HESI Comprehensive

1. A 2-day postpartum mother who is

breastfeeding asks, "Why do I feel

this tingling in my breasts after the

baby sucks for a few minutes?"

Which information should the nurse

provide?

A. This feeling occurs during feeding

with a breast infection.

B. This sensation occurs as breast

milk moves to the nipple.

C. The baby does not have good

latch-on.

D. The infant is not positioned

correctly.

B. This sensation occurs as breast milk

moves to the nipple.

Rationale:

When the mother's milk comes in,

usually 2 to 3 days after delivery,

women often report they feel a tingling

sensation in their nipples (B) when letdown occurs. (A, C, and D) provide

inaccurate information.

2. A 40-year-old office worker who is

at 36 weeks' gestation presents to the

occupational health clinic

complaining of a pounding

headache, blurry vision, and swollen

ankles. Which intervention should

the nurse implement first?

A. Check the client's blood

pressure.

B. Teach her to elevate her feet

when sitting.

C. Obtain a 24-hour diet history to

evaluate for the intake of salty

foods.

D. Assess the fetal heart rate.

A. Check the client's blood pressure.

Rationale:

The blood pressure (A) should be

assessed first. Preeclampsia is a

multisystem disorder, and women older

than 35 years and have chronic

hypertension are at increased risk.

Classic signs include headache, visual

changes, edema, recent rapid weight

gain, and elevated blood pressure. (B,

C, and D) can be done if the blood

pressure is normal.

3. A 50-year-old man arrives at the

clinic with complaints of pain on

ejaculation. Which action should the

nurse implement?

A. Teach the client testicular selfexamination (TSE).

B. Assess for the presence of blood

C. Ask about scrotal pain or blood in

the semen.

Rationale:

Orchitis is an acute testicular

inflammation resulting from recurrent

urinary tract infection, recurrent

sexually transmitted disease (STD), or

in the urine.

C. Ask about scrotal pain or blood

in the semen.

D. Inquire about a history of kidney

stones.

an indwelling urethral urinary catheter

causing pain on ejaculation, scrotal

pain, blood in the semen, and penile

discharge, so the nurse should

determine the presence of other

symptoms (C). Although all men

should practice TSE, the client's

symptoms are suggestive of an

inflammatory syndrome rather than

testicular cancer (A). Although

hematuria (B) is associated with renal

disease or calculi (D), the client's pain

is associated with ejaculate, not urine.

4. A 77-year-old female client states

that she has never been so large

around the waist and that she has

frequent periods of constipation.

Colon disease has been ruled out

with a flexible sigmoidoscopy. Which

information should the nurse provide

to this client?

A. As women age, they often become

rounder in the middle because they

do not exercise properly.

B. Further assessment is indicated

because loss of abdominal muscle

tone and constipation do not occur

with aging.

C. With age, more fatty tissue

develops in the abdomen and

decreased intestinal movement can

cause constipation.

D. Because there is no evidence of a

diseased colon, there is no need to

worry about abdominal size.

C. With age, more fatty tissue

develops in the abdomen and

decreased intestinal movement can

cause constipation.

Rationale:

With aging, the abdominal muscles

weaken as fatty tissue is deposited

around the trunk and waist. Slowing

peristalsis also affects the emptying of

the colon, resulting in constipation (C).

(A) is not the primary reason for the

changes in body structure. (B) is not

indicated because loss of muscle tone

and constipation are age-related

changes. (D) dismisses the client's

concerns and does not help her

understand the changes that she is

experiencing.

5. According to Erikson, which client

should the nurse identify as having

difficulty completing the

developmental stage of older adults?

D. A 75-year-old woman who wishes

her friends were still alive so she could

change some of the choices she made

over the years

A. A 60-year-old man who tells the

nurse that he is feeling fine and

really does not need any help from

anyone

B. A 78-year-old widower who has

come to the mental health clinic for

counseling after the recent death of

his wife

C. An 81-year-old woman who states

that she enjoys having her

grandchildren visit but is usually

glad when they go home

D. A 75-year-old woman who wishes

her friends were still alive so she

could change some of the choices she

made over the years

Rationale:

The older woman who wishes she

could change the choices she has made

in her lifetime is expressing despair

and is still searching for integrity (D).

