BSN 246 HESI HEALTH EXAM V1 STUDY
GUIDE 100% VERIFIED
1. A nurse is caring for a client with a history of congestive heart failure who is receiving
digoxin 0.25 mg daily. Which assessment finding is the most critical to report to the
healthcare provider immediately?
A. Heart rate of 62 beats/minute
B. Anorexia and nausea
C. Potassium level of 4.8 mEq/L
D. Occasional premature ventricular contractions
Answer: B
Conceptual Explanation: Early signs of digoxin toxicity include gastrointestinal
disturbances like anorexia, nausea, and vomiting. While a low heart rate is concerning,
nausea is often the first sign of toxicity. A potassium of 4.8 is normal.
2. A client is admitted with Diabetic Ketoacidosis (DKA). The nurse identifies which primary
goal as the priority in the first 24 hours of treatment?
A. Fluid resuscitation and restoration of circulatory volume
,B. Correction of metabolic acidosis
C. Normalization of blood glucose levels
D. Replacement of total body potassium
Answer: A
Conceptual Explanation: In DKA, the priority is addressing dehydration and hypovolemia.
Fluid resuscitation must begin immediately before or alongside insulin therapy to prevent
circulatory collapse.
3. The nurse is reviewing the lab results for a client receiving Heparin via continuous IV
infusion. The aPTT is 110 seconds. What is the priority action?
A. Administer Protamine Sulfate immediately
B. Decrease the infusion rate by 50%
C. Stop the heparin infusion
D. Notify the provider and prepare Vitamin K
Answer: C
Conceptual Explanation: An aPTT of 110 seconds is significantly above the therapeutic
range (usually 1.5 to 2.5 times the control). The infusion must be stopped first to prevent
hemorrhage before further intervention.
, 4. A client with a chest tube following a lobectomy has 200 mL of bright red drainage in the
collection chamber over the last hour. Which action should the nurse take first?
A. Milk the chest tube to ensure patency
B. Increase the suction to -30 cm H2O
C. Document the findings as normal post-operative drainage
D. Notify the surgeon immediately
Answer: D
Conceptual Explanation: Drainage greater than 100-200 mL/hr is considered excessive
and may indicate active hemorrhage, requiring immediate surgical notification.
5. A child is admitted with suspected bacterial meningitis. Which action should the nurse
prioritize during the initial assessment?
A. Administer the first dose of IV antibiotics
B. Perform a neurological assessment
C. Assist with a lumbar puncture
D. Implement droplet precautions
Answer: D
Conceptual Explanation: To protect others and prevent the spread of infection, droplet
precautions must be implemented as soon as meningitis is suspected, even before
diagnostic confirmation.
GUIDE 100% VERIFIED
1. A nurse is caring for a client with a history of congestive heart failure who is receiving
digoxin 0.25 mg daily. Which assessment finding is the most critical to report to the
healthcare provider immediately?
A. Heart rate of 62 beats/minute
B. Anorexia and nausea
C. Potassium level of 4.8 mEq/L
D. Occasional premature ventricular contractions
Answer: B
Conceptual Explanation: Early signs of digoxin toxicity include gastrointestinal
disturbances like anorexia, nausea, and vomiting. While a low heart rate is concerning,
nausea is often the first sign of toxicity. A potassium of 4.8 is normal.
2. A client is admitted with Diabetic Ketoacidosis (DKA). The nurse identifies which primary
goal as the priority in the first 24 hours of treatment?
A. Fluid resuscitation and restoration of circulatory volume
,B. Correction of metabolic acidosis
C. Normalization of blood glucose levels
D. Replacement of total body potassium
Answer: A
Conceptual Explanation: In DKA, the priority is addressing dehydration and hypovolemia.
Fluid resuscitation must begin immediately before or alongside insulin therapy to prevent
circulatory collapse.
3. The nurse is reviewing the lab results for a client receiving Heparin via continuous IV
infusion. The aPTT is 110 seconds. What is the priority action?
A. Administer Protamine Sulfate immediately
B. Decrease the infusion rate by 50%
C. Stop the heparin infusion
D. Notify the provider and prepare Vitamin K
Answer: C
Conceptual Explanation: An aPTT of 110 seconds is significantly above the therapeutic
range (usually 1.5 to 2.5 times the control). The infusion must be stopped first to prevent
hemorrhage before further intervention.
, 4. A client with a chest tube following a lobectomy has 200 mL of bright red drainage in the
collection chamber over the last hour. Which action should the nurse take first?
A. Milk the chest tube to ensure patency
B. Increase the suction to -30 cm H2O
C. Document the findings as normal post-operative drainage
D. Notify the surgeon immediately
Answer: D
Conceptual Explanation: Drainage greater than 100-200 mL/hr is considered excessive
and may indicate active hemorrhage, requiring immediate surgical notification.
5. A child is admitted with suspected bacterial meningitis. Which action should the nurse
prioritize during the initial assessment?
A. Administer the first dose of IV antibiotics
B. Perform a neurological assessment
C. Assist with a lumbar puncture
D. Implement droplet precautions
Answer: D
Conceptual Explanation: To protect others and prevent the spread of infection, droplet
precautions must be implemented as soon as meningitis is suspected, even before
diagnostic confirmation.
