H ESI V ER SION 2 ACTUAL EXAM Questions
w ith 100% Verified Correct Answ ers
1. The nurse assumes care of a postoperative adult client with diabetes
mellitus and learns that the client has a current blood glucose level of 720
mg. When assessing the client what is the priority?
A. Assess for vital signs of fluid volume deficit.
B. Observe wound drainage characteristics.
C. Measure the level of acute pain.
D. Determine when the client last ate.
Correct A. Assess for vital signs of fluid volume deficit.
a blood glucose level of 720 mg/dL is significantly elevated and may indicate a state of hyperosmolar hyperglycemic
state or diabetic ketoacidosis. Both conditions can lead to fluid volume deficit. Assessing for signs of dehydration, such as
altered vital signs and dry mucous membranes, is a priority.
2. A male client tells the nurse that he is concerned that he may have a
stomach ulcer because he is experiencing heartburn and a dull gnawing pain.
Which is the *best* response by the nurse?
A. Encourage the client to obtain a complete physical exam since these symp-
toms are consistent with an ulcer.
B. Assure the client that his symptoms may only reflect reflux, since ulcer pain
,is not relieved with food.
C.Instruct the client that these mild symptoms can generally be controlled with
changes in his diet.
D. Advise the client that he needs to seek immediate medical evaluation and
treatment for these symptoms.
Correct A. encourage the client to obtain a complete physical exam since these symptoms are consistent
with an ulcer
This response is the most appropriate because it encourages the client to seek a professional medical evaluation, which is
necessary to accurately diagnose and treat potential ulcers. While the symptoms described by the client could indeed be
indicative of an ulcer, they could also be related to other gastrointestinal issues. A complete physical exam by a
healthcare provider is necessary to determine the exact cause and appropriate treatment.
3. A male client with stomach cancer returns to the unit following a total
gastrectomy. He has a nasogastric tube to suction and is receiving Lactated
Ringer' IV. One hour after admission to the unit, the nurse notes 300
mL of blood in the suction canister, the client's heart rate is 155
beats/minute. In
addition to reporting the findings to the surgeon, which action should the
nurse implement *first?*
A. Measure and document the client's urinary output.
B. Request the client's reserved unit of packed red blood cells.
,C. Prepare for the placement of central venous catheter.
D. Increase the infusion rate of Lactated Ringer's solution.
Correct D. increase the infusion rate of Lactated Ringer's solution
The client's symptoms are indicative of acute blood loss and potential hypovolemia. Increasing the infusion rate of IV
fluids, such as Lactated Ringer's solution, is a critical first step in managing potential hypovolemic shock. This will help to
maintain circulatory volume and perfusion until blood products can be administered or other interventions can be
performed.
4. A heparin infusion is prescribed for a client who weighs 220 pounds. After
administering a bolus dose of 80 units/kg the nurse calculates infusion rate
for the heparin solution at 18 units/kg/hour. The available solution is Heparin
Sodi-um 25,000 Units in 5% Dextrose Injection 250 mL. The nurse should
program the infusion pump to how many mL/hour?
Correct 18
5. An adult male who fell 20 feet from the roof of his home has multiple
injuries, including a right pneumothorax. Chest tubes were inserted in the
emergency department prior to his transfer to the intensive care unit
(ICU). The nurse notes that the suction control chamber is bubbling at the
-10 cm H2O mark with fluctuation in the water seal, and over the past hour
75 mL of bright red blood is measured in the collection chamber. Which
intervention should the nurse implement?
, A. Add sterile water to the suction control chamber
B. Give blood from the collection chamber as autotransfusion
C. Manipulate blood in tubing to drain into the chamber
D. Increase wall suction to eliminate fluctuation in water sea
Correct C. manipulate blood in tubing to drain into the chamber
The presence of bright red blood in the collection chamber, especially after a significant trauma like a 20-foot fall,
indicates ongoing bleeding. The nurse should ensure that all blood in the chest tube is drained into the collection
chamber to accurately monitor the client's bleeding. This can involve gently milking or stripping the tubing to facilitate
drainage, although this must be done with care to avoid creating excessive negative pressure in the chest tube system.
6. An adult male was diagnosed with stage IV lung cancer three weeks ago.
His wife approaches the nurse and asks how she will know that her husband's
death is imminent because their two adult children want to be there when he
dies. Which is the *best* response by the nurse?
A. Gather information regarding how long it will take for the children to
arrive
B. Explain that the client will start to lose consciousness and the body systems
will slow down.
C. Reassure the spouse that the healthcare provider will notify when to call the
children.
