Download H.E.S.I Comprehensive Exit Exam 2025 – 160-Item Practice Assessment, Verified Rationales and more Exams Nursing in PDF only on Docsity!
HESI Comprehensive Exit Exam 2025 – 160 - Item
Practice Assessment, Verified Rationales,
Interactive Study Modules, and NCLEX Mastery
Toolkit for Nursing Graduates
A nurse is monitoring a pregnant client with suspected partial placenta previa who is experiencing vaginal bleeding. Which finding would the nurse expect to note on assessment of the client? Painful vaginal bleeding Sustained tetanic contractions Complaints of abdominal pain Soft, relaxed, nontender uterus - - correct ans- - Soft, relaxed, nontender uterus Rationale: Partial placenta previa is incomplete coverage of the internal os by the placenta. One characteristic of placenta previa is painless vaginal bleeding. The abdominal assessment would reveal a soft, relaxed, nontender uterus with normal tone. Vaginal bleeding and uterine pain and tenderness accompany placental abruption, especially with a central abruption and blood trapped behind the placenta. In placental abruption, the abdomen feels hard and boardlike on palpation as the blood penetrates the myometrium, resulting in pain and uterine irritability. A sustained tetanic contraction may occur if the client is in labor and the uterine muscle cannot relax. A nurse assisting with a delivery is monitoring the client for placental separation after the delivery of a viable newborn. Which observation indicates to the nurse that placental separation has occurred? A discoid uterus
Sudden sharp vaginal pain Shortening of the umbilical cord A sudden gush of dark blood from the introitus - - correct ans- - A sudden gush of dark blood from the introitus Rationale: Placental separation occurs when the placenta separates from the uterus. Signs of placental separation include lengthening of the umbilical cord, a sudden gush of dark blood from the introitus, a firmly contracted uterus, and a change in uterine shape from discoid to globular. The client may experience vaginal fullness but sudden sharp vaginal pain is not usual. A nurse is conducting a preoperative psychosocial assessment of a client who is scheduled for a mastectomy. Which finding would cause the nurse to conclude that the client is at risk for poor sexual adjustment after the mastectomy? The client reports a history of sexual abuse by her father. The client reports irregular menses relationship with her spouse. The client reports a satisfying intimate relationship with her spouse. The client reports that her and her spouse have never been able to conceive children. - - correct ans- - The client reports a history of sexual abuse by her father. Rationale: Clients at risk for self-esteem problems and poor sexual adjustment after mastectomy include those who report a lack of support from a spouse or partner; the existence of an unhappy, unstable intimate relationship; or a history of sexual problems or of sexual abuse, such as rape or incest. Clients with problems involving intimate relationships and sexuality should be referred for counseling. The remaining options are unrelated to the problem of poor sexual adjustment. A nurse provides instructions to a client who is preparing for discharge after a radical vulvectomy for the treatment of cancer. Which statement by the client indicates a need for further instruction? "I can resume sexual activity in 4 to 6 weeks."
tenting), flat neck and peripheral veins, and low blood pressure. Peripheral pulses are weak, difficult to find, and easily obstructed with light pressure. An adult client with chronic kidney disease who is oliguric and undergoing hemodialysis is under a fluid restriction. What percentage of the total amount of fluid can the client consume during the evening shift? 10% 20% 40% 50% - - correct ans- - 40% Rationale: When calculating how to distribute fluid to a client under fluid restriction, the nurse usually allows half or 50% of the allotted total oral fluids between 7 a.m. and 3 p.m., the period during which the client is more active, consumes two meals, and takes most of oral medications. Another two fifths(40%)is allotted to the evening shift, and the balance(10%)is allowed during the night. A client diagnosed with advanced chronic kidney disease (CKD) and oliguria has been taught about sodium and potassium restriction between dialysis treatments. The nurse determines that the client understands this restriction if the client states that what is acceptable to use? Salt substitutes Herbs and spices Salt with cooking only Processed foods as desired - - correct ans- - Herbs and spices Rationale: Most clients with CKD retain sodium. The client with CKD is instructed not to add salt at the table or during food preparation. Herbs and spices may be used as an alternative to salt to enhance the flavor of food. The client with advanced CKD is instructed to limit potassium intake. The client is also instructed to avoid salt
