HESI E2 HESI Exit Exam - Set 2 - Part 2

Correct Answer: Thiamine 100 milligrams IV

Thiamine must be given before any glucose in a malnourished alcohol-dependent client to prevent precipitating Wernicke encephalopathy. Early thiamine protects the brain while the team also initiates benzodiazepines for withdrawal management. Option a is incorrect because giving glucose first in a thiamine-depleted client triggers Wernicke encephalopathy with confusion, ataxia, and ophthalmoplegia. The classic teaching is thiamine before dextrose precisely to prevent this irreversible injury. Option c is incorrect because disulfiram is a maintenance therapy initiated only after the client has been alcohol-free for at least 12 hours and is stable. Giving it now would produce a dangerous reaction as residual alcohol metabolizes. Option d is incorrect because while suicide monitoring may eventually be indicated, the immediate physiologic priority is preventing Wernicke encephalopathy. Maslow places airway, breathing, circulation, and brain protection above psychological observation.

Correct Answer: "Firm mattress with no loose items."

A firm flat mattress, tight-fitting sheet, and an empty crib free of bumpers, pillows, blankets, and toys is the AAP standard for SIDS prevention. Room-sharing without bed-sharing is also recommended through at least the first six months. Option a is incorrect because soft pillows of any size or placement raise the risk of suffocation and rebreathing. The crib should be empty aside from the fitted sheet, regardless of how reassuring the soft surroundings may appear to adults. Option b is incorrect because bed-sharing is a well-documented SIDS risk factor. Room-sharing with the infant in a separate firm sleep surface allows easy breastfeeding access without the suffocation and entrapment hazards of an adult mattress. Option c is incorrect because prone sleeping is the single largest modifiable SIDS risk factor. Healthy infants are placed supine to sleep, and the gag reflex protects them from choking even if they spit up in this position.

Correct Answer: Russell sign with dental erosion

Russell sign (calluses on knuckles) develops from inducing vomiting against the teeth, and gastric acid erodes dental enamel. Both are classic findings in bulimia, where weight typically stays near normal despite repeated binge-purge cycles. Option a is incorrect because lanugo, the soft body hair grown when fat stores fail to insulate the body, is characteristic of anorexia nervosa. Bulimic clients usually maintain enough body fat that this thermoregulatory response does not appear. Option b is incorrect because a BMI of 14.5 indicates severe underweight, which defines anorexia nervosa. Bulimic clients typically maintain a normal or slightly elevated BMI because binges replace the calories lost through compensatory behaviors. Option d is incorrect because amenorrhea is driven by low body weight and hypothalamic suppression, which is common in anorexia. Bulimic clients with preserved weight usually continue to menstruate, though cycles may become irregular with severe purging.

Correct Answer: Positive indirect Coombs test

A positive indirect Coombs test means the mother is already sensitized to Rh-positive blood. Once sensitization has occurred, RhoGAM no longer prevents antibody formation, so administration is held while the provider reassesses management. Option b is incorrect because 28 weeks is precisely the recommended time for routine prenatal RhoGAM administration in unsensitized Rh-negative women. This gestational milestone confirms readiness rather than serving as a reason to hold the dose. Option c is incorrect because Rh-negative status is exactly the indication for RhoGAM, not a contraindication. The medication targets Rh-negative mothers who have not yet developed antibodies against Rh-positive fetal red blood cells. Option d is incorrect because paternal Rh-positive status raises the chance of an Rh-positive fetus and supports administration. It justifies giving RhoGAM rather than holding it, since the fetus may carry the antigen mother could form antibodies against.

Correct Answer: "Colonoscopy every 10 years works."

USPSTF and ACS recommend starting colorectal cancer screening at age 45 for average-risk adults. Options include colonoscopy every 10 years, annual FIT, or stool DNA testing every three years, all with strong supporting evidence. Option a is incorrect because routine colorectal cancer screening for average-risk adults begins at age 45, not 30. Screening before 45 is reserved for clients with familial syndromes, inflammatory bowel disease, or significant family history. Option b is incorrect because age 50 is no longer a stopping point and currently marks five years past the recommended starting age. Screening typically continues through age 75 with individualized decisions for clients 76 to 85 years old. Option d is incorrect because waiting for symptoms defeats the purpose of secondary prevention. Most colorectal cancers are clinically silent until late stages, and screening identifies precancerous polyps long before any symptoms appear.

