HESI Exit Practice QUESTIONS, ANSWERS and
Rationale COMPREHENSIVE VERSION WITHTHE
MOST RECENT AND VERIFIED ANSWERS
GUARANTEED PASS
Potassium chloride intravenously is prescribed for a client with hypokalemia. Which actions should the
nurse take to plan for preparation and administration of the potassium? Select all that apply.
1. Obtain an intravenous (IV) infusion pump.
2.Monitor urine output during administration.
3.Prepare the medication for bolus administration.
4.Monitor the IV site for signs of infiltration or phlebitis.
5.Ensure that the medication is diluted in the appropriate volume of fluid.
6.Ensure that the bag is labeled so that it reads the volume of potassium in the solution.
1, 2, 4, 5, 6
Potassium chloride administered intravenously must always be diluted in IV fluid and infused via an
infusion pump. Potassium chloride is never given by bolus (IV push). Giving potassium chloride by IV
push can result in cardiac arrest. The nurse should ensure that the potassium is diluted in the
appropriate amount of diluent or fluid. The IV bag containing the potassium chloride should always be
labeled with the volume of potassium it contains. The IV site is monitored closely because potassium
chloride is irritating to the veins and there is risk of phlebitis. In addition, the nurse should monitor for
infiltration. The nurse monitors urinary output during administration and contacts the health care
provider if the urinary output is less than 30 mL/hour.
,A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus is scheduled
for cardiac catheterization. Which medication would need to be withheld for 24 hours before the
procedure and for 48 hours after the procedure?
1.Glipizide
2.Metformin
3.Repaglinide
4.Regular insulin
2
Metformin needs to be withheld 24 hours before and for 48 hours after cardiac catheterization because
of the injection of contrast medium during the procedure. If the contrast medium affects kidney
function, with metformin in the system the client would be at increased risk for lactic acidosis. The
medications in the remaining options do not need to be withheld 24 hours before and 48 hours after
cardiac catheterization.
A client who had cardiac surgery 24 hours ago has had a urine output averaging 20 mL/hour for 2 hours.
The client received a single bolus of 500 mL of intravenous fluid. Urine output for the subsequent hour
was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL (16 mmol/L)
and the serum creatinine level is 2.2 mg/dL (194 mcmol/L). On the basis of these findings, the nurse
would anticipate that the client is at risk for which problem?
1. Hypovolemia
2.Acute kidney injury 3.Glomerulonephritis
4.Urinary tract infection
2
The client who undergoes cardiac surgery is at risk for renal injury from poor perfusion, hemolysis, low
cardiac output, or vasopressor medication therapy. Renal injury is signaled by decreased urine output
and increased blood urea nitrogen (BUN) and creatinine levels. Normal reference levels are BUN, 10-20
mg/dL (3.6-7.1 mmol/L), and creatinine, male, 0.6-1.2 mg/dL (53-106 mcmol/L) and female 0.5-1.1
mg/dL (44-97 mcmol/L). The client may need medications to increase renal perfusion and possibly could
need peritoneal dialysis or hemodialysis. No data in the question indicate the presence of hypovolemia,
glomerulonephritis, or urinary tract infection.
,The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular.
The PR interval is 0.16 seconds, and QRS complexes measure 0.06 seconds. The overall heart rate is 64
beats/minute. Which action should the nurse take?
1. Check vital signs.
2.Check laboratory test results. 3.Notify the health care provider. 4.Continue to monitor for any rhythm
change.
4
Normal sinus rhythm is defined as a regular rhythm, with an overall rate of 60 to 100 beats/minute. The
PR and QRS measurements are normal, measuring between 0.12 and 0.20 seconds and 0.04 and 0.10
seconds, respectively. There are no irregularities in this rhythm currently, so there is no immediate need
to check vital signs or laboratory results, or to notify the health care provider. Therefore, the nurse
would continue to monitor the client for any rhythm change.
A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse sees no
electrocardiographic complexes on the screen. Which is the priority nursing action?