substitutes, many of which are composed of potassium chloride, if oliguria is present. Processed foods are discouraged because they are high in sodium. A nurse provides dietary instruction to a hospitalized client with chronic obstructive pulmonary disease (COPD). Which menu selection by the client tells the nurse that the client understands the instructions? Coffee Broccoli Cheeseburger Chocolate milk - - correct ans- - Cheeseburger Rationale: The client with COPD is encouraged to eat a high-calorie, high-protein diet and to choose foods that are easy to chew and do not promote gas formation. Dry foods stimulate coughing, and foods such as milk and chocolate may increase the thickness of saliva and other secretions. The nurse advises the client to avoid these foods, as well as caffeinated beverages, which promote diuresis, contributing to dehydration, and may increase nervousness. Chlorpromazine has been prescribed to a client with Huntington's disease for the relief of choreiform movements (repetitive and rapid, jerky, involuntary movements that appear well-coordinated). Of which common side effect does the nurse warn the client? Headache Drowsiness Photophobia Urinary frequency - - correct ans- - Drowsiness Rationale: Chlorpromazine is an antipsychotic, antiemetic, antianxiety, and antineuralgia adjunct. Common side effects of chlorpromazine include drowsiness, blurred vision, hypotension, defective color vision, impaired night vision, dizziness,
Rationale: The mother should be taught to count wet and soiled diapers to help determine whether the infant is receiving enough milk. Generally an infant should have at least 6 to 10 wet diapers (after the first 2 days of life) and at least 4 stools each day. The mother may also assess the swallowing and nutritive suckling of the infant, but this would not provide the best indication of adequate milk intake. Counting the number of times that the infant swallows during a feeding is an inadequate indicator of milk intake. The mother is not usually encouraged to weigh the infant at home, because this focuses too much attention on weight gain. Infants generally gain approximately 15 to 30 g (0. to 1 oz) each day after the early months of life. Pumping the breasts, placing the milk in a bottle, measuring the amount, and then bottle-feeding the infant constitute an assessment of the mother's bottle-feeding technique. A child who has just been found to have scoliosis will need to wear a thoracolumbosacral orthotic (TLSO) brace, and the nurse provides information to the mother about the brace. Which statement by the mother indicates a need for further information? "My child will need to do exercises." "My child needs to wear the brace 18 to 23 hours per day." "Wearing the brace is really important in curing the scoliosis." "I need to check my child's skin under the brace to be sure it doesn't break down." - - correct ans- - "Wearing the brace is really important in curing the scoliosis." Rationale: Scoliosis is a lateral curvature of the spine. There is a need for further information when the mother says, "Wearing the brace is really important in curing the scoliosis." Bracing is not curative of scoliosis but may slow the progression of the curvature to allow skeletal growth and maturation. A brace needs to be worn 18 to 23 hours a day, but it may be removed at night for sleep if this is prescribed. To be more cosmetically acceptable, a brace is usually worn under loose-fitting clothing. Back exercises are important in maintaining and strengthening the abdominal and spinal muscles. The child's skin must be meticulously monitored for signs of breakdown. Ferrous sulfate is prescribed for a client. What does the nurse tell the client is best to take the medication with?