D. Offer to discuss the client's health status with each of the adult children.
Correct B. Explain that the client will start to lose consciousness and the body systems will slow down.
w ith 100% Verified Correct Answ ers
1. The nurse assumes care of a postoperative adult client with diabetes
mellitus and learns that the client has a current blood glucose level of 720
mg. When assessing the client what is the priority?
A. Assess for vital signs of fluid volume deficit.
B. Observe wound drainage characteristics.
C. Measure the level of acute pain.
D. Determine when the client last ate.
Correct A. Assess for vital signs of fluid volume deficit.
a blood glucose level of 720 mg/dL is significantly elevated and may indicate a state of hyperosmolar hyperglycemic
state or diabetic ketoacidosis. Both conditions can lead to fluid volume deficit. Assessing for signs of dehydration, such as
altered vital signs and dry mucous membranes, is a priority.
2. A male client tells the nurse that he is concerned that he may have a
stomach ulcer because he is experiencing heartburn and a dull gnawing pain.
Which is the *best* response by the nurse?
A. Encourage the client to obtain a complete physical exam since these symp-
toms are consistent with an ulcer.
B. Assure the client that his symptoms may only reflect reflux, since ulcer pain
,is not relieved with food.
C.Instruct the client that these mild symptoms can generally be controlled with
changes in his diet.
D. Advise the client that he needs to seek immediate medical evaluation and
treatment for these symptoms.
Correct A. encourage the client to obtain a complete physical exam since these symptoms are consistent
with an ulcer
This response is the most appropriate because it encourages the client to seek a professional medical evaluation, which is
necessary to accurately diagnose and treat potential ulcers. While the symptoms described by the client could indeed be
indicative of an ulcer, they could also be related to other gastrointestinal issues. A complete physical exam by a
healthcare provider is necessary to determine the exact cause and appropriate treatment.
3. A male client with stomach cancer returns to the unit following a total
gastrectomy. He has a nasogastric tube to suction and is receiving Lactated
Ringer' IV. One hour after admission to the unit, the nurse notes 300
mL of blood in the suction canister, the client's heart rate is 155
beats/minute. In
addition to reporting the findings to the surgeon, which action should the
nurse implement *first?*
A. Measure and document the client's urinary output.
B. Request the client's reserved unit of packed red blood cells.
,C. Prepare for the placement of central venous catheter.
D. Increase the infusion rate of Lactated Ringer's solution.
Correct D. increase the infusion rate of Lactated Ringer's solution
The client's symptoms are indicative of acute blood loss and potential hypovolemia. Increasing the infusion rate of IV
fluids, such as Lactated Ringer's solution, is a critical first step in managing potential hypovolemic shock. This will help to
maintain circulatory volume and perfusion until blood products can be administered or other interventions can be
performed.
4. A heparin infusion is prescribed for a client who weighs 220 pounds. After
administering a bolus dose of 80 units/kg the nurse calculates infusion rate
for the heparin solution at 18 units/kg/hour. The available solution is Heparin
Sodi-um 25,000 Units in 5% Dextrose Injection 250 mL. The nurse should
program the infusion pump to how many mL/hour?
Correct 18
5. An adult male who fell 20 feet from the roof of his home has multiple
injuries, including a right pneumothorax. Chest tubes were inserted in the
emergency department prior to his transfer to the intensive care unit
(ICU). The nurse notes that the suction control chamber is bubbling at the
-10 cm H2O mark with fluctuation in the water seal, and over the past hour
75 mL of bright red blood is measured in the collection chamber. Which
intervention should the nurse implement?
, A. Add sterile water to the suction control chamber
B. Give blood from the collection chamber as autotransfusion
C. Manipulate blood in tubing to drain into the chamber
D. Increase wall suction to eliminate fluctuation in water sea
Correct C. manipulate blood in tubing to drain into the chamber
The presence of bright red blood in the collection chamber, especially after a significant trauma like a 20-foot fall,
indicates ongoing bleeding. The nurse should ensure that all blood in the chest tube is drained into the collection
chamber to accurately monitor the client's bleeding. This can involve gently milking or stripping the tubing to facilitate
drainage, although this must be done with care to avoid creating excessive negative pressure in the chest tube system.
6. An adult male was diagnosed with stage IV lung cancer three weeks ago.
His wife approaches the nurse and asks how she will know that her husband's
death is imminent because their two adult children want to be there when he
dies. Which is the *best* response by the nurse?
A. Gather information regarding how long it will take for the children to
arrive
B. Explain that the client will start to lose consciousness and the body systems
will slow down.
C. Reassure the spouse that the healthcare provider will notify when to call the
children.
D. Offer to discuss the client's health status with each of the adult children.
Correct B. Explain that the client will start to lose consciousness and the body systems will slow down.
