HESI Exit Practice and Rationale Exam
Questions and Answers
1. 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.
2. 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
,HESI Exit Practice and Rationale Exam
Questions and Answers
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 attects 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.
3. 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
,HESI Exit Practice and Rationale Exam
Questions and Answers
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.
4. 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.
5. 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.
,HESI Exit Practice and Rationale Exam
Questions and Answers
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.
Questions and Answers
1. 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.
2. 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
,HESI Exit Practice and Rationale Exam
Questions and Answers
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 attects 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.
3. 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
,HESI Exit Practice and Rationale Exam
Questions and Answers
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.
4. 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.
5. 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.
,HESI Exit Practice and Rationale Exam
Questions and Answers
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.