Milk Water Any meal Tomato juice - - correct ans- - Tomato juice Rationale: Ferrous sulfate is an iron product. Absorption of iron is best promoted when the supplement is taken with orange juice or tomato juice another food source of vitamin C or ascorbic acid. Calcium and phosphorus in milk decrease iron absorption. Water has no effect on the absorption of vitamin C. Telling the client to take the medication with any meal of the day does not guarantee that the iron will be taken with a food source of vitamin C or ascorbic acid. Additionally, it is best to take the iron supplement between meals with a drink high in ascorbic acid. client diagnosed with type 1 diabetes mellitus has just been told that she is 6 weeks pregnant. The nurse provides information to the client about dietary and insulin needs. What comment by the client suggests an understanding of the information?"I know I will have to increase my insulin during this time period." "My insulin needs should decrease during the first trimester." "Needs for insulin will not change during the first 3 months of pregnancy." "I will have to double up on the insulin dose during this time span." - - correct ans- - "My insulin needs should decrease during the first trimester." Rationale: Insulin needs generally decrease during the first trimester of pregnancy because the secretion of placental hormones antagonistic to insulin remains low. An increase in insulin need, lack of change in insulin need, and doubling of insulin need are all incorrect. A nurse is assessing a pregnant woman for the presence of edema. The nurse places a thumb on the top of the client's foot, then exerts pressure and releases it and notes that the thumb has left a persistent depression. On the basis of this finding, what does the nurse conclude? No edema is present
Hysterectomy Insertion of an indwelling catheter Administration of oxytocin Replacement of the uterus through the vagina into a normal position - - correct ans- - Replacement of the uterus through the vagina into a normal position Rationale: If uterine inversion is suspected, the immediate intervention by the nurse is to prepare the client for replacement of the uterus through the vagina. If this is not possible or effective, laparotomy with replacement is performed. Hysterectomy may be required. Intravenous lines are established to allow rapid fluid and blood replacement. A tocolytic medication or general anesthesia is usually needed to relax the uterus enough to replace it. Once the uterus has been replaced and the placenta removed, oxytocin is given to induce uterine contraction and control blood loss. To help prevent trapping of the inverted fundus in the cervix, oxytocin is not given until the uterus has been repositioned. An indwelling catheter is often inserted to aid monitoring of fluid balance and keep the bladder empty so that the uterus can contract fully, but this is not the immediate action taken by the nurse. A nurse in the postpartum unit is caring for a client who delivered a healthy newborn 12 hours ago. The nurse checks the client's temperature and notes that it is 100.4° F (38° C). On the basis of this finding, what should the nurse do? Notify the primary health care provider Recheck the temperature in 4 hours Encourage the client to breastfeed the newborn Institute strict bedrest for the client and notify the primary health care provider - - correct ans- - Recheck the temperature in 4 hours Rationale: The nurse would recheck the temperature in 4 hours. A temperature of 100.4° F (38° C) is common during the 24 hours after childbirth and may be the result of dehydration or normal postpartum leukocytosis. If the increased temperature persists for more than 24 hours or exceeds 100.4° F (38° C), infection is a possibility, and the fever is reported. There is no reason to restrict place the client to strict bedrest or to
notify the primary health care provider. Although the client would be encouraged to breastfeed her newborn, this action is unrelated to the client's temperature. A nurse checking the fundus of a postpartum woman notes that it is above the expected level, at the umbilicus, and that it has shifted from the midline position to the right. What initial action should the nurse take? Document the findings Encourage the woman to walk Help the woman empty her bladder Massage the fundus gently until it becomes firm - - correct ans- - Help the woman empty her bladder Rationale: Ths initial action by the nurse is to help the woman empty her bladder. In the postpartum period, the fundus should be firmly contracted and at or near the level of the umbilicus. If the uterus is found to be higher than the expected level or shifted from the midline position (usually to the right), the bladder may be distended. The location of the fundus should be rechecked after the woman has emptied her bladder. If the fundus is difficult to locate or is boggy (soft), the nurse stimulates the uterine muscle to contract by gently massaging the uterus. Encouraging the woman to walk is inappropriate at this time. The nurse would document fundal position, consistency, and height and any other interventions taken (e.g., uterine massage) after the woman has emptied her bladder. A nurse is preparing to care for a client who was admitted to the antepartum unit at 34 weeks' gestation after an episode of vaginal bleeding resulting from total placenta previa. In report, the nurse is told that the client's vital signs are stable, that the fetal heart rate is 140 beats/min with a reassuring pattern, and that both the client and her husband are worried about the condition of the fetus. On reviewing the client's plan of care, which client concern does the nurse identify as the priority at this time? Anxiety Premature grief Fluid volume loss