Correct Answer: "I do not hear those messages."

Presenting reality calmly without arguing acknowledges the client's distress while not reinforcing the delusion. This technique builds trust and keeps the conversation grounded in the client's emotional experience rather than the false belief content. Option a is incorrect because arguing with a delusion strengthens it. The client lacks the cognitive flexibility to reconsider the belief on logical grounds, and direct confrontation usually deepens paranoia and damages the therapeutic alliance. Option c is incorrect because exploring the content of a delusion reinforces it by treating the false belief as worthy of detailed analysis. "Why" questions also imply judgment and demand the client justify an experience already real to them. Option d is incorrect because unplugging the television implicitly agrees that messages were coming through it. Acting on the delusion's premise validates the false belief and may make the client mistrust the nurse during future episo

Correct Answer: "Grandpa died and will not return."

Preschoolers are concrete thinkers and interpret euphemisms literally. Saying someone is sleeping can cause fear of bedtime, while honest, simple language conveys the permanence of death in terms the child can absorb without distorted meaning. Option a is incorrect because "a better place" lacks meaning for a preschooler and may suggest grandpa chose to leave the child. Religious framing also needs parental consent and works only when the family already shares that worldview. Option b is incorrect because comparing death to sleep frequently produces bedtime terror, refusal to nap, and fear that family members will not awaken. Concrete preschoolers cannot distinguish the metaphor and translate it into a literal threat. Option c is incorrect because dismissing the question invalidates the child's emotional reality. Preschoolers process loss through repeated questioning, and brushing them off teaches them not to bring grief to trusted adults in the future.

Correct Answer: "Occasional wine in moderation is fine."

No safe amount of alcohol has been established during pregnancy because fetal alcohol spectrum disorders can occur with any exposure. The other statements reflect appropriate avoidance of listeria, excess caffeine, and high-mercury fish during pregnancy. Option a is incorrect because avoiding unpasteurized soft cheeses correctly reduces listeria risk, which carries a high rate of fetal loss. This statement reflects accurate teaching and would not need correction during the follow-up session. Option b is incorrect because limiting caffeine to under 200 milligrams daily matches current ACOG guidance. The teaching is appropriate, balancing modest enjoyment with the small but real association between high caffeine intake and miscarriage. Option d is incorrect because skipping high-mercury fish such as shark, swordfish, and king mackerel reflects sound prenatal counseling. Mercury crosses the placenta and concentrates in fetal brain tissue, so this avoidance protects neurodevelopment.

Correct Answer: Pap every 3 years or co-test

Women 30 to 65 with no risk factors can choose Pap every 3 years, Pap with HPV co-test every 5 years, or primary HPV testing every 5 years. All three options are endorsed by current ACS and USPSTF guidelines. Option a is incorrect because cervical cancer screening starts at age 21, not 18, and annual Paps have been replaced by less frequent intervals for low-risk women. Excess screening detects transient HPV changes without improving cancer outcomes. Option c is incorrect because skipping screening entirely misses precancerous lesions that are highly treatable when caught early. Cervical cancer remains a leading cancer killer worldwide where screening programs are absent or interrupted. Option d is incorrect because age 30 is where screening intervals lengthen, not where screening ends. Average-risk women may discontinue screening at age 65 only after adequate prior negative results documented within the recommended windows.

Correct Answer: "Let's talk about a safety plan."

Affirming the disclosure and offering collaborative safety planning honors autonomy while increasing the client's tools to stay safer. Pressuring her to leave may push her back into silence and is the most dangerous time for an IPV survivor. Option a is incorrect because pressuring an IPV survivor to leave ignores autonomy and overlooks that the most dangerous time is right after leaving. The client may also rely on the abuser financially or for housing in unseen ways. Option b is incorrect because shaming the client for staying inflicts secondary trauma and confirms that disclosure will be met with judgment. The nurse should validate the courage of disclosure and meet the client where she is right now. Option d is incorrect because calling police without the client's consent breaches autonomy in most jurisdictions and may trigger retaliation. Adult IPV reporting laws vary by state, and most do not mandate involuntary police involvement at all.

