HESI COMPREHENSIVE EXAM 2024
ACTUAL EXAM COMPLETE 250
QUESTIONS WITH DETAILED
VERIFIED ANSWERS AND
RATIONALES (100% CORRECT
ANSWERS) /ALREADY GRADED A+ //
BRAND NEW!!
A nurse reviews the laboratory results of a hospitalized
pregnant client with a diagnosis of sepsis who is at risk for
disseminated intravascular coagulopathy (DIC). Which
laboratory finding would indicate to the nurse that DIC has
developed in the client?
Increased platelet count
Shortened prothrombin time
Positive result on d-dimer study
Decreased fibrin-degradation products -
....ANSWER...Positive result on d-dimer study
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Rationale: The d-dimer study is used to confirm the
presence of fibrin split products; a positive result is
indicative of DIC. DIC is a life-threatening defect in
coagulation. As plasma factors are consumed, the
circulating blood becomes deficient in clotting factors and
unable to clot. Even as anticoagulation is occurring,
inappropriate coagulation is also taking place in the
microcirculation, and tiny clots form in the smallest blood
vessels, blocking blood flow to the organs and causing
ischemia. Laboratory studies help establish a diagnosis.
The fibrinogen value and platelet count are usually
decreased, prothrombin and activated partial
thromboplastin times may be prolonged, and levels of
fibrin degradation products (the most sensitive
measurement) are increased.
A nurse is caring for a client with a diagnosis of abruptio
placentae. For which early signs/symptoms of
hypovolemic shock does the nurse closely monitor the
client? Select all that apply.
Urine output of less than 30 mL/hr -
....ANSWER...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
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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 -
....ANSWER...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.
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