HESI EXIT COMPREHENSIVE PROCTORED EXAM

1.Which information is most concerning to the nurse when caring for an older

client with bilateral cataracts?

A. States having difficulty with color perception

B. Presents with opacity of the lens upon assessment

C. Complains of seeing a cobweb-type structure in

the visual field

D. Reports the need to use a magnifying glass to see

small print

Rationale:

Visualization of a cobweb- or hairnet-type structure is a sign of a retinal

detachment, which constitutes a medical emergency. Clients with cataracts are at

increased risk for retinal detachment. Distorted color perception, opacity of the

lens, and gradual vision loss are expected signs and symptom of cataracts but do

not need immediate attention.

2.When caring for a client hospitalized with Guillain-Barré syndrome, which

information is most important for the nurse to report to the primary health care

provider?

A. Ascending numbness from the feet to the knees

B. Decrease in cognitive status of the client

C. Blurred vision and sensation changes

D. Persistent unilateral headache

Rationale:

A decline in cognitive status in a client is indicative of symptoms of hypoxia and a

possible need to assist the client with mechanical ventilation. A primary health care

provider will need to be contacted immediately. Options A, C, and D are findings

associated with Guillain-Barré syndrome that should also be reported but are not as

critical as the client's hypoxic status.

3. A client is admitted with a diagnosis of leukemia. This condition is manifested

by which of the following?

A. Fever, elevated white blood count, elevated

platelets

B. Fatigue, weight loss and anorexia, elevated red

blood cells

C. Hyperplasia of the gums, elevated white blood

count, weakness

D. Hypocellular bone marrow aspirate, fever,

decreased hemoglobin level

Rationale:

Hyperplastic gums, weakness, and elevated white blood count are classic signs of

leukemia. Options A, B, and D state incorrect information for symptoms of

leukemia.

4. The nurse enters the examination room of a client who has been told by her

health care provider that she has advanced ovarian cancer. Which response by the

nurse is likely to be most supportive for the client?

A. "I know many women who have survived ovarian

cancer."

B. "Let's talk about the treatments of ovarian

cancer."

C. "In my opinion I would suggest getting a second

opinion."

D. "Tell me about what you are feeling right now."

Rationale:

The most therapeutic action for the nurse is to be an active listener and to

encourage the client to explore her feelings. Giving false reassurance or personal

suggestions are not therapeutic communication for the client.

5. A nurse working in the emergency department admits a client with full-thickness

burns to 50% of the body. Assessment findings indicate high-pitched wheezing,

heart rate of 120 beats/min, and disorientation. Which action should the nurse take

first?

A. Insert a large-bore IV for fluid resuscitation.

B. Prepare to assist with maintaining the airway.

C. Cleanse the wounds using sterile technique.

D. Administer an analgesic for pain.

Rationale:

High-pitched wheezing indicates laryngeal stridor, a sign of laryngeal edema

associated with lung injury. Airway management is the first priority of care.

Options A, C, and D are all appropriate interventions in managing the client with a

burn but are not as critical as establishing an airway.

6. The nurse walks into the room and observes the client experiencing a tonicclonic seizure. Which intervention should the nurse implement first?

A. Restrain the client to protect from injury.

B. Flex the neck to ensure stabilization.

C. Use a tongue blade to open the airway.

D. Turn client on the side to aid ventilation.

Rationale:

Maintaining the airway during a seizure is the priority for safety. Options A, B, and

C are contraindicated during a seizure and may cause further injury to the client.

7. Which intervention should be included in the plan of care for a client admitted to

the hospital with ulcerative colitis?

A. Administer stool softeners.

B. Place the client on fluid restriction.

C. Provide a low-residue diet.

D. Add a milk product to each meal.

Rationale:

A low-residue diet will help decrease symptoms of diarrhea, which are clinical

manifestations of ulcerative colitis. Options A, B, and D are contraindicated and

could worsen the condition.

8. A nurse implements an education program to reduce hospital readmissions for

clients with heart failure. Which statement by the client indicates that teaching has

been effective?

A. "I will not take my digoxin if my heart rate is

higher than 100 beats/min."

B. "I should weigh myself once a week and report

any increases."

C. "It is important to increase my fluid intake

whenever possible."

D. "I should report an increase of swelling in my feet

or ankles."

Rationale:

An increase in edema indicates worsening right-sided heart failure and should be

reported to the primary health care provider. Digitalis should be held when the

heart rate is lower than 60 beats/min. The client with heart failure should weigh

himself or herself daily and report a gain of 2 to 3 lb. An increase in fluid can

worsen heart failure.

9. 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

Rationale:

A blood pressure of 159/98 mm Hg is hypertensive and increases the client's risk

for acute coronary syndrome and/or stroke. Options B and C are within defined

parameters, and Option D is not a recognized chronic complication of diabetes.

10. When caring for a client with a tracheostomy, which intervention should the

nurse delegate to the unlicensed assistive personnel (UAP)?

A. Teach the family about signs and symptoms of

hypoxia.

B. Take the vital signs and obtain an O2 saturation

level.

C. Evaluate the need for tracheal suctioning.

D. Revise the plan of care to include tracheostomy

care.

Rationale:

The nurse may delegate obtaining vital signs and O2 saturation; however, the nurse

is responsible for following up on any reported data. Options A, C, and D are all

part of the nursing process and should not be delegated under the nurse's scope of

practice.

11. The charge nurse is making assignments for the upcoming shift. Which client is

most appropriate to assign to the practical nurse (PN)?

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

Rationale:

The client mentioned in option A has a need for a skill that is within the scope of

practice for the PN. 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.

12. A nurse performs an initial admission assessment of a 56-year-old client.

Which factor(s) would indicate that the client is at risk for metabolic

syndrome? (Select all that apply.)

A. Abdominal obesity

B. Sedentary lifestyle

C. History of hypoglycemia

D. Hispanic or Asian ethnicity

E. Increased triglycerides

Rationale:

Metabolic syndrome is a name for a group of risk factors that increase the risk for

coronary artery disease, type 2 diabetes, and stroke (A, B, D, and E).

Hypoglycemia is not a risk factor for metabolic syndrome (C).

13. Which clinical manifestation in the client with hyperthyroidism is most

important to report to the health care provider?

A. Nervousness

B. Increased appetite

C. Apical heart rate of 130 beats/min

D. Insomnia

Rationale:

The apical heart rate of 130 beats/min is a critical finding that could lead to heart

failure or other cardiac disorders. Options A, B, and D are all expected findings

that should also be reported but are not as critical.

14. The nurse administers atropine sulfate ophthalmic drops preoperatively to the

right eye of a client scheduled for cataract surgery. Which response by the client

indicates that the drug was effective?

A. The pupils become equal and reactive to light.

B. The right pupil constricts within 30 minutes.

C. Bilateral visual accommodation is restored.

D. The right pupil dilates after drop instillation.

Rationale:

Atropine is a mydriatic drug which causes pupil dilation and paralysis in

preparation for surgery or examination. Options A, B, and C do not describe the

therapeutic effects of atropine sulfate ophthalmic drops prior to cataract surgery.