The nurse uses Erikson stages of

development over the life span to

assess an older client's adjustment to

aging and plans teaching strategies to

assist the clients attain integrity versus

despair. (A, B, and C) are normal

developmental tasks of older adults.

6. After administration of an 0730 dose

of Humalog 50/50 insulin to a client

with diabetes mellitus, which nursing

action has the highest priority?

A. Ensure that the client receives

breakfast within 30 minutes.

B. Remind the client to have a

midmorning snack at 1000.

C. Discuss the importance of a

midafternoon snack with the client.

D. Explain that the client's capillary

glucose will be checked at 1130.

A. Ensure that the client receives

breakfast within 30 minutes.

Rationale:

Insulin 50/50 contains 50% regular

and 50% NPH insulin. Therefore, the

onset of action is within 30 minutes

and the nurse's priority action is to

ensure that the client receives a

breakfast tray to avoid a hypoglycemic

reaction (A). (B, C, and D) are also

important nursing actions but are of

less immediacy than (A).

7. The antigout medication allopurinol

(Zyloprim) is prescribed for a client newly

diagnosed with gout. Which comment by

the client warrants intervention by the

nurse?

A. "I take aspirin for my pain."

B. "I frequently eat fruit and drink fruit

juices."

C. "I drink a great deal of water, so I have

to get up at night to urinate."

D. "I observe my skin daily to see if I have

A. "I take aspirin for my pain."

Rationale:

The client should be taught to

avoid aspirin (A) because the

ingestion of aspirin or diuretics

can precipitate an attack of

gout. (B, C, and D) are all

appropriate for the treatment of

gout. The client's urinary pH

can be increased by the intake

of alkaline ash foods, such as

an allergic rash to the medication." citrus fruits and juices, which

will help reduce stone

formation (B). Increasing fluids

helps prevent urinary calculi

(stone) formation and should

be encouraged, even if the

client must get up at night to

urinate (C). Allopurinol has a

rare but potentially fatal

hypersensitivity syndrome,

which is characterized by a

rash and fever. The medication

should be discontinued

immediately if this occurs (D).

8. Because of census overload, the charge

nurse of an acute care medical unit must

select a client who can be transferred back

to a residential facility. The client with

which symptomology is the most stable?

A. A stage 3 sacral pressure ulcer, with

colonized methicillin-resistant

Staphylococcus aureus (MRSA)

B. Pneumonia, with a sputum culture of

gram-negative bacteria

C. Urinary tract infection, with positive

blood cultures

D. Culture of a diabetic foot ulcer shows

gram-positive cocci

A. A stage 3 sacral pressure

ulcer, with colonized

methicillin-resistant

Staphylococcus aureus

(MRSA)

Rationale:

The client with colonized

MRSA (A) is the most stable

client, because colonization

does not cause symptomatic

disease. The gram-negative

organisms causing pneumonia

are typically resistant to drug

therapy (B), which makes

recovery very difficult. Positive

blood cultures (C) indicate a

systemic infection. Poor

circulation places the diabetic

with an infected ulcer (D) at

high risk for poor healing and

bone infection.

9. The charge nurse of a 16-bed medical unit is

making 0700 to 1900 shift assignments. The

team consists of two RNs, two PNs, and two

UAP. Which assignment is the most

B. Assign the UAPs to take

vital signs and obtain daily

weights.

Rationale:

effective use of the available team

members?

A. Assign the PNs to perform am care and

assist with feeding the clients.

B. Assign the UAPs to take vital signs and

obtain daily weights.

C. Assign the RNs to answer the call lights

and administer all medications.

D. Assign the PNs to assist health care

providers on rounds and perform

glucometer checks.

