Hesi RN Exit Comprehensive Exam 2021

Here's the actual test bank of the HESI RN exit comprehensive exam.

RN Comprehensive Predictor 2019 Form C

A nurse is caring for a client who has bipolar disorder and is experiencing

acute mania. The nurse obtained a verbal prescription for restraints. Which

of the following should the actions the nurse take?

A. Request a renewal of the prescription every 8 hr.

B. Check the client’s peripheral pulse rate every 30 min

C. Obtain a prescription for restraint within 4 hr.

D. Document the client’s condition every 15 minutes

1. A nursing planning care for a school-age child who is 4 hr

postoperative following perforated appendicitis. Which of the following

actions should the nurse include in the plan of care?

a. Offer small amounts of clear liquids 6 hr following surgery (assess for

gag reflex first)

b. Give cromolyn nebulizer solution every 6 hr (for asthma)

c. Apply a warm compress to the operative site every 4 hr

d. Administer analgesics on a scheduled basis for the first 24 hr

2. A nurse is receiving change-of-shift report for a group of clients.

Which of the following clients should the nurse plan to assess first?

a. A client who has sinus arrhythmia and is receiving cardiac monitoring

b. A client who has diabetes mellitus and a hemoglobin A1C of 6.8%

c. A client who has epidural analgesia and weakness in the lower

extremities

d. A client who has a hip fracture and a new onset of tachypnea

3. A nurse is preparing to apply a transdermal nicotine patch for a

client. Which of the following actions should the nurse tak e?

a. Shave hairy areas of skin prior to application (apply to hairless, clean &

dry areas to promote absorption; avoid oily or broken skin)

b. Wear gloves to apply the patch to the client’s skin

c. Apply the patch within 1 hr of removing it from the protective pouch

(apply immediately)

d. Remove the previous patch and place it in a tissue (fold patch in

half with sticky sides pressed together)

4. A nurse has just received change-of-shift report for four clients.

Which of the following clients should the nurse assess first?

a. A client who was just given a glass of orange juice for a low blood

glucose level

b. A client who is schedule for a procedure in 1 hr (can wait)

c. A client who has 100 mL fluid remaining in his IV bag (can wait)

d. A client who received a pain medication 30 min ago for postoperative

pain

5. A nurse is caring for a client who is receiving intermittent enteral

tube feedings. Which of the following places the client at risk for

aspiration?

a. A history of gastroesophageal reflux disease

b. Receiving a high osmolarity formula

c. Sitting in a high-Fowler’s position during the feeding

d. A residual of 65 mL 1hr postprandial

6. A nurse is reviewing the laboratory results for a client who has

Cushing’s disease. The nurse should expect the client to have an increase

in which of the following laboratory values? a.Serum glucose levelincreased

b. Serum calcium level-decreased

c. Lymphocyte count- decreased immune system.

d. Serum potassium level- decreased

. 8. A nurse is caring for a client who has severe preeclampsia and is

receiving magnesium sulfate intravenously. The nurse discontinues the

magnesium sulfate after the client displaces toxicity. Which of the

following actions should the nurse take?

a. Position the client supine

b. Prepare an IV bolus of dextrose 5% in water

c. Administer methylergonovine IM

d. Administer calcium gluconate IV

Calcium gluconate is given for magnesium sulfate toxicity. Always have an

injectable form of calcium gluconate available when administering

magnesium sulfate by IV.

9. A charge nurse is teaching new staff members about factors that

increase a client’s risk to become violent. Which of the following risk factors

should the nurse include as the best predictor of future violence?

a. Experiencing delusions

b. Male gender

c. Previous violent behavior

d. A history of being in prison

Risk factors also include: past history of aggression, poor impulse control,

and violence. Comorbidity that leads to acts of violence (psychotic

delusions, command hallucinations, violent angry reactions with cognitive

disorders).

Individual Assessment for Violence

10. A nurse is preparing to perform a sterile dressing change. Which of

the following actions should the nurse take when setting up the sterile

field?

a. Place the cap from the solution sterile side up on clean surface

b. Open the outermost flap of the sterile kit toward the body→ flap

AWAY from the body's first

c. Place the sterile dressing within 1.25 cm (0.5in) of the edge of the

sterile field → 2.5 cm (1-inch) border around any sterile drape or wrap

that is considered contaminated.

d. Set up the sterile field 5 cm (2 in) below waist level→ it says BELOW

waist level; should be ABOVE waist level

11. A nurse is providing teaching to an older adult client about methods

to promote nighttime sleep. Which of the following instructions should the

nurse include?

a. Eat a light snack before bedtime

b. Stay in bed at least 1 hr if unable to fall asleep

c. Take a 1 hr nap during the day

d. Perform exercises prior to bedtime

12. A home health nurse is preparing for an initial visit with an older

adult client who lives alone. Which of the following actions should the

nurse take first?

a. Educate the client about current medical diagnosis

b. Refer the client to a meal delivery program

c. Identify environmental hazards in the home

d. Arrange for client transportation to follow-up

appointments Rationale Priority: Assess first.

13. A nurse is assessing the remote memory of an older adult client who

has mild dementia. Which of the following questions should the nurse

ask the client?

a. “Can you tell me who visited you today?”

b. “What high school did you graduate from

c. “Can you list your current medications?”

d. “What did you have for breakfast yesterday?”

14. A nurse is providing teaching to an adolescent who has type 1

diabetes mellitus. Which of the following goals should the nurse include in

the teaching

a. HbA1c level greater than 8%- 6.5 - 8 is the target reference. >

b. Blood glucose level greater than 200 mg/dL at bedtime

c. Blood glucose level less than 60 mg/dL before breakfast- < 70 =

HYPOGLYCEMIC d. HbA1c level less than 7%

15. A nurse is caring for a client who is receiving phenytoin for

management of grand mal seizures and has a new prescription for

isoniazid and rifampin. Which of the following should the nurse

conclude if the client develops ataxia and incoordination?

a. The client is experiencing an adverse reaction to rifampin

b. The client’s seizure disorder is no longer under control

d. The client is having adverse effects due to combination antimicrobial

therapy

16. A nurse is caring for a client who is 1 hr postoperative following

manifestations requires immediate

action by the nurse?

a. Increase in frequency of swallowing→ may indicate bleeding

b. Moderate sanguineous drainage on the drip pad

c. Bruising to the face→ side effect

rhinoplasty. Which of the following

c. The client is showing evidence of phenytoin toxicity

b. Monitor the child’s

d. Absent gag reflex→ possibly due to anesthesia given. (1 hour

postoperative) Rationale “Requires immediate action” choose the worst

possibility that could lead to. ABC

17. A nurse is planning care for a preschool-age child who is in the

acute phase Kawasaki disease. Which of the following interventions

should the nurse include in the plan of care?

a. Give scheduled doses of acetaminophen

every 6 hr

cardiac status

c. Administer antibiotics via intermittent IV bolus for 24 hr

d. Provide stimulation with children of the same age in the playroom