1 HESI Exit Practice Questions and Rationale Questions & Correct Answers/ Graded A+ Potassium chloride intravenously is prescr ibed 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.Prepa re 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 g iven 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 l abeled with the volume of potassium it contains. The 2 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 outpu t during administration and contacts the health care provider if the urinary output is less than 30 mL/hour. A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus is scheduled for cardiac catheterization. Which medica tion 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 Metformin needs to be withheld 24 hours before and for 48 hours after cardiac catheter ization because of the injection of contrast medium during the procedure. If the contrast medium affects kidney function, with metformin in the system the client would be at increased risk for lactic acidosis. The medications in the remaining options do no t need to be withheld 24 hours before and 48 hours after cardiac catheterization. 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. Uri ne output 3 for the subsequent hour was 25 mL. Daily 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 ou tput, 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 (5 3-106 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, glomerulonephrit is, or urinary tract infection. 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. 4 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 laborato ry results, or to notify the health care provider. Therefore, the nurse would continue to monitor the client for any rhythm change. A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse sees no electrocardiographic c omplexes on the screen. Which is the priority nursing action? 1. Call a code. 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. Accurate assessment of the client and equipment is necessary to determine the cause and identify the appropriate intervention. The remaining op tions are secondary to client assessment.
1.2 mg/dL (5 3-106 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, glomerulonephrit is, or urinary tract infection. 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. 4 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 laborato ry results, or to notify the health care provider. Therefore, the nurse would continue to monitor the client for any rhythm change. A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse sees no electrocardiographic c omplexes on the screen. Which is the priority nursing action? 1. Call a code. 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. Accurate assessment of the client and equipment is necessary to determine the cause and identify the appropriate intervention. The remaining op tions are secondary to client assessment.
