ANALYZED EXIT HESI FINAL
EXAM QUESTIONS AND
ANSWERS
A client presents at the ED complaining of a raspy voice, cold intolerance, and fatigue. Lab tests indicate
an elevated TSH and low T3 and T4 levels. After the client is admitted to the telemetry unit, which
intervention is most important for the nurse to implement?
A) Assess for presence of non-pitting edema.
B) Administer the prescribed dose of levothyroxine.
C) Offer additional blankets and a warm drink.
D) Note client's most recent hemoglobin levels. - CORRECT ANSWER -B) Administer the prescribed dose
of levothyroxine.
Rationale: In the negative feedback mechanism of hypothyroidism, a low level of thyroid hormone
stimulates TSH production by the hypothalamus and results in an elevated TSH level, but the thyroid
gland does not respond with adequate production of T3 and T4 to regulate basal metabolic rate. These
serum hormone levels indicate the need to administer supplementary thyroid hormone as soon as
possible to avert possible myxedema coma. Non-pitting edema is seen in chronic hypothyroidism and
assessment of the presence and location of the edema (A) is not a top priority. Providing warmth (C) is
beneficial but of less priority than (B). Anemia is common in hypothyroidism, but (D) is of lower priority
than initiating treatment to prevent myxedema coma.
The nurse suspects that a client might be hemorrhaging internally. Which findings of an orthostatic tilt
test are a most likely indication of a major bleed (> 1000 ml)?
A) A decrease in the systolic BP of 10 mm Hg with a corresponding increase in the HR of 20.
,B) A decrease in the systolic BP of 10 mm Hg with a corresponding decrease in the HR of 20.
C) A decrease in the systolic BP of 20 mm Hg with a corresponding decrease in the HR of 10.
D) A decrease in the systolic BP of 20 mm Hg with a corresponding increase in the HR of 10. - CORRECT
ANSWER -Ans: A) A decrease in the systolic BP of 10 mm Hg with a corresponding increase in the HR of
20.
Rationale: The loss of circulatory volume results in a 10 mm Hg drop in the systolic pressure, while the
HR increases by 20 % above normal as a compensatory response to the low pressure.
When conducting diet teaching for a client who is on a postoperative full liquid diet, which foods should
the nurse encourage the client to eat? SATA.
A) Canned fruit cocktail
B) Creamy peanut butter
C) Vegetable juice
D) Vanilla frozen yogurt
E) Clear beef broth - CORRECT ANSWER -Ans: C, D, E
A full liquid diet includes all liquids that are not clear such as vegetable juice and frozen yogurt, as well
as clear liquids. Pieces of fruit as found in fruit cocktail and peanut butter are not considered liquids.
A client is receiving ophthalmic drops preoperatively for a cataract extraction and asks the nurse why he
is prescribed all these medications? SATA.
A) One of the medications is used to anesthetize the corneal surface.
B) The iris must be paralyzed during the surgery to prevent it from reacting to light.
C) Medication is used to induce sleep during the procedure.
D) Pupillary dilation is necessary to access the eye chamber for lens removal.
,E) These meds assist in obstructing the client's vision during the surgery. - CORRECT ANSWER -Ans: A, B,
D
Cataract surgery is accessed through the cornea using eyelid retractors while the client is awake. It is
necessary to anesthetize the corneal surface (A), paralyze the ciliary body (B), and provide pupil dilation
(D)(mydriasis) to facilitate access to the lens which ties behind the iris (posterior chamber of the anterior
cavity). A sedative may be administered to reduce anxiety but it is not used to induce sleep. (C) Cloudy
vision may be a side effect of these agents, but the client will still be able to see during the surgery (E).
When assessing an IV site that is sued for fluid replacement and medication administration, the client
complains of the tenderness when the arm is touched above the site. Which additional assessment
warrants immediate intervention by the nurse?
