HESI Comprehensive RN Exam

HESI Comprehensive RN Exam

VERSION 3

• 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?

• Because the child's heart rate and

digoxin level are within normal range, assess for the cause of the nausea.

• Hold the next dose of digoxin until

the health care provider can be notified because the serum digoxin level is elevated.

• Administer the next dose of digoxin

and notify the health care provider that the child is showing signs of toxicity.

• Notify the health care provider that

the child's pulse rate is below normal for her age group.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).

• 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 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.

• A 45-year-old female client is admitted

to the psychiatric unit for evaluation.Her husband states that she has been reluctant to leave home for the last 6 months. The client has not gone to work for a month, has been terminated from her job, and has not left the house since that time. This client is displaying symptoms of which disorder?A.Claustrophobia B.Acrophobia C.Agoraphobia D.Necrophobia C

Rationale:

Agoraphobia (C) is the fear of crowds or of being in an open place.(A) is the fear of being in closed places. (B) is the fear of high places.(D) is an abnormal fear of death or bodies after death. A phobia is an unrealistic fear associated with severe anxiety.

• An adult client with a medical

diagnosis of substance abuse and schizophrenia was recently switched from oral fluphenazineHCl (Prolixin) to IM fluphenazinedecanoate (ProlixinDecanoate) because of medication noncompliance. What should the nurse teach the client and family about this change in medication regimen?A.Long-acting medication is more effective than daily medication.B.A client with substance abuse must not take any oral medications.C.There will continue to be a risk of alcohol and drug interaction.D.Support groups are only helpful for substance abuse treatment.C

Rationale:

Alcohol enhances the side effects of Prolixin. The half-life of Prolixin PO is 8 hours, whereas the half-life of the ProlixinDecanoate IM is 2 to

• weeks. Therefore, the side effects

of drinking alcohol are far more severe when the client drinks alcohol after taking the long-acting ProlixinDecanoate IM (C). (A, B, and D) provide incorrect information.

• An adult female who presents at the

mental clinic trembling and crying becomes distressed when the nurse attempts to conduct an assessment.She complains about the number of questions that are being asked, which she is convinced are going to cause D

Rationale:

The client is exhibiting signs of moderate anxiety, which include voice tremors, shakiness, somatic complaints, and selective inattention.(D) is the best method for addressing 2 / 4

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.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.

• 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 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.

• 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 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).

• The charge nurse observes a student

nurse enter the room of a client who B

Rationale: 3 / 4

is prescribed airborne precautions.The application of which personal protective equipment by the student indicates a correct understanding of this precaution?

• Surgical mask, clean gloves, and

gown

• Properly fitted N95 respirator or

mask

• Sterile gloves and gown
• Goggles, clean gloves, and gown

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.

• 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 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.

• 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 breaths/min D.Serum magnesium level, 7.5 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 that the drug is effective. A respiratory rate below 12 breaths/min indicates

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