HESI Comprehensive Exit Exam 1 (And Rationale)
1. 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 Ans: D
(Neurological vital signs include serial assessments of TPR, blood pressure, and
components of the Glasgow coma scale (GCS), which includes verbal, muscu-
loskeletal, 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.)
2. 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 Ans: 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.)
3. A client who has active tuberculosis (TB) is admitted to the medical unit.
What action is most important for the nurse to implement?
a. Place an isolation cart in the hallway.
b. Fit the client with a respirator mask.
c. Don a clean gown for client care.
d. Assign the client to a negative air-flow room Ans: D
,(Active tuberculosis requires implementation of airborne precautions, so the client
should be assigned to a negative pressure air-flow room. Although isolation gowns
and isolation carts should be implemented for clients in isolation with contact
precautions, it is most important that air flow from the room is minimized when the
client has TB. The respirator mask should be implemented when the client leaves
the isolation environment.)
4. The nurse is planning to conduct nutritional assessments and diet teaching
to clients at a family health clinic. Which individual has the greatest nutritional
and energy demands?
a. A pregnant woman.
b. A teenager beginning puberty.
c. A 3-month-old infant.
d. A school-aged child Ans: A
A pregnant woman's metabolic demands are 20 to 24% more than the basic meta-
bolic rate. The other clients require only 15 to 20% more than the basic metabolic
rate.
5. What nursing delivery of care provides the nurse to plan and direct care of
a group of clients over a 24-hour period?
a. Team nursing.
b. Primary nursing.
c. Case management.
d. Functional nursing Ans: B
(Primary nursing is a model of delivery of care where a nurse is accountable for
planning care for clients around the clock. Functional nursing is a care delivery model
, that provides client care by assignment of functions or tasks. Team nursing is a care
delivery model where assignments to a group of clients are provided by a mixed-staff
team. Case management is the delivery of care that uses a collaborative process of
assessment, planning, facilitation, and advocacy for options and services to meet
an individual's health needs and promote quality cost-effective outcomes.)
6. Which approach should the nurse use when preparing a toddler for a
procedure?
a. Demonstrate the procedure using a doll.
b. Avoid asking the child to make choices.
c. Plan a teaching session to last about 20 minutes.
d. Show equipment but prevent child from handling it Ans: A
1. 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 Ans: D
(Neurological vital signs include serial assessments of TPR, blood pressure, and
components of the Glasgow coma scale (GCS), which includes verbal, muscu-
loskeletal, 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.)
2. 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 Ans: 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.)
3. A client who has active tuberculosis (TB) is admitted to the medical unit.
What action is most important for the nurse to implement?
a. Place an isolation cart in the hallway.
b. Fit the client with a respirator mask.
c. Don a clean gown for client care.
d. Assign the client to a negative air-flow room Ans: D
,(Active tuberculosis requires implementation of airborne precautions, so the client
should be assigned to a negative pressure air-flow room. Although isolation gowns
and isolation carts should be implemented for clients in isolation with contact
precautions, it is most important that air flow from the room is minimized when the
client has TB. The respirator mask should be implemented when the client leaves
the isolation environment.)
4. The nurse is planning to conduct nutritional assessments and diet teaching
to clients at a family health clinic. Which individual has the greatest nutritional
and energy demands?
a. A pregnant woman.
b. A teenager beginning puberty.
c. A 3-month-old infant.
d. A school-aged child Ans: A
A pregnant woman's metabolic demands are 20 to 24% more than the basic meta-
bolic rate. The other clients require only 15 to 20% more than the basic metabolic
rate.
5. What nursing delivery of care provides the nurse to plan and direct care of
a group of clients over a 24-hour period?
a. Team nursing.
b. Primary nursing.
c. Case management.
d. Functional nursing Ans: B
(Primary nursing is a model of delivery of care where a nurse is accountable for
planning care for clients around the clock. Functional nursing is a care delivery model
, that provides client care by assignment of functions or tasks. Team nursing is a care
delivery model where assignments to a group of clients are provided by a mixed-staff
team. Case management is the delivery of care that uses a collaborative process of
assessment, planning, facilitation, and advocacy for options and services to meet
an individual's health needs and promote quality cost-effective outcomes.)
6. Which approach should the nurse use when preparing a toddler for a
procedure?
a. Demonstrate the procedure using a doll.
b. Avoid asking the child to make choices.
c. Plan a teaching session to last about 20 minutes.
d. Show equipment but prevent child from handling it Ans: A