A) Sluggish blood return
B) Client uses the arm cautiously
C) Spot of dried blood at the insertion site
D) Red streak tracking the vein - CORRECT ANSWER -Ans: D
A red streak (D) indicates vein irritation and necessitates discontinuing the IV at the present site. A, B,
and C are indications for relocating the IV site or other immediate intervention.
A client with a liver abscess develops septic shock. A sepsis resuscitation bundle protocol is initiated and
the client receives a bolus of IV fluids. Which parameter should the nurse monitor to assess
effectiveness of the fluid bolus?
A) Blood cultures.
B) Oxygen saturation.
C) White blood count.
D) Mean arterial pressure (MAP). - CORRECT ANSWER -D) Mean arterial pressure (MAP)
The cornerstone of initial sepsis resuscitation is fluid volume administration to restore and then
maintain MAP of at least 65 mmHg.
, When attempting to establish risk reduction strategies in a community, the nurse notes that regional
studies indicate a high number of persons with growth stunting and irreversible mental deficiencies
(cretinism) caused by hypothyroidism. The nurse should seek funding to implement which screening
measure?
A) T4 levels in newborns.
B) TSH levels in women over 45.
C) T3 levels in school-aged children
D) Iodine levels in all persons over 60. - CORRECT ANSWER -A) T4 levels in newborns.
Screening for low T4 levels in newborns with follow-up treatment can reduce the risk for irreversible
growth stunting and mental deficiencies caused by congenital hypothyroidism.
For the past 24 hours, an antidiarrheal agent, diphenoxylate, has been administered to a bedridden,
older client with infectious gastroenteritis. Which finding requires the nurse to take further action?
A) Loss of appetite
B) Serum K+ 4.0 mEq/L or mmol/L (SI)
C) Loose, runny stools.
D) Tented skin turgor. - CORRECT ANSWER -D) Tented skin turgor.
Indicates dehydration, a serious complication following prolonged diarrhea that requires further
intervention by the nurse.
A male client with ulcerative colitis received an Rx for a corticosteroid last month but because of the S/E,
he stopped taking the medications 6 days ago. Which finding warrants immediate intervention by the
nurse?
A) Fluid retention
EXAM QUESTIONS AND
ANSWERS
A client presents at the ED complaining of a raspy voice, cold intolerance, and fatigue. Lab tests indicate
an elevated TSH and low T3 and T4 levels. After the client is admitted to the telemetry unit, which
intervention is most important for the nurse to implement?
A) Assess for presence of non-pitting edema.
B) Administer the prescribed dose of levothyroxine.
C) Offer additional blankets and a warm drink.
D) Note client's most recent hemoglobin levels. - CORRECT ANSWER -B) Administer the prescribed dose
of levothyroxine.
Rationale: In the negative feedback mechanism of hypothyroidism, a low level of thyroid hormone
stimulates TSH production by the hypothalamus and results in an elevated TSH level, but the thyroid
gland does not respond with adequate production of T3 and T4 to regulate basal metabolic rate. These
serum hormone levels indicate the need to administer supplementary thyroid hormone as soon as
possible to avert possible myxedema coma. Non-pitting edema is seen in chronic hypothyroidism and
assessment of the presence and location of the edema (A) is not a top priority. Providing warmth (C) is
beneficial but of less priority than (B). Anemia is common in hypothyroidism, but (D) is of lower priority
than initiating treatment to prevent myxedema coma.
The nurse suspects that a client might be hemorrhaging internally. Which findings of an orthostatic tilt
test are a most likely indication of a major bleed (> 1000 ml)?
A) A decrease in the systolic BP of 10 mm Hg with a corresponding increase in the HR of 20.
,B) A decrease in the systolic BP of 10 mm Hg with a corresponding decrease in the HR of 20.
C) A decrease in the systolic BP of 20 mm Hg with a corresponding decrease in the HR of 10.
D) A decrease in the systolic BP of 20 mm Hg with a corresponding increase in the HR of 10. - CORRECT
ANSWER -Ans: A) A decrease in the systolic BP of 10 mm Hg with a corresponding increase in the HR of
20.
