HESI COMPREHENSIVE EXAM 3 QUESTION AND ANSWERS 2024/2025 UPDATED
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HESI
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HESI
HESI COMPREHENSIVE EXAM 3 QUESTION AND ANSWERS 2024/2025 UPDATED
1. A client returns from surgery after undergoing an abdominal-perineal resection with a sigmoid colostomy. The colostomy is dressed with petroleum jelly gauze and dry gauze dressings. The perineal incision is partially closed w...
HESI COMPREHENSIVE EXAM 3 QUESTION
AND ANSWERS 2024/2025 UPDATED
1. A client returns from surgery after undergoing an abdominal-perineal resection
with a sigmoid colostomy. The colostomy is dressed with petroleum jelly gauze
and dry gauze dressings. The perineal incision is partially closed with two drains
attached to Jackson-Pratt suction bulbs. During the early postoperative period,
the nurse should give the highest priority to which nursing action?
a. Provide a low-residue diet.
b. Monitor drainage from the colostomy stoma.
c. Maintain dry perineal dressings.
d. Encourage looking at the colostomy site.
C
Rationale
During the immediate postoperative period, the perineal dressing should be assessed,
reinforced, and changed frequently because profuse drainage during the first hours after
surgery macerates tissue and compromises incisional approximation and healing. The
priority action should include measures to promote healing and prevent infection.
2. A 50-year-old male client with amyotropic lateral sclerosis (ALS) is becoming
increasingly debilitated and tells the nurse, "Since I haven't been able to go to
church, I feel out of touch with God. I pray, but I wonder whether my prayers are
heard." Which nursing diagnosis should the nurse include in the client's plan of
care?
a. Death anxiety.
b. Powerlessness.
c. Spiritual distress.
d. Disturbed thought processes.
C
Rationale
Based on the client's verbalized concern about his relationship with God and the
inability to participate in religious services are defining characteristics for the nursing
diagnosis of spiritual distress. Although the client may be experiencing death anxiety
and powerlessness about his clinical diagnosis and prognosis, the client's spiritual
coping strategies are compromised.
3. The nurse is caring for a client who is scheduled for surgery in 2 hours. The
client tells the nurse, "My doctor came by to tell me a lot of stuff that I didn't
understand, but I signed the papers for surgery anyway." To fulfill the role of
advocate, which action should the nurse implement?
,a. Reassure the client that surgery should progress as planned.
b. Explain the surgery and possible outcomes to the client.
c. Complete the client's preoperative teaching plan.
d. Ask the surgeon to return to clarify questions for the client.
D
Rationale
Examples of nursing advocacy include questioning prescriptions, promoting client
comfort, and supporting client decisions regarding healthcare choices. Requesting the
surgeon to return to clarify the client's concerns best fulfills the role of client advocate.
Although a well-planned surgical experience is expected you should not provides false
reassurance. Explanation of the surgical procedure and client outcomes is the surgeon's
responsibility, not an action of client advocacy.
4. The nurse is teaching a client with Addison's disease about this new diagnosis.
What pathophysiological explanation should the nurse share with the client?
a. End stage renal disease causes hypertension due to decreased renal perfusion
that results in an increased secretion of renin.
b. Hyperthyroidism is an autoimmune disease that causes an increased secretion
of thyroxine resulting in an increased basal metabolic rate.
c. Adrenal insufficiency is an autoimmune dysfunction that results from white
blood cells damaging the adrenal cortex.
d. Pituitary dysfunction, such as diabetes insipidus, can occur after a head injury
or primary tumor that causes increased intracranial pressure.
C
Rationale
Addison's disease is primary adrenal insufficiency related to autoimmune dysfunction
and lymphocytic infiltration. Adrenal glands are located on top of your kidneys. These
glands produce many of the hormones that your body needs for normal functions.
Addison's disease occurs when the adrenal cortex is damaged and the adrenal glands
do not produce enough of the steroid hormones cortisol and aldosterone. Cortisol
regulates the body's reaction to stressful situations. Aldosterone helps with sodium and
potassium regulation. The adrenal cortex also produces sex hormones (androgens).
