HESI Comprehensive B Practice

1 An 8-year-old child is receiving

. digoxin (Lanoxin) for congestive heart

failure (CHF). In assessing the child,

the nurse finds that her apical heart

rate is 80 beats/min, she complains of

being slightly nauseated, and her

serum digoxin level is 1.2 ng/mL.

What action should the nurse take?

A.Because the child's heart rate and

digoxin level are within normal range,

assess for the cause of the nausea.

B.Hold the next dose of digoxin until

the health care provider can be

notified because the serum digoxin

level is elevated.

C.Administer the next dose of digoxin

and notify the health care provider

that the child is showing signs of

toxicity.

D.Notify the health care provider that

the child's pulse rate is below normal

for her age group.

2 A 12-year-old boy complains to the

. nurse that he is "short" (4'5" [53

inches]). His twin sister is 5 inches

taller than he is (4'10" [58 inches]).

Based on these findings, what

conclusion should the nurse reach?

A.The boy is not growing as normally

expected.

B.The girl is experiencing a period of

unexpected growth.

C.A normal growth spurt occurs in

girls 1 to 2 years earlier than boys.

D.Male-female twins are not identical;

therefore, their growth cannot be

A

Rationale:

Nausea and vomiting are early signs

of digoxin toxicity. However, the

normal resting heart rate for a child

8 to 10 years of age is 70 to 110

beats/min and the therapeutic range

of serum digoxin levels is 0.5 to 2

ng/mL. Based on the objective data,

(A) is the best of the choices

provided because the serum digoxin

level is within normal levels. (B) is

not warranted by the data presented.

The digoxin level is within the

therapeutic range and the child is not

showing signs of toxicity (C). The

child's pulse rate is within normal

range for her age group (D).

C

Rationale:

Girls experience a growth spurt at

9.5 to 14.5 years of age and boys at

10.5 to 16 years of age (C). There

are insufficient data to support (A);

growth trends must be assessed to

reach such a conclusion. (B) is not

unexpected. The fact that the

children are twins has less to do

with their growth than the fact that

they are male and female (D).

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compared.

3 A 45-year-old female client is admitted C

. to the psychiatric unit for evaluation. Rationale:

Her husband states that she has been Agoraphobia (C) is the fear of

reluctant to leave home for the last 6 crowds or of being in an open

months. The client has not gone to place. (A) is the fear of being in

work for a month, has been terminated closed places. (B) is the fear of high

from her job, and has not left the places. (D) is an abnormal fear of

house since that time. This client is death or bodies after death. A

displaying symptoms of which phobia is an unrealistic fear

disorder? associated with severe anxiety.

A.Claustrophobia

B.Acrophobia

C.Agoraphobia

D.Necrophobia

4 An adult client with a medical C

. diagnosis of substance abuse and Rationale:

schizophrenia was recently switched Alcohol enhances the side effects of

from oral fluphenazine HCl (Prolixin) Prolixin. The half-life of Prolixin

to IM fluphenazine decanoate (Prolixin PO is 8 hours, whereas the half-life

Decanoate) because of medication of the Prolixin Decanoate IM is 2 to

noncompliance. What should the nurse 4 weeks. Therefore, the side effects

teach the client and family about this of drinking alcohol are far more

change in medication regimen? severe when the client drinks

A.Long-acting medication is more alcohol after taking the long-acting

effective than daily medication. Prolixin Decanoate IM (C). (A, B,

B.A client with substance abuse must and D) provide incorrect

not take any oral medications. information.

C.There will continue to be a risk of

alcohol and drug interaction.

D.Support groups are only helpful for

substance abuse treatment.

5 An adult female who presents at the D

. mental clinic trembling and crying Rationale:

becomes distressed when the nurse The client is exhibiting signs of

attempts to conduct an assessment. moderate anxiety, which include

She complains about the number of voice tremors, shakiness, somatic

questions that are being asked, which complaints, and selective inattention.

