HESI Comprehensive B, Comprehensive Exam A, 2021 exit v 2

HESI Comprehensive B, Comprehensive Exam A, 2021 exit v 2

The nrse is caring for a patient with a cerebrovascular accident (CVA) who is receiving enteral tube feedings. Which task performed by the UAP requires immediate intervention by the nrse?

A.Suctions oral secretions from mouth B.Positions head of bed flat when changing sheets C.Takes temperature using the axillary method D.Keeps head of bed elevated at 30 degrees Correct answer- B Rationale: Positioning the head of the bed flat when enteral feedings are in progress puts the patient at risk for aspiration (B). The others are all acceptable tasks performed by the UAP (A, C, and D). :https://www.stuvia.com/doc/1571731/hesi-comprehensive-b-comprehensive-exam-a2021-exit-v-2 When caring for a postsurgical patient who has undergone multiple blood transfusions, which serum laboratory finding is of most concern to the nrse?

A.Sodium level, 137 mEq/L B.Potassium level, 5.5 mEq/L C.Blood urea nitrogen (BUN) level, 18 mg/dL D.Calcium level, 10 mEq/L Correct answer- B Rationale: Multiple blood transfusions are a risk factor for hyperkalemia. A serum potassium level higher than 5.0 mEq/L indicates hyperkalemia (B). The others are normal findings (A, C, and D).

Which vaccination should the nrse administer to a newborn?

A.Hepatitis B B.Human papilloma virus (HPV) C.Varicella D.Meningococcal vaccine Correct answer- A Rationale: The hepatitis B vaccination should be given to all newborns before hospital discharge (A). HPV is not recommended until adolescence (B). Varicella immunization begins at 12 months (C). Meningococcal vaccine is administered beginning at 2 years (D).

The nrse is caring for a patient on the medical unit. Which task can be delegated to unlicensed assistive personnel (UAP)?

A.Assess the need to change a central line dressing.

B.Obtain a fingerstick blood glucose level.

C.Answer a family member's questions about the patient's plan of care.

D.Teach the patient side effects to report related to the current medication regimen.

Correct answer- B Rationale: Obtaining a fingerstick blood glucose level is a simple treatment and is an appropriate skill for UAP to perform (B). (A, C, and D) are skills that cannot be delegated to UAP. :https://www.stuvia.com/doc/1571731/hesi-comprehensive-b-comprehensive-exam-a2021-exit-v-2 The nrse is caring for a patient with an ischemic stroke who has a prescription for tissue plasminogen activator (t-PA) IV. Which action(s) should the nrse expect to implement? (Select all that apply.)

A.Administer aspirin with tissue plasminogen activator (t-PA).

B.Complete the National Institute of Health Stroke Scale (NIHSS).

C.Assess the patient for signs of bleeding during and after the infusion.

D.Start t-PA within 6 hours after the onset of stroke symptoms.

E.Initiate multidisciplinary consult for potential rehabilitation. Correct answer- B,C,E Rationale: Neurologic assessment, including the NIHSS, is indicated for the patient receiving tPA. This includes close monitoring for bleeding during and after the infusion; if bleeding or other signs of neurologic impairment occur, the infusion should be stopped (B, C, and E). Aspirin is contraindicated with t-PA because it increases the risk for bleeding (A). The administration of t-PA within 6 hours of symptoms is concurrent with a diagnosis of a myocardial infarction and within 4.5 hours of symptoms is concurrent for a stroke (D).

When caring for a patient in labor, which finding is most important to report to the primary health care provider?

A.Maternal heart rate, 90 beats/min.

B.Fetal heart rate, 100 beats/min C.Maternal blood pressure, 140/86 mm Hg D.Maternal temperature, 100.0° F Correct answer- B Rationale: A fetal heart rate (FHR) of 100 beats/min may indicate fetal distress (B) because the average FHR at term is 140 beats/min and the normal range is 110 to beats/min 160. The others (A, C, and D) are normal findings for a woman in labor. :https://www.stuvia.com/doc/1571731/hesi-comprehensive-b-comprehensive-exam-a2021-exit-v-2 The nrse is caring for a patient with heart failure who develops respiratory distress and coughs up pink frothy sputum. Which action should the nrse take first?

