EXIT HESI
EXAM
High-Yield Qs & Answers with Feedback
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High-Yield Qs
Answers with Feedback
Multiple Choices
100% Guaranteed Pass
1
,A client presents at the ED complaining of a raspy voice, cold intolerance, and fatigue. Lab tests
indicate an elevated TSH and low T3 and T4 levels. After the client is admitted to the telemetry
unit, which intervention is most important for the nurse to implement?
A) Assess for presence of non-pitting edema.
B) Administer the prescribed dose of levothyroxine.
C) Offer additional blankets and a warm drink.
D) Note client's most recent hemoglobin levels. - CORRECT ANSWER -B) Administer the
prescribed dose of levothyroxine.
In the negative feedback mechanism of hypothyroidism, a low level of thyroid hormone
stimulates TSH production by the hypothalamus and results in an elevated TSH level, but the
thyroid gland does not respond with adequate production of T3 and T4 to regulate basal
metabolic rate. These serum hormone levels indicate the need to administer supplementary
thyroid hormone as soon as possible to avert possible myxedema coma. Non-pitting edema is
seen in chronic hypothyroidism and assessment of the presence and location of the edema (A) is
not a top priority. Providing warmth (C) is beneficial but of less priority than (B). Anemia is
common in hypothyroidism, but (D) is of lower priority than initiating treatment to prevent
myxedema coma.
The nurse suspects that a client might be hemorrhaging internally. Which findings of an
orthostatic tilt test are a most likely indication of a major bleed (> 1000 ml)?
A) A decrease in the systolic BP of 10 mm Hg with a corresponding increase in the HR of 20.
B) A decrease in the systolic BP of 10 mm Hg with a corresponding decrease in the HR of
20. C) A decrease in the systolic BP of 20 mm Hg with a corresponding decrease in the
HR of 10.
D) A decrease in the systolic BP of 20 mm Hg with a corresponding increase in the HR of 10. -
CORRECT ANSWER -Ans: A) A decrease in the systolic BP of 10 mm Hg with a corresponding
increase in the HR of
20.
The loss of circulatory volume results in a 10 mm Hg drop in the systolic pressure, while the HR
increases by 20 % above normal as a compensatory response to the low pressure.
2
,When conducting diet teaching for a client who is on a postoperative full liquid diet, which foods
should the nurse encourage the client to eat? SATA.
A) Canned fruit cocktail
B) Creamy peanut butter
C) Vegetable juice
D) Vanilla frozen yogurt
E) Clear beef broth - CORRECT ANSWER -Ans: C, D, E
A full liquid diet includes all liquids that are not clear such as vegetable juice and frozen yogurt,
as well as clear liquids. Pieces of fruit as found in fruit cocktail and peanut butter are not
considered liquids.
A client is receiving ophthalmic drops preoperatively for a cataract extraction and asks the
nurse why he is prescribed all these medications? SATA.
A) One of the medications is used to anesthetize the corneal surface.
B) The iris must be paralyzed during the surgery to prevent it from reacting to light.
C) Medication is used to induce sleep during the procedure.
D) Pupillary dilation is necessary to access the eye chamber for lens removal.
E) These meds assist in obstructing the client's vision during the surgery. - CORRECT ANSWER -
Ans: A, B, D
Cataract surgery is accessed through the cornea using eyelid retractors while the client is
awake. It is necessary to anesthetize the corneal surface (A), paralyze the ciliary body (B), and
provide pupil dilation (D)(mydriasis) to facilitate access to the lens which ties behind the iris
(posterior chamber of the anterior cavity). A sedative may be administered to reduce anxiety
but it is not used to induce sleep. (C) Cloudy vision may be a side effect of these agents, but the
client will still be able to see during the surgery (E).
When assessing an IV site that is sued for fluid replacement and medication administration, the
client complains of the tenderness when the arm is touched above the site. Which additional
assessment warrants immediate intervention by the nurse?
3
, A) Sluggish blood return
B) Client uses the arm cautiously
C) Spot of dried blood at the insertion site
D) Red streak tracking the vein - CORRECT ANSWER -Ans: D
A red streak (D) indicates vein irritation and necessitates discontinuing the IV at the present
site. A, B, and C are indications for relocating the IV site or other immediate intervention.
A client with a liver abscess develops septic shock. A sepsis resuscitation bundle protocol is
initiated and the client receives a bolus of IV fluids. Which parameter should the nurse monitor
to assess effectiveness of the fluid bolus?
A) Blood cultures.
B) Oxygen saturation.
C) White blood count.
D) Mean arterial pressure (MAP). - CORRECT ANSWER -D) Mean arterial pressure (MAP)
The cornerstone of initial sepsis resuscitation is fluid volume administration to restore and then
maintain MAP of at least 65 mmHg.
When attempting to establish risk reduction strategies in a community, the nurse notes that
regional studies indicate a high number of persons with growth stunting and irreversible mental
deficiencies (cretinism) caused by hypothyroidism. The nurse should seek funding to implement
which screening measure?
A)T4 levels in newborns.
B) TSH levels in women over 45.
C) T3 levels in school-aged children
D) Iodine levels in all persons over 60. - CORRECT ANSWER -A) T4 levels in newborns.
Screening for low T4 levels in newborns with follow-up treatment can reduce the risk for
irreversible growth stunting and mental deficiencies caused by congenital hypothyroidism.