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she is convinced are going to cause

her to have a heart attack. What

action should the nurse take?

A.Take the client's blood pressure

and reassure her that questioning

will not cause a heart attack.

B.Explain that treatment is based on

information obtained in the

assessment.

C.Encourage the client to relax so

that she can provide the information

requested.

D.Empower the client to share her

story of why she is here at the mental

health clinic.

6 After assessing a 26-year-old client

. with type 1 diabetes mellitus, which

data may indicate that the client is

experiencing chronic complications

of diabetes?

A.Blood pressure, 159/98 mm Hg

B.Hemoglobin A1c (HbA1c), 6%

C.Creatinine level, 1.0 mg/dL

D.Chronic sciatica

7 The charge nurse is making

. assignments for the upcoming shift.

Which client is most appropriate to

assign to the licensed practical nurse

(LPN)?

A.A client with nausea who needs a

nasogastric tube inserted

B.A client in hypertensive crisis who

needs titration of IV nitroglycerin

C.

A newly admitted client who needs to

have a plan of care established

D.A client who is ready for discharge

who needs discharge teaching

(D) is the best method for addressing

this client's level of anxiety by

creating a shared understanding of

the client's concerns. Although

assessment of her blood pressure (A)

might be a worthwhile intervention,

reassuring her that questioning will

not cause a heart attack (A) is

argumentative. (B) suggests that

treatment cannot be provided without

the information, which is

manipulative. Asking the client to

relax (C) is likely to increase her

anxiety.

A

Rationale:

A blood pressure of 159/98 mm Hg is

hypertensive and increases the

client's risk for acute coronary

syndrome and/or stroke (A). (B and

C) are within defined parameters, and

(D) is not a recognized chronic

complication of diabetes.

A

Rationale:

This client has a need for a skill that

is within the scope of practice for the

LPN (A). Titration of an IV drip,

establishing care plans, and discharge

teaching are within the scope of

practice of a registered nurse (RN)

and are not delegated (B, C, and D).

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8 The charge nurse observes a student

. nurse enter the room of a client who

is prescribed airborne precautions.

The application of which personal

protective equipment by the student

indicates a correct understanding of

this precaution?

A.Surgical mask, clean gloves, and

gown

B.Properly fitted N95 respirator or

mask

C.Sterile gloves and gown

D.Goggles, clean gloves, and gown

9 The charge nurse reviews the

. charting of a graduate nurse. Which

indicates a need for further

education on documentation?

A.Uses descriptive words such as

"gurgling" to describe breath sounds

B.Records temperature 30 minutes

before and after giving

acetaminophen

C.Charts some actions in advance of

performing them

D.Includes the client's response to an

intervention

B

Rationale:

The use of personal protective

equipment (PPE) for airborne

precautions includes a properly

prefitted N95 respirator or mask (B).

(A, C and D) do not provide the

appropriate respiratory equipment for

airborne precautions. A surgical mask

is used for preventing transmission of

droplet precautions.

C

Rationale:

Charting actions prior to

implementing them is an example of

fraudulent charting and the graduate

nurse should receive further

education (C). (A, B, and D) are

appropriate charting examples.

10 A client at 32 weeks of gestation is

. hospitalized with preeclampsia,

and magnesium sulfate is

prescribed to control the

symptoms. Before the next dose of

MgSO4 is given, which assessment

finding indicates that the patient is

at risk for toxicity?

A.Deep tendon reflexes—decrease

to 2+

B.100 mL of urine output in 4

hours

C.Respiratory rate decreases to 16

B

Rationale:

Magnesium sulfate, a central nervous

system (CNS) depressant, helps

prevent seizures, so (A) is a positive

sign that the medication is having a

desired effect. The minimum urine

output expected for a repeat dose of

magnesium sulfate is 30 mL/hr, so 100

mL of urine in 4 hours can lead to poor

excretion of magnesium, with a

possible cumulative effect (B). A

decreased respiratory rate (C) indicates

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