HESI EXIT PRACTICE QUESTIONS
AND RATIONALE UPDATE|EXAM
QUESTIONS WITH MULTIPLE
CHOICES |VERIFIED & REVISED
ANSWERS (NEW)!!!
Potassiummchloridemintravenouslymismprescribedmformamclientmwithmhypokalemia.mWhichmactionsms
houldmthemnursemtakemtomplanmformpreparationmandmadministrationmofmthempotassium?mSelectmallm
thatmapply.
1.mObtainmanmintravenousm(IV)minfusionmpump.
m 2.Monitormurinemoutputmduringmadministration.
m 3.Preparemthemmedicationmformbolusmadministration.
m 4.MonitormthemIVmsitemformsignsmofminfiltrationmormphlebitis.
m 5.Ensuremthatmthemmedicationmismdilutedminmthemappropriatemvolumemofmfluid.
m6.Ensuremthatmthembagmismlabeledmsomthatmitmreadsmthemvolumemofmpotassiumminmthemsolution.m-
mCORRECTmANSWERm1,m2,m4,m5,m6
PotassiummchloridemadministeredmintravenouslymmustmalwaysmbemdilutedminmIVmfluidmandminfused
mviamanminfusionmpump.mPotassiummchloridemismnevermgivenmbymbolusm(IVmpush).mGivingmpotassiu
mmchloridembymIVmpushmcanmresultminmcardiacmarrest.mThemnursemshouldmensuremthatmthempotassiu
mmismdilutedminmthemappropriatemamountmofmdiluentmormfluid.mThemIVmbagmcontainingmthempotassi
ummchloridemshouldmalwaysmbemlabeledmwithmthemvolumemofmpotassiummitmcontains.mThemIVmsitemi
smmonitoredmcloselymbecausempotassiummchloridemismirritatingmtomthemveinsmandmtheremismriskmofm
phlebitis.mInmaddition,mthemnursemshouldmmonitormforminfiltration.mThemnursemmonitorsmurinarymo
utputmduringmadministrationmandmcontactsmthemhealthmcaremprovidermifmthemurinarymoutputmismles
smthanm30mmL/hour.
Amclientmadmittedmtomthemhospitalmwithmchestmpainmandmamhistorymofmtypem2mdiabetesmmellitusmism
scheduledmformcardiacmcatheterization.mWhichmmedicationmwouldmneedmtombemwithheldmform24mh
oursmbeforemthemproceduremandmform48mhoursmaftermthemprocedure?
1.Glipizide
,2.Metforminm
3.Repaglinidem
4.Regularminsulinm-mCORRECTmANSWERm2
Metforminmneedsmtombemwithheldm24mhoursmbeforemandmform48mhoursmaftermcardiacmcatheterizati
onmbecausemofmtheminjectionmofmcontrastmmediummduringmthemprocedure.mIfmthemcontrastmmediu
mmaffectsmkidneymfunction,mwithmmetforminminmthemsystemmthemclientmwouldmbematmincreasedmris
kmformlacticmacidosis.mThemmedicationsminmthemremainingmoptionsmdomnotmneedmtombemwithheldm2
4mhoursmbeforemandm48mhoursmaftermcardiacmcatheterization.
Amclientmwhomhadmcardiacmsurgerym24mhoursmagomhasmhadmamurinemoutputmaveragingm20mmL/hour
mform2mhours.mThemclientmreceivedmamsinglembolusmofm500mmLmofmintravenousmfluid.mUrinemoutputmf
ormthemsubsequentmhourmwasm25mmL.mDailymlaboratorymresultsmindicatemthatmthembloodmureamnitr
ogenmlevelmism45mmg/dLm(16mmmol/L)mandmthemserummcreatininemlevelmism2.2mmg/dLm(194mmcmol
/L).mOnmthembasismofmthesemfindings,mthemnursemwouldmanticipatemthatmthemclientmismatmriskmformw
hichmproblem?