A.Draw arterial blood gases.

B.Notify the primary health care provider.

C.Position in a high Fowler's position with the legs down.

D.Obtain a chest X-ray. Correct answer- C Rationale:

Positioning the patient in a high Fowler's position with dangling feet will decrease further venous return to the left ventricle (C). The other actions should be performed after the change in position (A, B, and D).

A patient who is prescribed chlorpromazine HCl (Thorazine) for schizophrenia develops rigidity, a shuffling gait, and tremors. Which action by the nrse is most important?A.Administer a dose of benztropine mesylate (Cogentin) PRN. B.Determine if the patient has increased photosensitivity.

C.Provide comfort measures for sore muscles.

D.Assess the patient for visual and auditory hallucinations. Correct answer- A Rationale: Rigidity, shuffling gait, pill-rolling hand movements, tremors, dyskinesia, and masklike face are extrapyramidal side effects associated with Thorazine. It is most important for the nrse to administer an anticholinergic such as Cogentin to reverse these effects (A). The others (B, C, D) may be appropriate interventions but are not as urgent as (A).

A nrse is interviewing a mother during a well-child visit. Which finding would alert the nrse to continue further assessment of the infant?

A.Two-month-old who is unable to roll from back to abdomen B.Ten-month-old who cannot sit without support C.Nine-month-old who cries when his mother leaves the room D.Eight-month-old who has not yet begun to speak words Correct answer- B Rationale: As a developmental milestone, infants should sit unsupported by 8 months (B). The milestone of rolling over is achieved at 5 to 6 months for most infants (A). Stranger anxiety is common from 7 to 9 months (C). Speaking a few words is expected at about 12 months (D).

Which intervention should be included in the plan of care for a patient admitted to the hospital with ulcerative colitis?

A.Administer stool softeners.

B.Place the patient on fluid restriction.

C.Provide a low-residue diet.

D.Add a milk product to each meal. Correct answer- C Rationale: A low-residue diet (C) will help decrease symptoms of diarrhea, which are clinical manifestations of ulcerative colitis. (A, B, and D) are contraindicated and could worsen the condition.

The nrse is caring for a patient with deep vein thrombosis who is on a continuous IV heparin infusion. The activated partial prothrombin time (aPTT) is 120 seconds.

Which action should the nrse take?

A.Increase the rate of the heparin infusion using a nomogram.

B.Decrease the heparin infusion rate and give vitamin K IM. C.Continue the heparin infusion at the current prescribed rate.

D.Stop the heparin drip and prepare to administer protamine sulfate. Correct answer- D Rationale: An aPTT more than 100 seconds is a critically high value; therefore, the heparin should be stopped. The antidote for heparin is protamine sulfate (D). Increasing the rate would increase the risk for hemorrhage (A). The infusion should be stopped, and vitamin K is the antidote for warfarin (Coumadin) (B). Keeping the infusion at the current rate would increase the risk for hemorrhage (C).

While assessing a patient with recurring chest pain, the unit secretary notifies the nrse that the patient's health care provider is on the telephone. What action should the nrse instruct the unit secretary to implement?

A.Transfer the call into the room of the patient.

B.Instruct the secretary to explain reason for the call.

C.Ask another nrse to take the phone call.

D.Ask the health care provider to see the patient on the unit. Correct answer- C

Rationale: Another nrse should be asked to take the phone call (C), which allows the nrse to stay at the bedside to complete the assessment of the patient's chest pain. (A and B) should not be done during an acute change in the patient's condition. Requesting the health care provider (D) to come to the unit is premature until the nrse completes assessment of the patient's status.

Which instruction(s) should the nrse include in the discharge teaching plan of a male patient who has had a myocardial infarction and who has a new prescription for nitroglycerin (NTG)? (Select all that apply.)