A UAP can take vital signs and

daily weights on stable clients

(B). UAPs can perform am care

and feed clients, which is a

better use of personnel than

assigning the task to the PN

(A). All team members can

answer call lights and PNs can

administer some of the

medications, so assigning the

RN (C) these tasks is not an

effective use of the available

personnel. The RN is the best

team member to assist on

rounds (D), and the UAP can

perform glucometer checks, so

assigning the PN these tasks is

not an effective use of

available personnel.

10. The charge nurse of a medical

surgical unit is alerted to an

impending disaster requiring

implementation of the

hospital's disaster plan.

Specific facts about the nature

of this disaster are not yet

known. Which instruction

should the charge nurse give

to the other staff members at

this time?

A. Prepare to evacuate the

unit, starting with the

bedridden clients.

B. UAPs should report to the

emergency center to handle

transports.

C. The licensed staff should

begin counting wheelchairs

and IV poles on the unit.

D. Continue with current

assignments until more

instructions are received.

Rationale:

When faced with an impending

disaster, hospital personnel

may be alerted but should

continue with current client

care assignments until further

instructions are received (D).

Evacuation is typically a

response of last resort that

begins with clients who are

most able to ambulate (A). (B)

is premature and is likely to

increase the chaos if incoming

casualties are anticipated. (C)

is poor utilization of personnel.

D. Continue with current

assignments until more

instructions are received.

11. The charge nurse overhears a

staff member asking for a

doughnut from

a client's meal

tray. Which action should the

charge nurse implement?

A. Advise the client that food

from the meal tray should not

be shared with others.

B. Leave the room and discuss

the incident privately with the

staff member.

C. Objectively document the

situation as observed on a

variance report.

D. Call the nurse

-manager to

the client's room immediately.

B. Leave the room and discuss

the incident privately with the

staff member.

Rationale:

Discussing the incident

privately (B) promotes open

communication between the

charge nurse and staff

member. The client is free to

share unwanted food (A) with

family or friends, but the

employee should not ask for

the client's food. (C) is not

necessary, and the charge

nurse can respond to this

situation without implementing

(D).

12. The charge nurse working in

the surgical department is

making shift assignments. The

shift personnel include an RN

with 12 years of nursing

experience, an RN with 2

years of nursing experience,

and an RN with 3 months of

nursing experience. Which

client should the charge nurse

assign to the RN with 3

months of experience?

A. A client who is 2 days

postoperative with

a right

total knee replacement

B.

A client who is scheduled

for a sigmoid colostomy

surgery today

C.

A client who has

a surgical

A. A client who is 2 days

postoperative with

a right total

knee replacement

Rationale:

(A) is the least critical client

and should be assigned to the

RN with the least experience.

A client with a knee

replacement is probably

ambulating and able to

perform self-care, and a

physical therapist is likely to

be assisting with the client's

care. (B) will require a high

level of nursing care when

returned from surgery. (C)

means that there is

a separation

or rupture of the wound, which

requires an experienced nurse

abdominal wound with

dehiscence

D. A client who is 1 day

postoperative following a

right-sided mastectomy

to provide care. (D) requires

extensive teaching and should

be assigned to a more

experienced nurse.

13. A child is having a generalized

tonic-clonic seizure. Which

action should the nurse take?

A. Move objects out of the

child's immediate area.

B. Quickly slip soft restraints

on the child's wrists.

C. Insert a padded tongue

blade between the teeth.

D. Place in the recovery

position before going for help.

A. Move objects out of the

child's immediate area.

Rationale:

The first priority during a

seizure is to provide a safe

environment, so the nurse

should clear the area (A) to

reduce the risk of trauma. The

child should not be restrained

(B) because this may cause

more trauma. Objects should

not be placed in the child's

mouth (C) because it may pose

a choking hazard. Although

(D) should be implemented

after the seizure, the nurse

should not leave the child

during a seizure to get help.