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HESI NEW COMPREHENSIVE ACTUAL EXAMS

5. The nurse is implementing the plan of care for a patient. Which action best reflects the "evaluation" phase of the nursing process? A. Taking the patient's blood pressure 30 minutes after admin... istering an antihypertensive medication. B. Asking the patient to rate their pain on a 0-10 scale after receiving a pain medication. C. Repositioning the patient to promote comfort. D. Comparing the patient's current mobility level to the goal set in the care plan. Answer: D *Rationale: * Evaluation is the process of looking at the patient's response and comparing it to the expected outcomes (goals) to determine if the interventions were effective. A and B are data collection (assessment). C is an intervention. 6. A patient with diabetes has a blood glucose level of 45 mg/dL. The patient is awake and able to swallow. What is the nurse's priority action? A. Administer 50% dextrose IV push. B. Call the healthcare provider immediately. C. Give the patient 4 ounces of orange juice. D. Recheck the blood glucose in 15 minutes. Answer: C *Rationale: * *The priority for a conscious patient with hypoglycemia is to quickly raise blood glucose with a fast-acting carbohydrate (15-15 rule). IV dextrose (A) is for unconscious patients. The provider (B) should be notified, but treatment is the priority.* 7. A patient who had a stroke is unable to move their left arm. The nurse correctly documents this finding as which of the following? A. Hemiparesis B. Hemiplegia C. Paraplegia D. Quadriplegia Answer: B *Rationale: * Hemiplegia refers to paralysis of one side of the body. Hemiparesis is weakness on one side. Paraplegia is paralysis of the lower half. Quadriplegia is paralysis of all four limbs. 8. A nurse is using Maslow's Hierarchy of Needs to prioritize care for a patient. Which patient need should the nurse address first? A. The patient expresses a need to see their family. B. The patient reports feeling "lonely and anxious." C. The patient reports difficulty sleeping due to pain. D. The patient's oxygen saturation is 88% on room air. Answer: D *Rationale: * Physiological needs (oxygen, food, water, shelter) are at the base of the pyramid and take priority. Oxygen saturation of 88% indicates hypoxemia, a critical physiological need that must be addressed before safety, psychosocial, or esteem needs. 9. The nurse is preparing to administer 0800 medications. Which of the following medications requires the nurse to assess the patient's apical pulse for a full minute before administering? A. Furosemide (Lasix) B. Digoxin (Lanoxin) C. Metformin (Glucophage) D. Lisinopril (Zestril) Answer: B *Rationale: * Digoxin is a cardiac glycoside that strengthens heart contractions but can cause bradycardia. The nurse must assess the apical pulse; if it is below 60 bpm in an adult (or below the parameter set by the provider), the medication is held and the provider is notified. 10. A patient with a history of falls is attempting to get out of bed alone. What is the nurse's priority intervention? A. Remind the patient to call for help. B. Place the bed in the lowest position. C. Put the call light within the patient's reach. D. Go to the patient and assist them immediately. Answer: D *Rationale: * Patient safety is paramount. If a patient is actively attempting an unsafe action, the nurse must intervene physically to prevent injury. The other options are important preventive measures but are ineffective if the patient is already trying to get up. [Show More]

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