1.mHypovolemia
2.Acutemkidneyminjurym3.Glomerulonephritism
4.Urinarymtractminfectionm-mCORRECTmANSWERm2m
Themclientmwhomundergoesmcardiacmsurgerymismatmriskmformrenalminjurymfrommpoormperfusion,mhem
olysis,mlowmcardiacmoutput,mormvasopressormmedicationmtherapy.mRenalminjurymismsignaledmbymdec
reasedmurinemoutputmandmincreasedmbloodmureamnitrogenm(BUN)mandmcreatininemlevels.mNormalmr
eferencemlevelsmaremBUN,m10-20mmg/dLm(3.6-7.1mmmol/L),mandmcreatinine,mmale,m0.6-
1.2mmg/dLm(53-106mmcmol/L)mandmfemalem0.5-1.1mmg/dLm(44-
97mmcmol/L).mThemclientmmaymneedmmedicationsmtomincreasemrenalmperfusionmandmpossiblymcoul
dmneedmperitonealmdialysismormhemodialysis.mNomdataminmthemquestionmindicatemthempresencemofm
hypovolemia,mglomerulonephritis,mormurinarymtractminfection.
Themnursemismreviewingmanmelectrocardiogrammrhythmmstrip.mThemPmwavesmandmQRSmcomplexesma
remregular.mThemPRmintervalmism0.16mseconds,mandmQRSmcomplexesmmeasurem0.06mseconds.mThemo
verallmheartmratemism64mbeats/minute.mWhichmactionmshouldmthemnursemtake?
1.mCheckmvitalmsigns.
,2.Checkmlaboratorymtestmresults.m3.Notifymthemhealthmcaremprovider.m4.Continuemtommonitormforma
nymrhythmmchange.m-mCORRECTmANSWERm4m
Normalmsinusmrhythmmismdefinedmasmamregularmrhythm,mwithmanmoverallmratemofm60mtom100mbeats/
minute.mThemPRmandmQRSmmeasurementsmaremnormal,mmeasuringmbetweenm0.12mandm0.20mseco
ndsmandm0.04mandm0.10mseconds,mrespectively.mTheremaremnomirregularitiesminmthismrhythmmcurren
tly,msomtheremismnomimmediatemneedmtomcheckmvitalmsignsmormlaboratorymresults,mormtomnotifymthem
healthmcaremprovider.mTherefore,mthemnursemwouldmcontinuemtommonitormthemclientmformanymrhyth
mmchange.
Amclientmismwearingmamcontinuousmcardiacmmonitor,mwhichmbeginsmtomsoundmitsmalarm.mThemnurse
mseesmnomelectrocardiographicmcomplexesmonmthemscreen.mWhichmismthemprioritymnursingmaction?
1.mCallmamcode.
2.Callmthemhealthmcaremprovider.m3.Checkmthemclient'smstatusmandmleadmplacement.m
4.Pressmthemrecordermbuttonmonmthemelectrocardiogrammconsole.m-mCORRECTmANSWERm3m
Suddenmlossmofmelectrocardiographicmcomplexesmindicatesmventricularmasystolemormpossiblymelect
rodemdisplacement.mAccuratemassessmentmofmthemclientmandmequipmentmismnecessarymtomdetermi
nemthemcausemandmidentifymthemappropriatemintervention.mThemremainingmoptionsmaremsecondary
mtomclientmassessment.
Themnursemismevaluatingmamclient'smresponsemtomcardioversion.mWhichmassessmentmwouldmbemthem
priority?
1.mBloodmpressure
2.Statusmofmairwaym
3.Oxygenmflowmratem
4.Levelmofmconsciousnessm-mCORRECTmANSWERm2
Nursingmresponsibilitiesmaftermcardioversionmincludemmaintenancemfirstmofmampatentmairway,mandm
thenmoxygenmadministration,massessmentmofmvitalmsignsmandmlevelmofmconsciousness,mandmdysrhyt
hmiamdetection.
Cardioversionmismammedicalmproceduremthatmrestoresmamnormalmheartmrhythmminmpeoplemwithmcer
tainmtypesmofmabnormalmheartbeatsm(arrhythmias)
, Themnursemismcaringmformamclientmwhomhasmjustmhadmimplantationmofmanmautomaticminternalmcardi
overter-defibrillator.mThemnursemshouldmassessmwhichmitemmbasedmonmpriority?
