HESI EXIT EXAM HCV2 PREP (WGU
D455) ADVANCED NURSING CONCEPTS
& PRIORITIZATION TEST BANK
Question 1
A nurse is preparing to administer packed red blood
cells to a client. Which intravenous solution should
the nurse use to prime the administration tubing?
A) 5% Dextrose in water (D5W)
B) 0.45% Sodium chloride
C) Lactated Ringer's
D) 0.9% Sodium chloride
Answer: D
Rationale: 0.9% sodium chloride (normal saline)
is the only fluid compatible with blood products.
Other solutions can cause hemolysis or clotting
of the blood cells within the tubing.
Question 2
A nurse is assessing a client who is 4 hours
postoperative following a subtotal thyroidectomy.
Which of the following findings is the priority for the
nurse to report to the provider?
A) Incisional pain rating of 6 on a 0-to-10 scale
B) Laryngeal stridor heard on expiration
C) Urinary output of 100 mL over the past 4 hours
,D) Direct tenderness at the back of the neck
Answer: B
Rationale: Laryngeal stridor indicates an acute
airway obstruction or laryngeal nerve damage,
making it a critical threat to the client's airway
(ABC priority). Incisional pain and localized
tenderness are expected, and the urine output is
acceptable.
Question 3
A client is admitted to the emergency department
with acute decompensated heart failure. Which of
the following laboratory values should the nurse
monitor to evaluate the severity of the heart failure?
A) Troponin I
B) B-type natriuretic peptide (BNP)
C) Creatinine kinase-MB (CK-MB)
D) Serum potassium
Answer: B
Rationale: BNP is secreted by the ventricles in
response to fluid volume overload and
stretching. It serves as a direct biomarker to
assess the severity and progression of heart
failure.
Question 4
,A nurse is caring for a client who is receiving a
continuous intravenous infusion of heparin. The
client's activated partial thromboplastin time (aPTT)
is 95 seconds. Which of the following actions should
the nurse take first?
A) Prepare to administer protamine sulfate
B) Stop the heparin infusion
C) Repeat the blood draw for another aPTT
D) Notify the healthcare provider
Answer: B
Rationale: A normal therapeutic aPTT range for
heparin therapy is typically 1.5 to 2.5 times the
control value (approx. 45 to 75 seconds). An
aPTT of 95 seconds indicates over-
anticoagulation, putting the client at high risk for
bleeding. The immediate priority action is to stop
the infusion to prevent further toxicity.
Question 5
A nurse is evaluating a client who has been taking
lithium carbonate for bipolar disorder for the past 6
months. The client reports a new onset of coarse
hand tremors, vomiting, and diarrhea. Which of the
following actions should the nurse take?
A) Advise the client that these are common,
transient side effects
, B) Request a prescription for an antiemetic
C) Instruct the client to hold the medication and
obtain a serum lithium level
D) Encourage the client to increase their dietary
sodium intake immediately
Answer: C
Rationale: Coarse hand tremors, gastrointestinal
distress (vomiting/diarrhea), and ataxia are
classic manifestations of moderate-to-severe
lithium toxicity. The client should stop the
medication until blood levels are checked.
Question 6
A nurse is reviewing the arterial blood gas (ABG)
results for a client with a history of severe
emphysema: pH 7.31, PaCO2 52 mmHg, HCO3 25
mEq/L, PaO2 78 mmHg. Which of the following acid-
base imbalances is this client experiencing?
A) Uncompensated respiratory acidosis
B) Partially compensated metabolic alkalosis
C) Compensated respiratory acidosis
D) Uncompensated metabolic acidosis
Answer: A
Rationale: The pH is low (acidemia), and the
PaCO2 is elevated (respiratory origin). Because
the HCO3 remains within the normal reference
D455) ADVANCED NURSING CONCEPTS
& PRIORITIZATION TEST BANK
Question 1
A nurse is preparing to administer packed red blood
cells to a client. Which intravenous solution should
the nurse use to prime the administration tubing?
A) 5% Dextrose in water (D5W)
B) 0.45% Sodium chloride
C) Lactated Ringer's
D) 0.9% Sodium chloride
Answer: D
Rationale: 0.9% sodium chloride (normal saline)
is the only fluid compatible with blood products.
Other solutions can cause hemolysis or clotting
of the blood cells within the tubing.
Question 2
A nurse is assessing a client who is 4 hours
postoperative following a subtotal thyroidectomy.
Which of the following findings is the priority for the
nurse to report to the provider?
A) Incisional pain rating of 6 on a 0-to-10 scale
B) Laryngeal stridor heard on expiration
C) Urinary output of 100 mL over the past 4 hours
,D) Direct tenderness at the back of the neck
Answer: B
Rationale: Laryngeal stridor indicates an acute
airway obstruction or laryngeal nerve damage,
making it a critical threat to the client's airway
(ABC priority). Incisional pain and localized
tenderness are expected, and the urine output is
acceptable.
Question 3
A client is admitted to the emergency department
with acute decompensated heart failure. Which of
the following laboratory values should the nurse
monitor to evaluate the severity of the heart failure?
A) Troponin I
B) B-type natriuretic peptide (BNP)
C) Creatinine kinase-MB (CK-MB)
D) Serum potassium
Answer: B
Rationale: BNP is secreted by the ventricles in
response to fluid volume overload and
stretching. It serves as a direct biomarker to
assess the severity and progression of heart
failure.
Question 4
,A nurse is caring for a client who is receiving a
continuous intravenous infusion of heparin. The
client's activated partial thromboplastin time (aPTT)
is 95 seconds. Which of the following actions should
the nurse take first?
A) Prepare to administer protamine sulfate
B) Stop the heparin infusion
C) Repeat the blood draw for another aPTT
D) Notify the healthcare provider
Answer: B
Rationale: A normal therapeutic aPTT range for
heparin therapy is typically 1.5 to 2.5 times the
control value (approx. 45 to 75 seconds). An
aPTT of 95 seconds indicates over-
anticoagulation, putting the client at high risk for
bleeding. The immediate priority action is to stop
the infusion to prevent further toxicity.
Question 5
A nurse is evaluating a client who has been taking
lithium carbonate for bipolar disorder for the past 6
months. The client reports a new onset of coarse
hand tremors, vomiting, and diarrhea. Which of the
following actions should the nurse take?
A) Advise the client that these are common,
transient side effects
, B) Request a prescription for an antiemetic
C) Instruct the client to hold the medication and
obtain a serum lithium level
D) Encourage the client to increase their dietary
sodium intake immediately
Answer: C
Rationale: Coarse hand tremors, gastrointestinal
distress (vomiting/diarrhea), and ataxia are
classic manifestations of moderate-to-severe
lithium toxicity. The client should stop the
medication until blood levels are checked.
Question 6
A nurse is reviewing the arterial blood gas (ABG)
results for a client with a history of severe
emphysema: pH 7.31, PaCO2 52 mmHg, HCO3 25
mEq/L, PaO2 78 mmHg. Which of the following acid-
base imbalances is this client experiencing?
A) Uncompensated respiratory acidosis
B) Partially compensated metabolic alkalosis
C) Compensated respiratory acidosis
D) Uncompensated metabolic acidosis
Answer: A
Rationale: The pH is low (acidemia), and the
PaCO2 is elevated (respiratory origin). Because
the HCO3 remains within the normal reference