1. Call a code.
2.Call the health care provider. 3.Check the client's status and lead placement.
4.Press the recorder button on the electrocardiogram console.
3
Sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly electrode
displacement. Accurate assessment of the client and equipment is necessary to determine the cause
and identify the appropriate intervention. The remaining options are secondary to client assessment.
The nurse is evaluating a client's response to cardioversion. Which assessment would be the priority?
1. Blood pressure
2.Status of airway
3.Oxygen flow rate
4.Level of consciousness
2
Nursing responsibilities after cardioversion include maintenance first of a patent airway, and then
oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection.
, Cardioversion is a medical procedure that restores a normal heart rhythm in people with certain types of
abnormal heartbeats (arrhythmias)
The nurse is caring for a client who has just had implantation of an automatic internal cardioverter-
defibrillator. The nurse should assess which item based on priority?
1. Anxiety level of the client and family
2.Presence of a MedicAlert card for the client to carry
3. Knowledge of restrictions on postdischarge physical activity
4. Activation status of the device, heart rate cutoff, and number of shocks it is programmed to deliver
4
The nurse who is caring for the client after insertion of an automatic internal cardioverter-defibrillator
needs to assess device settings, similar to after insertion of a permanent pacemaker. Specifically, the
nurse needs to know whether the device is activated, the heart rate cutoff above which it will fire, and
the number of shocks it is programmed to deliver. The remaining options are also nursing interventions
but are not the priority.
A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats/minute. The PR interval
is 0.14 seconds, the QRS complex measures 0.08 seconds, and the PP and RR intervals are regular. How
should the nurse correctly interpret this rhythm?
1.Sinus tachycardia
2.Sinus bradycardia
3.Sinus dysrhythmia
4.Normal sinus rhythm
1
Sinus tachycardia has the characteristics of normal sinus rhythm, including a regular PP interval and
normal-width PR and QRS intervals; however, the rate is the differentiating factor. In sinus tachycardia,
the atrial and ventricular rates are greater than 100 beats/minute.
The nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4
hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes
Rationale COMPREHENSIVE VERSION WITHTHE
MOST RECENT AND VERIFIED ANSWERS
GUARANTEED PASS
Potassium chloride intravenously is prescribed for a client with hypokalemia. Which actions should the
nurse take to plan for preparation and administration of the potassium? Select all that apply.
1. Obtain an intravenous (IV) infusion pump.
2.Monitor urine output during administration.
3.Prepare the medication for bolus administration.
4.Monitor the IV site for signs of infiltration or phlebitis.
5.Ensure that the medication is diluted in the appropriate volume of fluid.
6.Ensure that the bag is labeled so that it reads the volume of potassium in the solution.
1, 2, 4, 5, 6
Potassium chloride administered intravenously must always be diluted in IV fluid and infused via an
infusion pump. Potassium chloride is never given by bolus (IV push). Giving potassium chloride by IV
push can result in cardiac arrest. The nurse should ensure that the potassium is diluted in the
appropriate amount of diluent or fluid. The IV bag containing the potassium chloride should always be
labeled with the volume of potassium it contains. The IV site is monitored closely because potassium
chloride is irritating to the veins and there is risk of phlebitis. In addition, the nurse should monitor for
infiltration. The nurse monitors urinary output during administration and contacts the health care
provider if the urinary output is less than 30 mL/hour.
,A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus is scheduled
for cardiac catheterization. Which medication would need to be withheld for 24 hours before the
procedure and for 48 hours after the procedure?
1.Glipizide
2.Metformin
3.Repaglinide
4.Regular insulin
2
Metformin needs to be withheld 24 hours before and for 48 hours after cardiac catheterization because
of the injection of contrast medium during the procedure. If the contrast medium affects kidney
function, with metformin in the system the client would be at increased risk for lactic acidosis. The
medications in the remaining options do not need to be withheld 24 hours before and 48 hours after
cardiac catheterization.
A client who had cardiac surgery 24 hours ago has had a urine output averaging 20 mL/hour for 2 hours.