1.mAnxietymlevelmofmthemclientmandmfamily
2.PresencemofmamMedicAlertmcardmformthemclientmtomcarry
3.mKnowledgemofmrestrictionsmonmpostdischargemphysicalmactivity
4.mActivationmstatusmofmthemdevice,mheartmratemcutoff,mandmnumbermofmshocksmitmismprogrammedm
tomdeliverm-mCORRECTmANSWERm4
Themnursemwhomismcaringmformthemclientmafterminsertionmofmanmautomaticminternalmcardioverter-
defibrillatormneedsmtomassessmdevicemsettings,msimilarmtomafterminsertionmofmampermanentmpacem
aker.mSpecifically,mthemnursemneedsmtomknowmwhethermthemdevicemismactivated,mthemheartmratemcu
toffmabovemwhichmitmwillmfire,mandmthemnumbermofmshocksmitmismprogrammedmtomdeliver.mThemrem
ainingmoptionsmaremalsomnursingminterventionsmbutmaremnotmthempriority.
Amclient'smelectrocardiogrammstripmshowsmatrialmandmventricularmratesmofm110mbeats/minute.mThe
mPRmintervalmism0.14mseconds,mthemQRSmcomplexmmeasuresm0.08mseconds,mandmthemPPmandmRRmint
ervalsmaremregular.mHowmshouldmthemnursemcorrectlyminterpretmthismrhythm?
1.Sinusmtachycardia
2.Sinusmbradycardiam
3.Sinusmdysrhythmiam
4.Normalmsinusmrhythmm-mCORRECTmANSWERm1
Sinusmtachycardiamhasmthemcharacteristicsmofmnormalmsinusmrhythm,mincludingmamregularmPPminter
valmandmnormal-
widthmPRmandmQRSmintervals;mhowever,mthemratemismthemdifferentiatingmfactor.mInmsinusmtachycardi
a,mthematrialmandmventricularmratesmaremgreatermthanm100mbeats/minute.
Themnursemismassessingmthemneurovascularmstatusmofmamclientmwhomreturnedmtomthemsurgicalmnursi
ngmunitm4mhoursmagomaftermundergoingmaortoiliacmbypassmgraft.mThemaffectedmlegmismwarm,mandmt
hemnursemnotesmrednessmandmedema.mThempedalmpulsemismpalpablemandmunchangedmfrommadmiss
ion.mHowmshouldmthemnursemcorrectlyminterpretmthemclient'smneurovascularmstatus?
AND RATIONALE UPDATE|EXAM
QUESTIONS WITH MULTIPLE
CHOICES |VERIFIED & REVISED
ANSWERS (NEW)!!!
Potassiummchloridemintravenouslymismprescribedmformamclientmwithmhypokalemia.mWhichmactionsms
houldmthemnursemtakemtomplanmformpreparationmandmadministrationmofmthempotassium?mSelectmallm
thatmapply.
1.mObtainmanmintravenousm(IV)minfusionmpump.
m 2.Monitormurinemoutputmduringmadministration.
m 3.Preparemthemmedicationmformbolusmadministration.
m 4.MonitormthemIVmsitemformsignsmofminfiltrationmormphlebitis.
m 5.Ensuremthatmthemmedicationmismdilutedminmthemappropriatemvolumemofmfluid.
m6.Ensuremthatmthembagmismlabeledmsomthatmitmreadsmthemvolumemofmpotassiumminmthemsolution.m-
mCORRECTmANSWERm1,m2,m4,m5,m6
PotassiummchloridemadministeredmintravenouslymmustmalwaysmbemdilutedminmIVmfluidmandminfused
mviamanminfusionmpump.mPotassiummchloridemismnevermgivenmbymbolusm(IVmpush).mGivingmpotassiu
mmchloridembymIVmpushmcanmresultminmcardiacmarrest.mThemnursemshouldmensuremthatmthempotassiu
mmismdilutedminmthemappropriatemamountmofmdiluentmormfluid.mThemIVmbagmcontainingmthempotassi
ummchloridemshouldmalwaysmbemlabeledmwithmthemvolumemofmpotassiummitmcontains.mThemIVmsitemi
smmonitoredmcloselymbecausempotassiummchloridemismirritatingmtomthemveinsmandmtheremismriskmofm
phlebitis.mInmaddition,mthemnursemshouldmmonitormforminfiltration.mThemnursemmonitorsmurinarymo
utputmduringmadministrationmandmcontactsmthemhealthmcaremprovidermifmthemurinarymoutputmismles
smthanm30mmL/hour.