A.Keep the medication in your pocket so that it can be accessed quickly.

B.Call 911 if chest pain is not relieved after one nitroglycerin.

C.Store the medication in its original container and protect it from light.

D.Activate the emergency medical system after three doses of medication.

E.Do not use within 1 hour of taking sildenafil citrate (Viagra). Correct answer- B,C Rationale: Emergency action should be taken if chest pain is not relieved after one nitroglycerin tablet (B). The medication should be kept in the original container to protect from light (C). Keeping the medication in the shirt pocket provides an environment that is too warm (A). The newest guidelines recommend calling 911 after one nitroglycerin tablet if chest pain is not relieved (D). Nitroglycerin and other nitrates should never be taken with Viagra (E).

The nrse prepares to administer 3 units of regular insulin and 20 units of NPH insulin subcutaneously to a patient with an elevated blood glucose level. Which procedure is correct?

A.Using one syringe, first insert air into the regular vial and then insert air into the NPH vial.

B.Using one syringe, add the regular insulin into the syringe and then add the NPH insulin.

C.Avoid combining the two insulins because incompatibility could cause an adverse reaction.

D.Administer the regular insulin subcutaneously and then give the NPH IV to prevent a separate stick. Correct answer- B Rationale: :https://www.stuvia.com/doc/1571731/hesi-comprehensive-b-comprehensive-exam-a2021-exit-v-2 The regular or "clear" insulin should be withdrawn into the syringe first, followed by the NPH (B). Air should first be injected into the NPH vial and then air should be inserted into the regular vial (A). NPH and regular insulin are compatible, and combining will reduce the number of injections (C). The insulin is ordered subcutaneously and NPH cannot be given IV (D).

An 8-year-old child is receiving digoxin (Lanoxin) for congestive heart failure (CHF).

In assessing the child, the nrse 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 nrse 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. Correct answer- 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).

The nrse prepares to administer acetaminophen oral suspension to a child who weighs 66 pounds. The prescription reads: Administer 15 mg/kg every 6 hours by mouth. The Tylenol is available 150 mg/5 ml. Which is the correct dosage indicated on the image?

A.30ml B.15ml C.10ml D.5ml Correct answer- B Rationale: 66 lb/(2.2 kg/lb) = 30 kg 30 kg × (15 mg/kg) = 450 mg (5 mL/150 mg) × 450 mg = 15 mL or (450 mg/150 mg) × 5 mL = 15 mL When assessing the laboratory findings of a 38-year-old patient with tuberculosis who is taking rifampin (Rifadin), which laboratory finding would be most important to report to the primary health care provider immediately?

A.Orange-colored urine B.Potassium level, 4.9 mEq/L C.Elevated liver enzyme levels D.Blood urea nitrogen (BUN) level, 12 mg/dL Correct answer- C Rationale: Rifampin can cause hepatoxicity, so elevated liver enzyme levels need to be closely monitored and reported to the health care provider (C). Orange discoloration of the urine is an expected side effect of this medication (A). The potassium level (B) is normal. A BUN level of 12 mg/dL is within defined parameters (D).

A patient is receiving propylthiouracil (PTU) prior to thyroid surgery. Which diagnostic test results indicate that the medication is producing the desired effect?

A.Increased hemoglobin and hematocrit levels B.Increased serum calcium level C.Decreased white blood cell (WBC) count D.Decreased triiodothyronine (T3) and thyroxine (T4) levels Correct answer- D Rationale: Propylthiouracil (PTU) is an adjunct therapy used to control hyperthyroidism by inhibiting the production of thyroid hormones (D). It is often prescribed in preparation for thyroidectomy or radioactive iodine therapy. It is does not affect (A).

(B) must be monitored after surgery in case the parathyroid glands were removed, but preoperative PTU does not increase the serum calcium level. If the patient has an infection preoperatively, antibiotics will be given and (C) monitored.

The nrse teaches a class on bioterrorism. Which method(s) of transmission is(are) possible with the biologic agent Bacillus anthracis (Anthrax)? (Select all that apply.)