Tachycardia Cool, clammy skin Decreased respiratory rate Diminished peripheral pulses Urine output of less than 30 mL/hr - - correct ans- - Tachycardia Diminished peripheral pulses Rationale: When hypovolemic shock develops, the body attempts to compensate for decreased blood volume and to maintain oxygenation of essential organs by increasing the rate and effort of the heart and lungs by shunting blood from less essential organs, such as the skin and extremities, to more essential ones, such as the brain and kidneys. This compensatory mechanism results in the early signs/symptoms of hypovolemic shock, which include tachycardia, diminished peripheral pulses, normal or slightly decreased blood pressure, increased respiratory rate, and cool, pale skin and mucous membranes. The compensatory mechanism fails if hypovolemic shock progresses and there is insufficient blood to perfuse the brain, heart, and kidneys. Later signs/symptoms of hypovolemic shock include decreasing blood pressure, pallor, cold and clammy skin, and urine output of less than 30 mL/hr. A nurse developing a nursing care plan for a client with abruptio placentae includes initial nursing measures to be implemented in the event of the development of shock. After contacting the primary health care provider, which does the nurse specify as the first action in the event of shock? Checking the client's urine output Inserting an intravenous (IV) line Obtaining informed consent for a cesarean delivery Placing the client in a lateral position with the bed flat - - correct ans- - Placing the client in a lateral position with the bed flat Rationale: If the client exhibits signs/symptoms of hypovolemic shock, the client would first be placed in a lateral position, with the head of the bed flat to increase cardiac return. It is necessary for the nurse to take this initial action to minimize the effects of
hypovolemic shock and promote tissue oxygenation and thus increase circulation and oxygenation of the placenta and other vital organs. The nurse would also contact the primary health care provider and monitor fetal status closely. After positioning the client, the nurse would insert IV lines in accordance with the primary health care provider's prescriptions and hospital protocols so that blood and replacement fluids may be administered. Quick preparation of the client for cesarean delivery may be necessary, but obtaining informed consent for the procedure is not the first action. Urine output is monitored to ensure an output of at least 30 mL/hr but, again, this is not the first action. A postpartum nurse provides information about normal and abnormal characteristics of lochia to a client who has delivered a healthy newborn. Which finding does the nurse tell the client to report to the primary health care provider? Pink lochia on postpartum day 4 White lochia on postpartum day 11 Bloody lochia on postpartum day 2 Reddish lochia on postpartum day 8 - - correct ans- - Reddish lochia on postpartum day 8 Rationale: Reddish lochia on postpartum day 8 is an abnormal finding and would be reported to the primary health care provider. Lochia is the postdelivery vaginal discharge from the uterus consisting of blood from the vessels of the placental site and debris from the deciduas. Rubra is the bright-red lochial discharge that appears from delivery day to day 3. Serosa is the brownish-pink lochial discharge that appears on days 4 to 10. Alba is the white lochial discharge that appears on days 10 to 14. A nurse in a primary health care provider's office is conducting a 2-week postpartum assessment of a client. During abdominal assessment, the nurse is unable to palpate the uterine fundus. This finding would prompt what action by the nurse? Document the findings Ask the primary health care provider to see the client immediately Ask another nurse to check for the uterine fundus
Nagele's rule, what item of client information is needed for the nurse to accurately determine estimated date of delivery (EDD)? Client has never had an abortion Client has regular 28-day menstrual cycle Client was 14 years old when menses first started Client's menstrual periods never last longer than 3 days - - correct ans- - Client has regular 28-day menstrual cycle Rationale: Accurate use of Nagele's rule is used to calculate the EDD. It requires that the woman have a regular 28-day menstrual cycle. A client has been given a prescription for lovastatin. Which food does the nurse instruct the client to limit consumption of while taking this medication? Steak Spinach Chicken Oranges - - correct ans- - Steak Rationale: Lovastatin is a lipid-lowering agent. The client is instructed to consume foods that are low in fat, cholesterol, and complex sugars. The item highest in fat here is steak; therefore the client should limit the intake of steak. Fruits, vegetables, and chicken are low in fat.Test-Taking Strategy: Focus on the subject A nurse is reviewing the laboratory results of a female client with ovarian cancer who is undergoing chemotherapy. Which finding indicates to the nurse that the client is experiencing an adverse effect of the chemotherapy? Sodium 140 mEq/L (140 mmol/L) Hemoglobin 12.5 g/dL (125 g/L)
