of
psychotic disorders and, because Risperdal is associated with
weight gain, it is probable that the client is complying with the
treatment plan. The TSH level (B) indicates thyroid function,
which regulates basal metabolic rate and influences weight. It is
important to obtain information about occurrences of mania and
depression (C) since the last visit, but if the client is compliant
with the medication regimen, these symptoms are likely to have
been controlled. Diet and exercise (D) should also be assessed, but
weight gain is a likely indicator of medication compliance.
◉ The nurse is caring for a client with chronic renal failure (CRF)
who is receiving dialysis therapy. Which nursing intervention has
the greatest priority when planning this client's care?
A.Palpate for pitting edema.
B.Provide meticulous skin care.
C.Administer phosphate binders.
D.Monitor serum potassium levels.
Answer: D
Rationale:
Clients with CRF are at risk for electrolyte imbalances, and
imbalances in potassium can be life threatening (D). One sign of
fluid retention is pitting edema (A), but it is an expected symptom
of renal failure and is not as high a priority as (D). (B and C) are
common nursing interventions for CRF but not as high a priority
as (D).
, ◉ A client is admitted with a diagnosis of leukemia. This condition
is manifested by which of the following?
A.Fever, elevated white blood count, elevated platelets
B.Fatigue, weight loss and anorexia, elevated red blood cells
C.Hyperplasia of the gums, elevated white blood count, weakness
D.Hypocellular bone marrow aspirate, fever, decreased
hemoglobin level
Answer: C
Rationale:
Hyperplastic gums, weakness, and elevated white blood count are
classic signs of leukemia (C). (A, B, and D) state incorrect
information for symptoms of leukemia.
◉ Which monitored pattern of fetal heart rate alerts the nurse to
seek immediate intervention by the health care provider?
A.Accelerations in response to fetal movement
B.Early decelerations in the second stage of labor
C.Fetal heart rate of 130 beats/min between contractions
D.Late decelerations with absent variability and tachycardia
Answer: D
Rationale:
Late decelerations indicate uteroplacental insufficiency and can
be indicative of complications. When occurring with absent
variability and tachycardia, the situation is ominous (D). 130
beats/min is an expected heart rate (C). The others are not as
critical (A and B).