Rationale: The loss of circulatory volume results in a 10 mm Hg drop in the systolic pressure, while the
HR increases by 20 % above normal as a compensatory response to the low pressure.
When conducting diet teaching for a client who is on a postoperative full liquid diet, which foods should
the nurse encourage the client to eat? SATA.
A) Canned fruit cocktail
B) Creamy peanut butter
C) Vegetable juice
D) Vanilla frozen yogurt
E) Clear beef broth - CORRECT ANSWER -Ans: C, D, E
A full liquid diet includes all liquids that are not clear such as vegetable juice and frozen yogurt, as well
as clear liquids. Pieces of fruit as found in fruit cocktail and peanut butter are not considered liquids.
A client is receiving ophthalmic drops preoperatively for a cataract extraction and asks the nurse why he
is prescribed all these medications? SATA.
A) One of the medications is used to anesthetize the corneal surface.
B) The iris must be paralyzed during the surgery to prevent it from reacting to light.
C) Medication is used to induce sleep during the procedure.
D) Pupillary dilation is necessary to access the eye chamber for lens removal.
,E) These meds assist in obstructing the client's vision during the surgery. - CORRECT ANSWER -Ans: A, B,
D
Cataract surgery is accessed through the cornea using eyelid retractors while the client is awake. It is
necessary to anesthetize the corneal surface (A), paralyze the ciliary body (B), and provide pupil dilation
(D)(mydriasis) to facilitate access to the lens which ties behind the iris (posterior chamber of the anterior
cavity). A sedative may be administered to reduce anxiety but it is not used to induce sleep. (C) Cloudy
vision may be a side effect of these agents, but the client will still be able to see during the surgery (E).
When assessing an IV site that is sued for fluid replacement and medication administration, the client
complains of the tenderness when the arm is touched above the site. Which additional assessment
warrants immediate intervention by the nurse?
A) Sluggish blood return
B) Client uses the arm cautiously
C) Spot of dried blood at the insertion site
D) Red streak tracking the vein - CORRECT ANSWER -Ans: D
A red streak (D) indicates vein irritation and necessitates discontinuing the IV at the present site. A, B,
and C are indications for relocating the IV site or other immediate intervention.
A client with a liver abscess develops septic shock. A sepsis resuscitation bundle protocol is initiated and
the client receives a bolus of IV fluids. Which parameter should the nurse monitor to assess
effectiveness of the fluid bolus?
A) Blood cultures.
B) Oxygen saturation.
C) White blood count.
D) Mean arterial pressure (MAP). - CORRECT ANSWER -D) Mean arterial pressure (MAP)
The cornerstone of initial sepsis resuscitation is fluid volume administration to restore and then
maintain MAP of at least 65 mmHg.
, When attempting to establish risk reduction strategies in a community, the nurse notes that regional
studies indicate a high number of persons with growth stunting and irreversible mental deficiencies
(cretinism) caused by hypothyroidism. The nurse should seek funding to implement which screening
measure?
A) T4 levels in newborns.
B) TSH levels in women over 45.
C) T3 levels in school-aged children
D) Iodine levels in all persons over 60. - CORRECT ANSWER -A) T4 levels in newborns.
Screening for low T4 levels in newborns with follow-up treatment can reduce the risk for irreversible
growth stunting and mental deficiencies caused by congenital hypothyroidism.
For the past 24 hours, an antidiarrheal agent, diphenoxylate, has been administered to a bedridden,
older client with infectious gastroenteritis. Which finding requires the nurse to take further action?
A) Loss of appetite
B) Serum K+ 4.0 mEq/L or mmol/L (SI)
C) Loose, runny stools.
D) Tented skin turgor. - CORRECT ANSWER -D) Tented skin turgor.
Indicates dehydration, a serious complication following prolonged diarrhea that requires further
intervention by the nurse.
A male client with ulcerative colitis received an Rx for a corticosteroid last month but because of the S/E,
he stopped taking the medications 6 days ago. Which finding warrants immediate intervention by the
nurse?
A) Fluid retention