4
EXAM
High-Yield Qs & Answers with Feedback
This Exam Description:
High-Yield Qs
Answers with Feedback
Multiple Choices
100% Guaranteed Pass
1
,A client presents at the ED complaining of a raspy voice, cold intolerance, and fatigue. Lab tests
indicate an elevated TSH and low T3 and T4 levels. After the client is admitted to the telemetry
unit, which intervention is most important for the nurse to implement?
A) Assess for presence of non-pitting edema.
B) Administer the prescribed dose of levothyroxine.
C) Offer additional blankets and a warm drink.
D) Note client's most recent hemoglobin levels. - CORRECT ANSWER -B) Administer the
prescribed dose of levothyroxine.
In the negative feedback mechanism of hypothyroidism, a low level of thyroid hormone
stimulates TSH production by the hypothalamus and results in an elevated TSH level, but the
thyroid gland does not respond with adequate production of T3 and T4 to regulate basal
metabolic rate. These serum hormone levels indicate the need to administer supplementary
thyroid hormone as soon as possible to avert possible myxedema coma. Non-pitting edema is
seen in chronic hypothyroidism and assessment of the presence and location of the edema (A) is
not a top priority. Providing warmth (C) is beneficial but of less priority than (B). Anemia is
common in hypothyroidism, but (D) is of lower priority than initiating treatment to prevent
myxedema coma.
The nurse suspects that a client might be hemorrhaging internally. Which findings of an
orthostatic tilt test are a most likely indication of a major bleed (> 1000 ml)?
A) A decrease in the systolic BP of 10 mm Hg with a corresponding increase in the HR of 20.
B) A decrease in the systolic BP of 10 mm Hg with a corresponding decrease in the HR of
20. C) A decrease in the systolic BP of 20 mm Hg with a corresponding decrease in the
HR of 10.
D) A decrease in the systolic BP of 20 mm Hg with a corresponding increase in the HR of 10. -
CORRECT ANSWER -Ans: A) A decrease in the systolic BP of 10 mm Hg with a corresponding
increase in the HR of
20.
The loss of circulatory volume results in a 10 mm Hg drop in the systolic pressure, while the HR
increases by 20 % above normal as a compensatory response to the low pressure.
2
,When conducting diet teaching for a client who is on a postoperative full liquid diet, which foods
should the nurse encourage the client to eat? SATA.
A) Canned fruit cocktail
B) Creamy peanut butter
C) Vegetable juice
D) Vanilla frozen yogurt
E) Clear beef broth - CORRECT ANSWER -Ans: C, D, E
A full liquid diet includes all liquids that are not clear such as vegetable juice and frozen yogurt,
as well as clear liquids. Pieces of fruit as found in fruit cocktail and peanut butter are not
considered liquids.
A client is receiving ophthalmic drops preoperatively for a cataract extraction and asks the
nurse why he is prescribed all these medications? SATA.
A) One of the medications is used to anesthetize the corneal surface.
B) The iris must be paralyzed during the surgery to prevent it from reacting to light.
C) Medication is used to induce sleep during the procedure.
D) Pupillary dilation is necessary to access the eye chamber for lens removal.
E) These meds assist in obstructing the client's vision during the surgery. - CORRECT ANSWER -
Ans: A, B, D
Cataract surgery is accessed through the cornea using eyelid retractors while the client is
awake. It is necessary to anesthetize the corneal surface (A), paralyze the ciliary body (B), and
provide pupil dilation (D)(mydriasis) to facilitate access to the lens which ties behind the iris
(posterior chamber of the anterior cavity). A sedative may be administered to reduce anxiety
but it is not used to induce sleep. (C) Cloudy vision may be a side effect of these agents, but the
client will still be able to see during the surgery (E).
When assessing an IV site that is sued for fluid replacement and medication administration, the
client complains of the tenderness when the arm is touched above the site. Which additional
assessment warrants immediate intervention by the nurse?
3
, A) Sluggish blood return
B) Client uses the arm cautiously
C) Spot of dried blood at the insertion site
D) Red streak tracking the vein - CORRECT ANSWER -Ans: D
A red streak (D) indicates vein irritation and necessitates discontinuing the IV at the present
site. A, B, and C are indications for relocating the IV site or other immediate intervention.
A client with a liver abscess develops septic shock. A sepsis resuscitation bundle protocol is
initiated and the client receives a bolus of IV fluids. Which parameter should the nurse monitor
to assess effectiveness of the fluid bolus?
A) Blood cultures.
B) Oxygen saturation.
C) White blood count.
D) Mean arterial pressure (MAP). - CORRECT ANSWER -D) Mean arterial pressure (MAP)
The cornerstone of initial sepsis resuscitation is fluid volume administration to restore and then
maintain MAP of at least 65 mmHg.
When attempting to establish risk reduction strategies in a community, the nurse notes that
regional studies indicate a high number of persons with growth stunting and irreversible mental
deficiencies (cretinism) caused by hypothyroidism. The nurse should seek funding to implement
which screening measure?
A)T4 levels in newborns.
B) TSH levels in women over 45.
C) T3 levels in school-aged children
D) Iodine levels in all persons over 60. - CORRECT ANSWER -A) T4 levels in newborns.
Screening for low T4 levels in newborns with follow-up treatment can reduce the risk for
irreversible growth stunting and mental deficiencies caused by congenital hypothyroidism.
4
