HESI Comprehensive Exam A Practice
1
.
A 2-day postpartum mother who is
breastfeeding asks, "Why do I feel
this tingling in my breasts after the
baby sucks for a few minutes?"
Which information should the
nurse p
...
HESI Comprehensive Exam A Practice
1
.
A 2-day postpartum mother who is
breastfeeding asks, "Why do I feel
this tingling in my breasts after the
baby sucks for a few minutes?"
Which information should the
nurse provide?
A. This feeling occurs during
feeding with a breast infection.
B. This sensation occurs as breast
milk moves to the nipple.
C. The baby does not have good
latch-on.
D. The infant is not positioned
correctly.
B. This sensation occurs as breast milk
moves to the nipple.
Rationale:
When the mother's milk comes in,
usually 2 to 3 days after delivery,
women often report they feel a tingling
sensation in their nipples (B) when letdown occurs. (A, C, and D) provide
inaccurate information.
2
.
A 40-year-old office worker who is
at 36 weeks' gestation presents to
the occupational health clinic
complaining of a pounding
headache, blurry vision, and
swollen ankles. Which intervention
should the nurse implement first?
A. Check the client's blood
pressure.
B. Teach her to elevate her feet
when sitting.
C. Obtain a 24-hour diet history to
evaluate for the intake of salty
foods.
D. Assess the fetal heart rate.
A. Check the client's blood pressure.
Rationale:
The blood pressure (A) should be
assessed first. Preeclampsia is a
multisystem disorder, and women older
than 35 years and have chronic
hypertension are at increased risk.
Classic signs include headache, visual
changes, edema, recent rapid weight
gain, and elevated blood pressure. (B,
C, and D) can be done if the blood
pressure is normal.
3
.
A 50-year-old man arrives at the
clinic with complaints of pain on
ejaculation. Which action should
the nurse implement?
A. Teach the client testicular selfexamination (TSE).
B. Assess for the presence of blood
C. Ask about scrotal pain or blood in
the semen.
Rationale:
Orchitis is an acute testicular
inflammation resulting from recurrent
urinary tract infection, recurrent
sexually transmitted disease (STD), or
in the urine.
C. Ask about scrotal pain or blood
in the semen.
D. Inquire about a history of kidney
stones.
an indwelling urethral urinary catheter
causing pain on ejaculation, scrotal
pain, blood in the semen, and penile
discharge, so the nurse should
determine the presence of other
symptoms (C). Although all men
should practice TSE, the client's
symptoms are suggestive of an
inflammatory syndrome rather than
testicular cancer (A). Although
hematuria (B) is associated with renal
disease or calculi (D), the client's pain
is associated with ejaculate, not urine.
4
.
A 77-year-old female client states
that she has never been so large
around the waist and that she has
frequent periods of constipation.
Colon disease has been ruled out
with a flexible sigmoidoscopy.
Which information should the nurse
provide to this client?
A. As women age, they often become
rounder in the middle because they
do not exercise properly.
B. Further assessment is indicated
because loss of abdominal muscle
tone and constipation do not occur
with aging.
C. With age, more fatty tissue
develops in the abdomen and
decreased intestinal movement can
cause constipation.
D. Because there is no evidence of a
diseased colon, there is no need to
worry about abdominal size.
C. With age, more fatty tissue
develops in the abdomen and
decreased intestinal movement can
cause constipation.
Rationale:
With aging, the abdominal muscles
weaken as fatty tissue is deposited
around the trunk and waist. Slowing
peristalsis also affects the emptying of
the colon, resulting in constipation
(C). (A) is not the primary reason for
the changes in body structure. (B) is
not indicated because loss of muscle
tone and constipation are age-related
changes. (D) dismisses the client's
concerns and does not help her
understand the changes that she is
experiencing.
5
.
According to Erikson, which client
should the nurse identify as having
difficulty completing the
developmental stage of older adults?
D. A 75-year-old woman who wishes
her friends were still alive so she
could change some of the choices she
made over the years
A. A 60-year-old man who tells the
nurse that he is feeling fine and
really does not need any help from
anyone
B. A 78-year-old widower who has
come to the mental health clinic for
counseling after the recent death of
his wife
C. An 81-year-old woman who states
that she enjoys having her
grandchildren visit but is usually
glad when they go home
D. A 75-year-old woman who wishes
her friends were still alive so she
could change some of the choices she
made over the years
Rationale:
The older woman who wishes she
could change the choices she has
made in her lifetime is expressing
despair and is still searching for
integrity (D). The nurse uses Erikson
stages of development over the life
span to assess an older client's
adjustment to aging and plans
teaching strategies to assist the clients
attain integrity versus despair. (A, B,
and C) are normal developmental
tasks of older adults.
6
.
After administration of an 0730 dose
of Humalog 50/50 insulin to a client
with diabetes mellitus, which
nursing action has the highest
priority?
A. Ensure that the client receives
breakfast within 30 minutes.
B. Remind the client to have a
midmorning snack at 1000.
C. Discuss the importance of a
midafternoon snack with the client.
D. Explain that the client's capillary
glucose will be checked at 1130.
A. Ensure that the client receives
breakfast within 30 minutes.
Rationale:
Insulin 50/50 contains 50% regular
and 50% NPH insulin. Therefore, the
onset of action is within 30 minutes
and the nurse's priority action is to
ensure that the client receives a
breakfast tray to avoid a
hypoglycemic reaction (A). (B, C, and
D) are also important nursing actions
but are of less immediacy than (A).
7
.
The antigout medication allopurinol
(Zyloprim) is prescribed for a client newly
diagnosed with gout. Which comment by
the client warrants intervention by the
nurse?
A. "I take aspirin for my pain."
B. "I frequently eat fruit and drink fruit
juices."
C. "I drink a great deal of water, so I have
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