, BSN HESI 320 | Adult Health I Exam
Questions and Answers with
Rationales - Nightingale College
Question 1: Cardiovascular / Pharmacology
Scenario: A client with heart failure is receiving digoxin 0.25
mg PO daily and furosemide 40 mg PO daily. During the
morning assessment, the client reports nausea, blurred vision,
and seeing yellow-green halos around lights. Laboratory results
indicate a serum potassium level of 3.1 mEq/L. Which nursing
action takes priority?
A. Administer the scheduled morning dose of furosemide.
B. Hold the digoxin dose and notify the healthcare
provider.
C. Encourage the client to drink a glass of orange juice rich
in potassium.
D. Reassess the client's vital signs in 2 hours.
Correct Answer: B
Rationale: Nausea, visual disturbances (yellow-green halos),
and vomiting are classic signs of digoxin toxicity. Hypokalemia
(potassium less than 3.5 mEq/L), often caused by loop diuretics
like furosemide, significantly increases the risk of digoxin
toxicity because low potassium allows digoxin to bind more
heavily to cardiac receptors. The nurse must withhold the
digoxin and immediately notify the provider to evaluate serum
digoxin levels and address potassium replacement.
,Question 2: Endocrine / Acute Care
Scenario: A client with Type 1 Diabetes Mellitus is admitted to
the emergency department in Diabetic Ketoacidosis (DKA). The
client's blood glucose is 485 mg/dL, and serum potassium is 5.8
mEq/L. The nurse initiates a continuous intravenous regular
insulin infusion. Which laboratory parameter requires the nurse's
most immediate and frequent monitoring during insulin therapy?
A. Serum sodium
B. Blood urea nitrogen (BUN)
C. Serum potassium
D. Hemoglobin A1c
Correct Answer: C
Rationale: Insulin drives both glucose and potassium out of the
bloodstream and into the intracellular space. As DKA is treated
with intravenous regular insulin, serum potassium levels drop
rapidly, placing the client at severe risk for hypokalemia and
lethal cardiac dysrhythmias. Serum potassium must be
monitored closely (often hourly) and replaced intravenously
once levels approach the normal range.
Question 3: Respiratory / Post-Operative Care
Scenario: A client who underwent a left lower lobectomy 12
hours ago has a chest tube connected to a closed chest drainage
system. The nurse notes continuous, brisk bubbling in the water-
seal chamber. What is the correct interpretation and immediate
action for this finding?
, A. Normal finding; document that the lung is fully re-
expanding.
B. Indicates an air leak; check all connection sites from the
dressing to the drainage unit.
C. Suction pressure is too high; decrease the wall suction
regulator.
D. The chest tube is obstructed; milk the tubing toward the
container.
Correct Answer: B
Rationale: Continuous brisk bubbling in the water-seal
chamber indicates an active air leak in the chest tube system or
pleural space. (Intermittent bubbling during exhalation or
coughing is expected until the pleural leak heals). The nurse
should immediately assess connections and chest tube entry site.
High suction causes bubbling in the suction control chamber, not
continuous air-leak bubbling in the water-seal chamber.
Question 4: Renal / Electrolyte Emergency
Scenario: A client with Acute Kidney Injury (AKI) has a serum
potassium level of 6.8 mEq/L. The electrocardiogram (ECG)
reveals tall, peaked T waves and a widened QRS complex.
Which medication order should the nurse administer first to
stabilize myocardial electrical conduction?
A. Sodium polystyrene sulfonate PO
B. Calcium gluconate IV
C. Regular insulin IV with 50% Dextrose
D. Furosemide IV push
Correct Answer: B
Questions and Answers with
Rationales - Nightingale College
Question 1: Cardiovascular / Pharmacology
Scenario: A client with heart failure is receiving digoxin 0.25
mg PO daily and furosemide 40 mg PO daily. During the
morning assessment, the client reports nausea, blurred vision,
and seeing yellow-green halos around lights. Laboratory results
indicate a serum potassium level of 3.1 mEq/L. Which nursing
action takes priority?
A. Administer the scheduled morning dose of furosemide.
B. Hold the digoxin dose and notify the healthcare
provider.
C. Encourage the client to drink a glass of orange juice rich
in potassium.
D. Reassess the client's vital signs in 2 hours.
Correct Answer: B
Rationale: Nausea, visual disturbances (yellow-green halos),
and vomiting are classic signs of digoxin toxicity. Hypokalemia
(potassium less than 3.5 mEq/L), often caused by loop diuretics
like furosemide, significantly increases the risk of digoxin
toxicity because low potassium allows digoxin to bind more
heavily to cardiac receptors. The nurse must withhold the
digoxin and immediately notify the provider to evaluate serum
digoxin levels and address potassium replacement.
,Question 2: Endocrine / Acute Care
Scenario: A client with Type 1 Diabetes Mellitus is admitted to
the emergency department in Diabetic Ketoacidosis (DKA). The
client's blood glucose is 485 mg/dL, and serum potassium is 5.8
mEq/L. The nurse initiates a continuous intravenous regular
insulin infusion. Which laboratory parameter requires the nurse's
most immediate and frequent monitoring during insulin therapy?
A. Serum sodium
B. Blood urea nitrogen (BUN)
C. Serum potassium
D. Hemoglobin A1c
Correct Answer: C
Rationale: Insulin drives both glucose and potassium out of the
bloodstream and into the intracellular space. As DKA is treated
with intravenous regular insulin, serum potassium levels drop
rapidly, placing the client at severe risk for hypokalemia and
lethal cardiac dysrhythmias. Serum potassium must be
monitored closely (often hourly) and replaced intravenously
once levels approach the normal range.
Question 3: Respiratory / Post-Operative Care
Scenario: A client who underwent a left lower lobectomy 12
hours ago has a chest tube connected to a closed chest drainage
system. The nurse notes continuous, brisk bubbling in the water-
seal chamber. What is the correct interpretation and immediate
action for this finding?
, A. Normal finding; document that the lung is fully re-
expanding.
B. Indicates an air leak; check all connection sites from the
dressing to the drainage unit.
C. Suction pressure is too high; decrease the wall suction
regulator.
D. The chest tube is obstructed; milk the tubing toward the
container.
Correct Answer: B
Rationale: Continuous brisk bubbling in the water-seal
chamber indicates an active air leak in the chest tube system or
pleural space. (Intermittent bubbling during exhalation or
coughing is expected until the pleural leak heals). The nurse
should immediately assess connections and chest tube entry site.
High suction causes bubbling in the suction control chamber, not
continuous air-leak bubbling in the water-seal chamber.
Question 4: Renal / Electrolyte Emergency
Scenario: A client with Acute Kidney Injury (AKI) has a serum
potassium level of 6.8 mEq/L. The electrocardiogram (ECG)
reveals tall, peaked T waves and a widened QRS complex.
Which medication order should the nurse administer first to
stabilize myocardial electrical conduction?
A. Sodium polystyrene sulfonate PO
B. Calcium gluconate IV
C. Regular insulin IV with 50% Dextrose
D. Furosemide IV push
Correct Answer: B