Correct Answer: Conduct immediate safety assessment

The statement "the baby would be better off without me" is a classic warning sign of suicidal or infanticidal ideation associated with postpartum depression or psychosis. Immediate safety assessment overrides routine education or referrals at this point. Option a is incorrect because suggesting more sleep dismisses a life-threatening cue. The client's expressed thought of being a burden indicates a psychiatric emergency that cannot be addressed by sleep hygiene advice for routine postpartum fatigue. Option b is incorrect because a support group referral works on a timeline of days to weeks, which is far too slow for current ideation. Acute safety planning and same-day evaluation must occur before any outpatient follow-up is scheduled. Option c is incorrect because baby blues resolve within two weeks and never include thoughts of suicide or infant harm. Mislabeling the disclosure as a normal phase delays evaluation and could be catastrophic for the mother and the newborn.

Correct Answer: Conduct focused suicide risk assessment

Any positive response to PHQ-9 item 9 requires immediate safety assessment regardless of the total score. The nurse evaluates plan, means, intent, and protective factors before considering disposition and outpatient referrals at the close of the visit. Option a is incorrect because deferring documentation to a later visit ignores the most urgent finding on the screening tool. Item 9 demands same-encounter action, not scheduled charting that could leave the student at risk in the interim. Option b is incorrect because outpatient scheduling assumes the student is safe to leave the current encounter. Without a focused assessment of intent and means, the nurse cannot determine whether higher-level intervention is warranted today. Option d is incorrect because handing out pamphlets responds to a moderate-risk indicator with low-intensity self-help materials. Active suicidal ideation requires direct dialogue and possible escalation, not passive printed coping content.

Correct Answer: Reposition left side, stop oxytocin

Late decelerations signal uteroplacental insufficiency. Lateral positioning improves perfusion, stopping oxytocin reduces uterine stress, and oxygen plus IV bolus and provider notification follow. These interventions form the standard intrauterine resuscitation bundle. Option a is incorrect because passive monitoring during late decelerations allows fetal hypoxia and acidemia to worsen. The pattern is a Category II or III warning that demands active intrauterine resuscitation, not silent observation while the strip deteriorates. Option c is incorrect because increasing oxytocin during late decelerations intensifies the very uterine stress causing the deceleration. More contractions further compromise placental perfusion and accelerate fetal compromise instead of relieving it. Option d is incorrect because a scalp electrode improves signal quality but does not treat the hypoxic cause. Diagnostic clarity will not help a baby whose placenta is failing; the priority is to restore perfusion

Correct Answer: 9 out of 10

Color earns 1 for acrocyanosis with pink trunk, while pulse, grimace, activity, and respirations each earn 2. The total is 9 out of 10. Acrocyanosis is the only deduction, reflecting normal peripheral vasoconstriction in the first day. Option b is incorrect because a score of 7 would require deductions in two additional categories. The infant scored full marks for heart rate, reflex, tone, and respirations, so the only point lost is one for acrocyanosis-related color. Option c is incorrect because a score of 8 would require two minus-one categories rather than one. The exam findings only justify a single point deduction for acrocyanosis, leaving the correct total at 9. Option d is incorrect because acrocyanosis specifically costs one color point. A perfect 10 requires pink color throughout the body and extremities, which is unusual at five minutes due to normal peripheral vasoconstriction.

Correct Answer: Honor POLST and support the family

A valid POLST or DNR order represents the client's autonomous choice and is legally binding. The nurse honors the directive, supports the family through the loss, and offers chaplain, social work, and bereavement resources at the bedside. Option a is incorrect because family members cannot override a client's documented end-of-life wishes. Performing CPR contrary to a valid POLST violates autonomy and informed consent, and may expose the facility to legal action for battery. Option b is incorrect because excluding the family and starting compressions still violates the documented order. The right action is to honor the directive openly and use this difficult moment to provide compassionate education and support. Option c is incorrect because partial resuscitation has no clinical or legal validity. Compressions performed to satisfy the family while ignoring the POLST still constitute a violation of the client's expressed and documented wishes.