Amclientmadmittedmtomthemhospitalmwithmchestmpainmandmamhistorymofmtypem2mdiabetesmmellitusmism
scheduledmformcardiacmcatheterization.mWhichmmedicationmwouldmneedmtombemwithheldmform24mh
oursmbeforemthemproceduremandmform48mhoursmaftermthemprocedure?
1.Glipizide
,2.Metforminm
3.Repaglinidem
4.Regularminsulinm-mCORRECTmANSWERm2
Metforminmneedsmtombemwithheldm24mhoursmbeforemandmform48mhoursmaftermcardiacmcatheterizati
onmbecausemofmtheminjectionmofmcontrastmmediummduringmthemprocedure.mIfmthemcontrastmmediu
mmaffectsmkidneymfunction,mwithmmetforminminmthemsystemmthemclientmwouldmbematmincreasedmris
kmformlacticmacidosis.mThemmedicationsminmthemremainingmoptionsmdomnotmneedmtombemwithheldm2
4mhoursmbeforemandm48mhoursmaftermcardiacmcatheterization.
Amclientmwhomhadmcardiacmsurgerym24mhoursmagomhasmhadmamurinemoutputmaveragingm20mmL/hour
mform2mhours.mThemclientmreceivedmamsinglembolusmofm500mmLmofmintravenousmfluid.mUrinemoutputmf
ormthemsubsequentmhourmwasm25mmL.mDailymlaboratorymresultsmindicatemthatmthembloodmureamnitr
ogenmlevelmism45mmg/dLm(16mmmol/L)mandmthemserummcreatininemlevelmism2.2mmg/dLm(194mmcmol
/L).mOnmthembasismofmthesemfindings,mthemnursemwouldmanticipatemthatmthemclientmismatmriskmformw
hichmproblem?
1.mHypovolemia
2.Acutemkidneyminjurym3.Glomerulonephritism
4.Urinarymtractminfectionm-mCORRECTmANSWERm2m
Themclientmwhomundergoesmcardiacmsurgerymismatmriskmformrenalminjurymfrommpoormperfusion,mhem
olysis,mlowmcardiacmoutput,mormvasopressormmedicationmtherapy.mRenalminjurymismsignaledmbymdec
reasedmurinemoutputmandmincreasedmbloodmureamnitrogenm(BUN)mandmcreatininemlevels.mNormalmr
eferencemlevelsmaremBUN,m10-20mmg/dLm(3.6-7.1mmmol/L),mandmcreatinine,mmale,m0.6-
1.2mmg/dLm(53-106mmcmol/L)mandmfemalem0.5-1.1mmg/dLm(44-
97mmcmol/L).mThemclientmmaymneedmmedicationsmtomincreasemrenalmperfusionmandmpossiblymcoul
dmneedmperitonealmdialysismormhemodialysis.mNomdataminmthemquestionmindicatemthempresencemofm
hypovolemia,mglomerulonephritis,mormurinarymtractminfection.
Themnursemismreviewingmanmelectrocardiogrammrhythmmstrip.mThemPmwavesmandmQRSmcomplexesma
remregular.mThemPRmintervalmism0.16mseconds,mandmQRSmcomplexesmmeasurem0.06mseconds.mThemo
verallmheartmratemism64mbeats/minute.mWhichmactionmshouldmthemnursemtake?
1.mCheckmvitalmsigns.
,2.Checkmlaboratorymtestmresults.m3.Notifymthemhealthmcaremprovider.m4.Continuemtommonitormforma
nymrhythmmchange.m-mCORRECTmANSWERm4m
Normalmsinusmrhythmmismdefinedmasmamregularmrhythm,mwithmanmoverallmratemofm60mtom100mbeats/
minute.mThemPRmandmQRSmmeasurementsmaremnormal,mmeasuringmbetweenm0.12mandm0.20mseco
ndsmandm0.04mandm0.10mseconds,mrespectively.mTheremaremnomirregularitiesminmthismrhythmmcurren
tly,msomtheremismnomimmediatemneedmtomcheckmvitalmsignsmormlaboratorymresults,mormtomnotifymthem
healthmcaremprovider.mTherefore,mthemnursemwouldmcontinuemtommonitormthemclientmformanymrhyth
mmchange.