A.Inhalation of powder form B.Handling of infected animals C.Spread from person to person through coughing D.Eating undercooked meat from infected animals E.Direct cutaneous contact with the powder Correct answer- A,B,D,E Rationale: Anthrax can be transmitted by the inhalation, cutaneous, and digestive routes (A, B, D, and E); however, the disease is not spread from person to person (C).

The nrse assesses a woman in the emergency room who is in her third trimester of pregnancy. Which finding(s) is(are) indicative of abruptio placentae? (Select all that apply.)

A.Dark red vaginal bleeding B.Rigid boardlike abdomen C.Soft abdomen on palpation

D.Complaints of severe abdominal pain E.Painless bright red vaginal bleeding Correct answer- A,B,D Rationale: These are all signs of abruptio placentae (A, B, and D). The others are signs of placenta previa (C and E).

Which vital sign in a pediatric patient is most important to report to the primary health care provider?

A.Newborn with a heart rate of 140 beats/min B.Three-year-old with a respiratory rate of 28 breaths/min C.Six-year-old with a heart rate of 130 beats/min D.Twelve-year-old with a respiratory rate of 16 breaths/min Correct answer- C Rationale: The normal heart rate for a 6- to 10-year-old is 70 to 110 beats/min (C). The others are all within normal range for those ages (A, B, and D).

Which finding should be reported to the primary health care provider when caring for a patient who has a continuous bladder irrigation after a transurethral resection of the prostate gland (TURP)?

A.The patient reports a continuous feeling of needing to void.

B.Urinary drainage is pink 24 hours after surgery.

C.The hemoglobin level is 8.4 g/dL 3 days postoperatively.

D.Sterile saline is being used for bladder irrigation. Correct answer- C Rationale: A hemoglobin level of 8.4 g/dL is abnormally low and may indicate hemorrhage (C).

The others are all expected findings after a TURP (A, B, and D).

Which of the following cardiac rhythms is represented in the image?

A.Normal sinus rhythm B.Sinus tachycardia C.Ventricular fibrillation

D.Atrial fibrillation Correct answer- C Rationale: Ventricular fibrillation (C) is a life-threatening arrhythmia characterized by irregular undulations of varying amplitudes. (A, B, and D) are not represented in the image. :https://www.stuvia.com/doc/1571731/hesi-comprehensive-b-comprehensive-exam-a2021-exit-v-2 An adult patient with a medical diagnosis of substance abuse and schizophrenia was recently switched from oral fluphenazine HCl (Prolixin) to IM fluphenazine decanoate (Prolixin Decanoate) because of medication noncompliance. What should the nrse teach the patient and family about this change in medication regimen?

A.Long-acting medication is more effective than daily medication.

B.A patient 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. Correct answer- C Rationale: Alcohol enhances the side effects of Prolixin. The half-life of Prolixin PO is 8 hours, whereas the half-life of the Prolixin Decanoate IM is 2 to 4 weeks. Therefore, the side effects of drinking alcohol are far more severe when the patient drinks alcohol after taking the long-acting Prolixin Decanoate IM (C). (A, B, and D) provide incorrect information.

A patient comes to the obstetric clinic for her first prenatal visit and complains of feeling nauseated every morning. The patient tells the nrse, "I'm having second thoughts about wanting to have this baby." Which response is best for the nrse to make?

A."It's normal to feel ambivalent about a pregnancy when you are not feeling well."

B."I think you should discuss these feelings with your health care provider."

C."How does the father of your child feel about your having this baby?"

D."Tell me about these second thoughts you are having about this pregnancy."

Correct answer- D Rationale:

Although ambivalence is normal during the first trimester, (D) is the best nursing response at this time. It is reflective and keeps the lines of communication open. (A) is not the best response because it offers false reassurance. (B) dismisses the patient's feelings. The nrse should use communication skills that encourage this type of discussion, not shift responsibility to the care provider. (C) may eventually be discussed, but it is not the most important information to obtain at this time.

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