Herzing University HESI RN Exit
Exam with NGN Test Bank - 150
Questions & Correct Verified Answers
for an A+ Grade
**Question 1:**
The nurse is caring for a client with pneumonia who develops initial
signs of septic shock and multi-organ failure. The healthcare provider
prescribes a sepsis protocol. Which intervention is most important for
the nurse to include in the plan of care?
A) Keep the head of bed raised 45 degrees
B) Maintain strict intake and output
C) Assess warmth of extremities
D) Monitor blood glucose level
**Correct Answer: B) Maintain strict intake and output**
*Rationale:* Strict I&O monitoring is the most critical intervention in
sepsis. Septic shock can lead to fluid shifts, decreased perfusion, and
multi-organ failure, making fluid balance essential for guiding
treatment decisions including fluid resuscitation and vasopressor
therapy .
,**Question 2:**
A client has been diagnosed with bilateral lower lobe atelectasis. What
percussion sound should the nurse expect to hear when percussing
over the client's lower lobes?
A) Hyperresonance
B) Tympany
C) Dull, thud-like sound
D) Flatness
**Correct Answer: C) Dull, thud-like sound**
*Rationale:* Atelectasis (collapsed lung tissue) produces a dull
percussion sound due to increased density of non-aerated lung tissue.
Hyperresonance is heard with emphysema or pneumothorax, tympany
over a gastric bubble, and flatness over solid organs like the liver .
**Question 3:**
The rapid response team detects return of spontaneous circulation
(ROSC) after 2 minutes of continuous chest compressions. The client
has a weak, fast pulse and no respiratory effort, so the healthcare
provider performs successful oral intubation. What action should the
nurse implement FIRST?
A) Resume compressions for 2 minutes
,B) Administer a dose of epinephrine
C) Perform bilateral chest auscultation
D) Program the monitor for cardioversion
**Correct Answer: C) Perform bilateral chest auscultation**
*Rationale:* After intubation, the position of the endotracheal tube
should be assessed for proper placement immediately. Auscultating for
breath sounds is the first and quickest method to verify proper tube
placement, which can later be confirmed by chest x-ray .
**Question 4:**
A client with heart failure has a prescription for digoxin. The nurse is
aware that sufficient potassium should be included in the diet because
hypokalemia in combination with this medication:
A) Can predispose to dysrhythmias
B) May lead to oliguria
C) May cause irritability and anxiety
D) Sometimes alters consciousness
**Correct Answer: A) Can predispose to dysrhythmias**
, *Rationale:* Hypokalemia increases the risk of digoxin toxicity, which
commonly manifests as cardiac dysrhythmias. Low potassium levels
make cardiac cells more sensitive to digoxin's effects, increasing the risk
of serious arrhythmias .
**Question 5:**
A male client with cirrhosis has ascites and reports feeling short of
breath. The client is in semi-Fowler position with his arms at his side.
What action should the nurse implement?
A) Reposition the client in a side-lying position and support his
abdomen with pillows
B) Elevate the client's feet on a pillow while keeping the head of the
bed elevated
C) Raise the head of the bed to Fowler's position and support his arms
with a pillow
D) Place the client in a shock position and monitor vital signs frequently
**Correct Answer: C) Raise the head of the bed to Fowler's position and
support his arms with a pillow**
*Rationale:* Ascites is the accumulation of fluid in the peritoneal
cavity, which pushes on the diaphragm limiting lung expansion and
causing dyspnea. To relieve pressure, the head of the bed should be
elevated with the arms supported for comfort .
Exam with NGN Test Bank - 150
Questions & Correct Verified Answers
for an A+ Grade
**Question 1:**
The nurse is caring for a client with pneumonia who develops initial
signs of septic shock and multi-organ failure. The healthcare provider
prescribes a sepsis protocol. Which intervention is most important for
the nurse to include in the plan of care?
A) Keep the head of bed raised 45 degrees
B) Maintain strict intake and output
C) Assess warmth of extremities
D) Monitor blood glucose level
**Correct Answer: B) Maintain strict intake and output**
*Rationale:* Strict I&O monitoring is the most critical intervention in
sepsis. Septic shock can lead to fluid shifts, decreased perfusion, and
multi-organ failure, making fluid balance essential for guiding
treatment decisions including fluid resuscitation and vasopressor
therapy .
,**Question 2:**
A client has been diagnosed with bilateral lower lobe atelectasis. What
percussion sound should the nurse expect to hear when percussing
over the client's lower lobes?
A) Hyperresonance
B) Tympany
C) Dull, thud-like sound
D) Flatness
**Correct Answer: C) Dull, thud-like sound**
*Rationale:* Atelectasis (collapsed lung tissue) produces a dull
percussion sound due to increased density of non-aerated lung tissue.
Hyperresonance is heard with emphysema or pneumothorax, tympany
over a gastric bubble, and flatness over solid organs like the liver .
**Question 3:**
The rapid response team detects return of spontaneous circulation
(ROSC) after 2 minutes of continuous chest compressions. The client
has a weak, fast pulse and no respiratory effort, so the healthcare
provider performs successful oral intubation. What action should the
nurse implement FIRST?
A) Resume compressions for 2 minutes
,B) Administer a dose of epinephrine
C) Perform bilateral chest auscultation
D) Program the monitor for cardioversion
**Correct Answer: C) Perform bilateral chest auscultation**
*Rationale:* After intubation, the position of the endotracheal tube
should be assessed for proper placement immediately. Auscultating for
breath sounds is the first and quickest method to verify proper tube
placement, which can later be confirmed by chest x-ray .
**Question 4:**
A client with heart failure has a prescription for digoxin. The nurse is
aware that sufficient potassium should be included in the diet because
hypokalemia in combination with this medication:
A) Can predispose to dysrhythmias
B) May lead to oliguria
C) May cause irritability and anxiety
D) Sometimes alters consciousness
**Correct Answer: A) Can predispose to dysrhythmias**
, *Rationale:* Hypokalemia increases the risk of digoxin toxicity, which
commonly manifests as cardiac dysrhythmias. Low potassium levels
make cardiac cells more sensitive to digoxin's effects, increasing the risk
of serious arrhythmias .
**Question 5:**
A male client with cirrhosis has ascites and reports feeling short of
breath. The client is in semi-Fowler position with his arms at his side.
What action should the nurse implement?
A) Reposition the client in a side-lying position and support his
abdomen with pillows
B) Elevate the client's feet on a pillow while keeping the head of the
bed elevated
C) Raise the head of the bed to Fowler's position and support his arms
with a pillow
D) Place the client in a shock position and monitor vital signs frequently
**Correct Answer: C) Raise the head of the bed to Fowler's position and
support his arms with a pillow**
*Rationale:* Ascites is the accumulation of fluid in the peritoneal
cavity, which pushes on the diaphragm limiting lung expansion and
causing dyspnea. To relieve pressure, the head of the bed should be
elevated with the arms supported for comfort .