The client received a single bolus of 500 mL of intravenous fluid. Urine output for the subsequent hour
was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL (16 mmol/L)
and the serum creatinine level is 2.2 mg/dL (194 mcmol/L). On the basis of these findings, the nurse
would anticipate that the client is at risk for which problem?
1. Hypovolemia
2.Acute kidney injury 3.Glomerulonephritis
4.Urinary tract infection
2
The client who undergoes cardiac surgery is at risk for renal injury from poor perfusion, hemolysis, low
cardiac output, or vasopressor medication therapy. Renal injury is signaled by decreased urine output
and increased blood urea nitrogen (BUN) and creatinine levels. Normal reference levels are BUN, 10-20
mg/dL (3.6-7.1 mmol/L), and creatinine, male, 0.6-1.2 mg/dL (53-106 mcmol/L) and female 0.5-1.1
mg/dL (44-97 mcmol/L). The client may need medications to increase renal perfusion and possibly could
need peritoneal dialysis or hemodialysis. No data in the question indicate the presence of hypovolemia,
glomerulonephritis, or urinary tract infection.
,The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular.
The PR interval is 0.16 seconds, and QRS complexes measure 0.06 seconds. The overall heart rate is 64
beats/minute. Which action should the nurse take?
1. Check vital signs.
2.Check laboratory test results. 3.Notify the health care provider. 4.Continue to monitor for any rhythm
change.
4
Normal sinus rhythm is defined as a regular rhythm, with an overall rate of 60 to 100 beats/minute. The
PR and QRS measurements are normal, measuring between 0.12 and 0.20 seconds and 0.04 and 0.10
seconds, respectively. There are no irregularities in this rhythm currently, so there is no immediate need
to check vital signs or laboratory results, or to notify the health care provider. Therefore, the nurse
would continue to monitor the client for any rhythm change.
A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse sees no
electrocardiographic complexes on the screen. Which is the priority nursing action?
1. Call a code.
2.Call the health care provider. 3.Check the client's status and lead placement.
4.Press the recorder button on the electrocardiogram console.
3
Sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly electrode
displacement. Accurate assessment of the client and equipment is necessary to determine the cause
and identify the appropriate intervention. The remaining options are secondary to client assessment.
The nurse is evaluating a client's response to cardioversion. Which assessment would be the priority?
1. Blood pressure
2.Status of airway
3.Oxygen flow rate
4.Level of consciousness
2
Nursing responsibilities after cardioversion include maintenance first of a patent airway, and then
oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection.
, Cardioversion is a medical procedure that restores a normal heart rhythm in people with certain types of
abnormal heartbeats (arrhythmias)
The nurse is caring for a client who has just had implantation of an automatic internal cardioverter-
defibrillator. The nurse should assess which item based on priority?
1. Anxiety level of the client and family
2.Presence of a MedicAlert card for the client to carry
3. Knowledge of restrictions on postdischarge physical activity
4. Activation status of the device, heart rate cutoff, and number of shocks it is programmed to deliver
4
The nurse who is caring for the client after insertion of an automatic internal cardioverter-defibrillator
needs to assess device settings, similar to after insertion of a permanent pacemaker. Specifically, the
nurse needs to know whether the device is activated, the heart rate cutoff above which it will fire, and
the number of shocks it is programmed to deliver. The remaining options are also nursing interventions
but are not the priority.
A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats/minute. The PR interval
is 0.14 seconds, the QRS complex measures 0.08 seconds, and the PP and RR intervals are regular. How
should the nurse correctly interpret this rhythm?
1.Sinus tachycardia
2.Sinus bradycardia
3.Sinus dysrhythmia
4.Normal sinus rhythm
1
Sinus tachycardia has the characteristics of normal sinus rhythm, including a regular PP interval and
normal-width PR and QRS intervals; however, the rate is the differentiating factor. In sinus tachycardia,
the atrial and ventricular rates are greater than 100 beats/minute.
The nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4
hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes
