HESI comp exam 1:Questions and Answers
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? - ansObtain 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? - ansA 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 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? - ansRhinorrhoea 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 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? - ansDenial 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 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 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? - ans61
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? - ansAvoid 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? - ansPlace 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? - ansDemonstrate 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? - ansMonitor 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? - ansOne 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? - ansHypotension, 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? - ansRubber-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? - ansStop the code
immediately
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? - ansObtain 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? - ansA 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 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? - ansRhinorrhoea 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 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? - ansDenial 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 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 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? - ans61
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? - ansAvoid 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? - ansPlace 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? - ansDemonstrate 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? - ansMonitor 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? - ansOne 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? - ansHypotension, 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? - ansRubber-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? - ansStop the code
immediately