Correct Answer: "I can add honey to cereal."

Honey is contraindicated under 12 months because it may contain Clostridium botulinum spores that cause infant botulism. The other statements correctly describe iron-fortified starter cereals, allergy spacing, and choking-hazard reduction. Option a is incorrect because iron-fortified rice cereal is a developmentally appropriate first food at around 6 months. It supplies iron at a time when infant stores have been depleted, which makes this statement reflect correct understanding. Option c is incorrect because waiting 3 to 5 days between new foods is the recommended way to identify food allergies. The interval allows time to observe rashes, GI symptoms, or anaphylactic reactions before adding another new ingredient. Option d is incorrect because cutting grapes into small pieces removes the round, slick shape that obstructs an infant airway. This is a textbook example of safe food preparation for the 6 to 24 month age range.

Correct Answer: Delirium; check vitals and urine

Acute postoperative confusion in a previously oriented older adult is delirium until proven otherwise. Common reversible triggers include hypoxia, infection, electrolyte disturbances, urinary retention, and pain, so vital signs and a urinalysis come first. Option a is incorrect because Alzheimer disease develops gradually over months to years, not overnight after surgery. Imaging would not yield same-day actionable findings, and dementia does not explain the sudden hallucinations and fluctuating attention. Option b is incorrect because depression produces persistent low mood and anhedonia rather than acute hallucinations. SSRIs take weeks to act and could worsen confusion if added without first ruling out reversible causes of the acute change. Option d is incorrect because new-onset schizophrenia at age 80 is extraordinarily rare. The acute onset after surgery points squarely at delirium, and a psychiatric consult bypasses the medical workup that will identify the underlying cause.

Correct Answer: Long-acting benzodiazepine increases fall risk

Long-acting benzodiazepines appear on Beers Criteria because of accumulated sedation, cognitive impairment, and fall risk in older adults. The nurse should advocate for review, dose reduction, or substitution with a safer agent before discharge. Option b is incorrect because beta-blockers are not categorically restricted by Beers Criteria. Many older adults benefit from them for hypertension or heart failure, with monitoring for bradycardia and orthostatic symptoms rather than blanket avoidance. Option c is incorrect because opioids may be used in older adults with careful titration and bowel regimen. The Beers Criteria caution against specific opioids like meperidine, not opioids as a class for all clients past 65. Option d is incorrect because most sleep aids carry significant adverse effects, especially anticholinergics that worsen confusion and falls. Calling them effective without side effects directly contradicts the safety concerns the Beers list addresses.

Correct Answer: Partner with promotoras locally

Promotoras are trusted community health workers who share language and cultural background. Engaging them and using local accessible sites consistently outperforms hospital-based, English-only programs in measurable behavior change for Hispanic populations. Option a is incorrect because hospital-based, English-only programming creates location, language, and cultural barriers. Many community members will not attend, leaving the program unable to demonstrate population-level outcomes despite the nurse's investment. Option b is incorrect because mailings in a non-preferred language with phone translation are passive and rarely change behavior. Effective community health design embeds learning in trusted relationships, not in unfamiliar print or telephone follow-up. Option c is incorrect because forcing English exposure with no language support actively disadvantages clients. It also reflects an outdated assimilation mindset rather than the cultural humility now standard in community

Correct Answer: "Drink 6 to 8 glasses water daily."

Lithium clearance depends on stable hydration and sodium balance. Dehydration, salt restriction, and NSAIDs all raise lithium levels and increase toxicity risk, especially for someone exercising in heat. Steady fluids and avoiding ibuprofen are essential for safety. Option b is incorrect because grapefruit juice affects cytochrome P450 metabolism of other drugs but offers no absorption benefit for lithium. Recommending it confuses the teaching and adds no therapeutic value to the regimen. Option c is incorrect because reducing sodium intake increases lithium retention and raises toxicity risk. Clients on lithium should maintain a stable, consistent sodium intake rather than restricting it for cardiovascular reasons. Option d is incorrect because NSAIDs decrease lithium excretion through the kidney and can rapidly push levels into the toxic range. Permission to use ibuprofen freely would precipitate exactly the dangerous interaction this teaching aims to prevent.