Amclientmismwearingmamcontinuousmcardiacmmonitor,mwhichmbeginsmtomsoundmitsmalarm.mThemnurse
mseesmnomelectrocardiographicmcomplexesmonmthemscreen.mWhichmismthemprioritymnursingmaction?
1.mCallmamcode.
2.Callmthemhealthmcaremprovider.m3.Checkmthemclient'smstatusmandmleadmplacement.m
4.Pressmthemrecordermbuttonmonmthemelectrocardiogrammconsole.m-mCORRECTmANSWERm3m
Suddenmlossmofmelectrocardiographicmcomplexesmindicatesmventricularmasystolemormpossiblymelect
rodemdisplacement.mAccuratemassessmentmofmthemclientmandmequipmentmismnecessarymtomdetermi
nemthemcausemandmidentifymthemappropriatemintervention.mThemremainingmoptionsmaremsecondary
mtomclientmassessment.
Themnursemismevaluatingmamclient'smresponsemtomcardioversion.mWhichmassessmentmwouldmbemthem
priority?
1.mBloodmpressure
2.Statusmofmairwaym
3.Oxygenmflowmratem
4.Levelmofmconsciousnessm-mCORRECTmANSWERm2
Nursingmresponsibilitiesmaftermcardioversionmincludemmaintenancemfirstmofmampatentmairway,mandm
thenmoxygenmadministration,massessmentmofmvitalmsignsmandmlevelmofmconsciousness,mandmdysrhyt
hmiamdetection.
Cardioversionmismammedicalmproceduremthatmrestoresmamnormalmheartmrhythmminmpeoplemwithmcer
tainmtypesmofmabnormalmheartbeatsm(arrhythmias)
, Themnursemismcaringmformamclientmwhomhasmjustmhadmimplantationmofmanmautomaticminternalmcardi
overter-defibrillator.mThemnursemshouldmassessmwhichmitemmbasedmonmpriority?
1.mAnxietymlevelmofmthemclientmandmfamily
2.PresencemofmamMedicAlertmcardmformthemclientmtomcarry
3.mKnowledgemofmrestrictionsmonmpostdischargemphysicalmactivity
4.mActivationmstatusmofmthemdevice,mheartmratemcutoff,mandmnumbermofmshocksmitmismprogrammedm
tomdeliverm-mCORRECTmANSWERm4
Themnursemwhomismcaringmformthemclientmafterminsertionmofmanmautomaticminternalmcardioverter-
defibrillatormneedsmtomassessmdevicemsettings,msimilarmtomafterminsertionmofmampermanentmpacem
aker.mSpecifically,mthemnursemneedsmtomknowmwhethermthemdevicemismactivated,mthemheartmratemcu
toffmabovemwhichmitmwillmfire,mandmthemnumbermofmshocksmitmismprogrammedmtomdeliver.mThemrem
ainingmoptionsmaremalsomnursingminterventionsmbutmaremnotmthempriority.
Amclient'smelectrocardiogrammstripmshowsmatrialmandmventricularmratesmofm110mbeats/minute.mThe
mPRmintervalmism0.14mseconds,mthemQRSmcomplexmmeasuresm0.08mseconds,mandmthemPPmandmRRmint
ervalsmaremregular.mHowmshouldmthemnursemcorrectlyminterpretmthismrhythm?
1.Sinusmtachycardia
2.Sinusmbradycardiam
3.Sinusmdysrhythmiam
4.Normalmsinusmrhythmm-mCORRECTmANSWERm1
Sinusmtachycardiamhasmthemcharacteristicsmofmnormalmsinusmrhythm,mincludingmamregularmPPminter
valmandmnormal-
widthmPRmandmQRSmintervals;mhowever,mthemratemismthemdifferentiatingmfactor.mInmsinusmtachycardi
a,mthematrialmandmventricularmratesmaremgreatermthanm100mbeats/minute.
Themnursemismassessingmthemneurovascularmstatusmofmamclientmwhomreturnedmtomthemsurgicalmnursi
ngmunitm4mhoursmagomaftermundergoingmaortoiliacmbypassmgraft.mThemaffectedmlegmismwarm,mandmt
hemnursemnotesmrednessmandmedema.mThempedalmpulsemismpalpablemandmunchangedmfrommadmiss
ion.mHowmshouldmthemnursemcorrectlyminterpretmthemclient'smneurovascularmstatus?