Blood urea nitrogen (BUN) 20 mg/dL (7.1 mmol/L) White blood cell count of 2.5 × 103/μL (2.5 × 109/L) - - correct ans- - White blood cell count of 2.5 × 103/μL (2.5 × 109/L) Rationale: A white blood cell count of 2.5 × 103/μL (2.5 × 109/L) is low and puts the client at risk for infection. The normal white blood cell count ranges from 4.0-11.0 × 103/μL (4.0-11.0 × 109/L). All of the other values are within normal limits. The normal sodium level is 135-145 mEq/L (135-145 mmol/L). The normal hemoglobin level for a female ranges from 13.2-17.3 g/dL (132-173 g/L). The normal BUN concentration ranges from 6-20 mg/dL (2.1-7.1 mmol/L). Which finding in a client's history indicates the greatest risk of cervical cancer to the nurse? Nulliparity Early menarche Multiple sexual partners Hormone-replacement therapy - - correct ans- - Multiple sexual partners Rationale: Risk factors for cervical cancer include multiple sexual partners, a history of human papillomavirus infection, first sexual intercourse before the age of 16, cigarette smoking, environmental tobacco smoke exposure, and use of oral contraceptives for more than 5 years. Nulliparity, early menarche, and the use of hormone-replacement therapy are risk factors for ovarian rather than cervical cancer. A nurse caring for a woman in labor is reading the fetal monitor tracing (see figure). How does the nurse interpret this finding? Umbilical cord compression Pressure on the fetal head during a contraction Uteroplacental insufficiency during a contraction
Instructing the client in dietary changes to prevent constipation Encouraging the client to deep-breathe, cough, and use an incentive spirometer Encouraging the client to talk about the effects of the surgery on her femininity and sexuality - - correct ans- - Encouraging the client to deep-breathe, cough, and use an incentive spirometer Rationale: The nurse determines that the priority in the 24 hours after surgery is to encourage the client to deep-breathe, cough, and use an incentive spirometer. Care after abdominal hysterectomy includes maintenance of a patent airway, promotion of circulation and oxygenation, promotion of comfort, monitoring of output and drainage, promotion of elimination, and discharge teaching with regard to medications and therapeutic regimens. The priority is the maintenance of a patent airway and promotion of oxygenation and circulation. Monitoring the client for signs/symptoms of returning peristalis, instructing her in dietary habits to prevent constipation, and encouraging her to talk about the effects of her surgery are also components of care after this surgery but are of lower priority than encouraging the client to deep-breathe, cough, and use an incentive spirometer. A nurse is caring for a client with community-acquired pneumonia who is being treated with levofloxacin. Which finding, indicating an adverse reaction to the medication, does the nurse monitor the client? Fever Dizziness Flatulence Drowsiness - - correct ans- - Fever Rationale: Levofloxacin is an antibiotic of the fluoroquinolone class. Pseudomembranous colitis is an adverse reaction associated with the use of this medication. It is characterized by severe abdominal pain or cramps, severe watery diarrhea, and fever. Dizziness, flatulence, and drowsiness are side effects of the medication.
A nurse is providing instructions to a client with glaucoma who will be using acetazolamide daily. Which finding, an adverse effect, does the nurse instruct the client to report to the primary health care provider? Nausea Dark urine Urinary frequency Decreased appetite - - correct ans- - Dark urine Rationale: Acetazolamide is a carbonic anhydrase inhibitor. Nephrotoxicity and hepatotoxicity may occur, manifesting as dark urine and stools, lower back pain, jaundice, dysuria, crystalluria, renal colic, and calculi. Bone marrow depression may also occur as an adverse effect. Nausea, urinary frequency, and decreased appetite are side effects of the medication. A nurse is caring for a client with a cuffed endotracheal tube who is undergoing mechanical ventilation. Which intervention to prevent a tracheoesophageal fistula, a complication of this type of tube, does the nurse implement? Frequent suctioning Maintaining cuff pressure Maintaining mechanical ventilation settings Alternating the use of a cuffed tube with a cuffless tube on a daily basis - - correct ans- - Maintaining cuff pressure Rationale: Necrosis of the tracheal wall caused by pressure of the cuff of an endotracheal tube can lead to the development of an opening between the posterior trachea and esophagus, a complication known as tracheoesophageal fistula. The fistula allows air to escape into the stomach, resulting in abdominal distention. It also leads to the aspiration of gastric contents. To prevent this complication, the nurse must maintain cuff pressure, monitor the amount of air needed for cuff inflation, and help the client progress to a deflated cuff or cuffless tube as soon as possible as prescribed by the primary health care provider. Suctioning should be performed only as needed;
