BSN 246 HESI HEALTH EXAM V1
COMPREHENSIVE REVIEW QUESTIONS
AND ANSWERS
1. A patient with chronic kidney disease (CKD) presents with a potassium level of 6.8 mEq/L.
Which medication should the nurse expect to administer first to protect the heart?
A. Calcium gluconate
B. Sodium polystyrene sulfonate
C. Regular insulin and D50W
D. Furosemide
Answer: A
Conceptual Explanation: Calcium gluconate is administered in severe hyperkalemia to
stabilize the myocardial cell membrane and prevent life-threatening arrhythmias, though it
does not lower the potassium level itself.
2. Which clinical manifestation should a nurse prioritize when assessing a patient diagnosed
with systemic lupus erythematosus (SLE)?
A. Butterfly rash on the face
,B. Elevated serum creatinine and protein in urine
C. Fatigue and joint pain
D. Photosensitivity
Answer: B
Conceptual Explanation: Lupus nephritis is a severe complication of SLE. Monitoring
renal function (creatinine and proteinuria) is critical to prevent permanent kidney damage.
3. A patient is receiving a continuous intravenous infusion of heparin. The nurse notes the
patient’s PTT is 110 seconds (Control: 25-35). What is the priority action?
A. Continue to monitor the patient
B. Increase the infusion rate
C. Administer Vitamin K
D. Stop the heparin infusion
Answer: D
Conceptual Explanation: A PTT of 110 seconds is significantly above the therapeutic
range (usually 1.5 to 2.5 times the control). The infusion must be stopped to prevent
hemorrhage.
4. In the early stages of shock, which physiological response is primarily responsible for
maintaining blood pressure?
A. Decrease in heart rate
, B. Activation of the parasympathetic nervous system
C. Release of epinephrine and norepinephrine
D. Vasodilation of peripheral vessels
Answer: C
Conceptual Explanation: In the compensatory stage of shock, the sympathetic nervous
system releases catecholamines to increase heart rate and cause vasoconstriction to
maintain cardiac output.
5. A nurse is caring for a patient with right-sided heart failure. Which assessment finding is
most consistent with this diagnosis?
A. Crackles in the lungs
B. Pink frothy sputum
C. Dyspnea and orthopnea
D. Peripheral edema and jugular venous distention
Answer: D
Conceptual Explanation: Right-sided heart failure causes blood to back up into the
systemic circulation, leading to peripheral edema, hepatomegaly, and JVD.
6. Which dietary instruction is most important for a patient newly prescribed Lithium
carbonate for bipolar disorder?
A. Restrict fluid intake to 1 liter per day
COMPREHENSIVE REVIEW QUESTIONS
AND ANSWERS
1. A patient with chronic kidney disease (CKD) presents with a potassium level of 6.8 mEq/L.
Which medication should the nurse expect to administer first to protect the heart?
A. Calcium gluconate
B. Sodium polystyrene sulfonate
C. Regular insulin and D50W
D. Furosemide
Answer: A
Conceptual Explanation: Calcium gluconate is administered in severe hyperkalemia to
stabilize the myocardial cell membrane and prevent life-threatening arrhythmias, though it
does not lower the potassium level itself.
2. Which clinical manifestation should a nurse prioritize when assessing a patient diagnosed
with systemic lupus erythematosus (SLE)?
A. Butterfly rash on the face
,B. Elevated serum creatinine and protein in urine
C. Fatigue and joint pain
D. Photosensitivity
Answer: B
Conceptual Explanation: Lupus nephritis is a severe complication of SLE. Monitoring
renal function (creatinine and proteinuria) is critical to prevent permanent kidney damage.
3. A patient is receiving a continuous intravenous infusion of heparin. The nurse notes the
patient’s PTT is 110 seconds (Control: 25-35). What is the priority action?
A. Continue to monitor the patient
B. Increase the infusion rate
C. Administer Vitamin K
D. Stop the heparin infusion
Answer: D
Conceptual Explanation: A PTT of 110 seconds is significantly above the therapeutic
range (usually 1.5 to 2.5 times the control). The infusion must be stopped to prevent
hemorrhage.
4. In the early stages of shock, which physiological response is primarily responsible for
maintaining blood pressure?
A. Decrease in heart rate
, B. Activation of the parasympathetic nervous system
C. Release of epinephrine and norepinephrine
D. Vasodilation of peripheral vessels
Answer: C
Conceptual Explanation: In the compensatory stage of shock, the sympathetic nervous
system releases catecholamines to increase heart rate and cause vasoconstriction to
maintain cardiac output.
5. A nurse is caring for a patient with right-sided heart failure. