HESI Comprehensive RN Exam

HESI Comprehensive RN Exam

VERSION 14

10.A nurse is caring for a client who has a head injury. Using the Glasgow Coma Scale to collect data, the 1 / 3

nurse should obtain which information?

ANS: Motor Response

• The nurse should collect data about the client’s motor response & assign the response a score of 1-6,

according to the Glasgow Coma Scale.

• A home health nurse is reinforcing teaching with a client about the use of elastic stockings to decrease

peripheral edema. Which instruction should the nurse include?

ANS: Apply the stocking in the morning.

• The nurse should instruct the client to apply the elastic stocking in the morning and remove them at the end

of the day before bedtime.

• A nurse is obtaining health hx from a client who is scheduled to undergo cardiac catheterization in 2 days.

Which questions is the priority for the nurse to ask?

ANS: “Do you know if you’re allergic to iodine?”

• The greatest risk to the client is an allergic reaction to the contrast agent, which contains iodine.
• A nurse is planning to administer nystatin oral suspension to a client who has oral candidiasis. Which

instructions should the nurse give?ANS: “Hold the medication in your mouth for several minutes prior to swallowing”

• The client should swish & hold the liquid in the mouth for at least 2 min to facilitate contact of the

medication with the organism. The client should then swallow or spit out the medication.

• A nurse is preparing to care for the assigned clients on her upcoming shift. Which time management

strategies should the nurse plan to use?

ANS: Prepare a priority list of client needs for the shift.

• The nurse should prepare a client priority-to-do list, which could include administering time-critical

medications. This will allow the nurse to determine which clients should receive care first.

• After witnessing the consent, what action should the nurse take next?

ANS: Ask client what he understands about the procedure.

• Which task should the nurse assign to an AP for a pt 2 days post-op ff Total knee arthroplasty?

ANS: Reapply antiembolitic stockings to the client ff a shower.

• A nurse is reinforcing teaching with a client who is receiving radiation therapy for cancer of the larynx.

Which statement made by the client indicates understanding of the teaching?

ANS: “I will wear a soft scarf around my neck when I am outside”

• Wash it with plain water without soap. NO heat source therapy. Only use electric razor if necessary, for

shaving.

• A nurse is using FLACC scale to determine the level of pain for an 11-months-old infant who sis port-op.

Which factor should the nurse consider when using this pain scale?

ANS: Level Of Activity

• The nurse should consider the infants level of activity when using FLACC pain scale. The FLACC is

determined by five categories of behavior: Facial Expression, Leg Movement, Activity, and Consolability.

• A nurse is collecting data from a 5YO child at a well-child visit. Parent reports that the child is having

frequent nightmares. Which statements by the parents indicates to the nurse that the child Is experiencing sleep terrors rather than nightmares?

ANS: “My child goes back to sleep right away.”

• The nurse should realize that going back to sleep quickly is an indication of sleep terrors, rather than

nightmares. A child who is experiencing nightmare has difficulty returning to sleep because of continued 2 / 3

fear.

• A nurse is assisting with the care of a school-age child immediately ff surgery. The child weighs 21.8 kg

(48 lb) & has a chest tube applied to suction. Which finding should the nurse report to PCP?

ANS: 250 mL of sanguineous drainage over the last 3 hr

• More than 3 mL/kg/hr of sanguineous drainage occurs for more than 2-3 consecutive hr ff surgery. It

indicates active hemorrhaging.

• A nurse is reinforcing teaching with an older adult client who has osteoarthritis. Which instructions should

the nurse include?

ANS: Apply capsaicin cream 4x/day

• Apply it topically to provide warmth & relieve joint pain.
• A nurse is reinforcing teaching about managing manifestation of anxiety with a client who has generalized

anxiety disorder. Which information should the nurse include?

ANS: Say the word “STOP” when upsetting thoughts occur.

• A nurse in a LTC facility is collecting data form a client who has been receiving betaxolol to treat

glaucoma. Which findings is an A/E if this medication?

ANS: Bradycardia

• Betaxolol is a beta blocker that can produce systemic effects, including bradycardia.
• A nurse in an outpatient surgery center is reinforcing discharge teaching with a client ff a lithotripsy for

uric acid stones. Which instructions should the nurse plan to include?

ANS: Strain the urine to collect stone fragments.

• A nurse in a provider’s office is reinforcing teaching with a client who is to follow a 2,000 mg sodium-

restricted diet. Which client food selections indicates understanding of the teaching?

ANS: Canned Peaches.

• A nurse is preparing to perform a bladder scan for a client. Which action should the nurse take?

ANS: Tell the client she should not experience any discomfort.

• A nurse is contributing to the plan of care for a client who has a prescription for ROM exercises of the

shoulder. Which exercise should the nurse recommend promoting shoulder hyperextension?

ANS: Move her arm behind her body with her elbow straight.

• A nurse is collecting data from an older adult client who has a gastric ulcer. Which finding should the nurse

identify as a complication to report to the provider?

ANS: Hematemesis

• A nurse is discussing the use of epidural analgesia with a newly licensed nurse. Which statement by the

newly licensed nurse indicates understanding of this method of pain control?ANS: “I should report leaking at the insertion site to the anesthesiologist”

• A nurse is contributing to the plan of care for a client who is receiving continuous bladder irrigation

immediately ff a transurethral resection of the prostate (TURP). Which of the ff interventions should the nurse include?ANS: Maintain a drainage flow rate to keep the urine diluted to a reddish-pink color.

• A nurse is caring for a client who is scheduled for a mastectomy the ff day. The client is tearful & tells the

nurse that she is not ready to have this procedure done at this time. What response should the nurse give?ANS: “Would you like for me to talk to the surgeon with you?”

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