5. The nurse is evaluating a client's response to diuretic therapy. Which
assessment provides the best measure of the client's fluid volume status?
a. Blood pressure and pulse.
b. Intake, output, and daily weight.
c. Serum potassium and sodium levels.
d. Measurements of abdominal girth and calf circumference.
B
Rationale
Intake, output, and daily weight provide the best quantitative data about a client's fluid
volume status based on weight changes in 24 hours, using the equivalent of 1 gm = 1
,ml. Blood pressure and pulse are influenced by fluid volume, but some clients
compensate more effectively cardiovascularly than others. Although serum potassium
and sodium levels may change based on the amount of diuresis, body weight changes
in a 24 hour time frame provide the best measure of routine diuresis.
6. During admission to the mental health unit, a female client with bipolar
disorder, manic phase, is loud, hyperverbal, hyperactive, and is garishly dressed.
Which intervention should the nurse include when planning care for this client?
a. Encourage others to use peer pressure to modify the client's behaviors.
b. Plan group activities that focus on the client as the center of attention.
c. Maintain an environment that reduces stimulation of the client.
d. Include activities that require attention to detail to limit inappropriate behavior.
C
Rationale
A client in the manic phase of bipolar disorder demonstrates flight of ideas, feelings of
grandiosity, and has an inflated self-esteem, so the plan of care should include
interventions that minimize client stimulation.
7. Which intervention is most important for the nurse to include in the plan of
care for a client with ankylosing spondylitis?
a. Limit the client's daily fat intake to 30%.
b. Increase the client's fluid intake to 3000 ml daily.
c. Place pillows under the client when lying supine.
d. Initiate a smoking cessation program.
D
Rationale
As the spine progressively stiffens, the client with ankylosing spondylitis should be
encouraged to stop smoking to decrease the risk for pulmonary complications related to
reduced chest expansion and movement. Although recommended health promotion
practices should be encouraged, the risk of complications with ankylosing spondylitis is
increased if the client continues to smoke. Using pillows under the client when lying
supine may promote comfort, but should be evaluated to prevent flexion that increases
the client's risk for flexion or fixation deformity.
8. The charge nurse assigns one nurse to care for a client with shingles and
another nurse to care for a client with HIV/AIDS. Which client goal is addressed
by the charge nurse's assignments?
a. Physiologic integrity.
b. Psychosocial integrity.
c. Health promotion and maintenance.
d. Safe and effective care environment.
D
Rationale
, Management of the delivery of care should consider the risk of infection for a client who
is immunosuppressed. A safe and effective care environment is provided by the
assignment of care for these two clients to two different nurses so nosocomial
transmission is minimized.
9. A client is using an otic solution, hydrocortisone and polymyxin B (Otobiotic
otic), for external otitis media. Which therapeutic response should the nurse tell
the client to expect?
a. Decreases inflammation and pain.
b. Reduces the existing colony count.
c. Slows the rate of organism growth.
d. Prevents hearing loss as a possible complication.
A
Rationale
The otic preparation of polymyxin B and hydrocortisone is a combination antibiotic and
corticosteroid used to reduces inflammation and control pain.
10. An adolescent client is admitted to the mental health unit for impulsivity and
acting-out behavior at school. What intervention should the nurse implement that
is most beneficial for this client?
a. Administer an antianxiety agent PRN.
b. Implement close observation precautions.
c. Separate the adolescent from adult clients on the unit.
d. Explain the consequences for breaking the unit rules.
D
Rationale
Therapeutic interventions, such as limit-setting and consequences for breaches of rules
provide consistent expectations of behavior and are most beneficial in establishing trust
and reinforcing acceptable behaviors for interacting with others.
11. The nurse is evaluating the external fetal monitor and identifies variable fetal
heart rate (FHR) decelerations. The nurse recognizes that this change in the FHR
pattern is due to which pathophysiological incident?
a. Fetal hypoxemia.
b. Umbilical cord compression.
c. Uteroplacental insufficiency.
d. Altered fetal cerebral blood flow.
B
Rationale
Variable decelerations occur any time during the uterine contracting phase and are
caused by compression of the umbilical cord between the fetus and maternal pelvis, the
fetal cord around the fetal neck, arm, leg, or other body part, a short cord, a knot in the
cord, or a prolapsed cord.
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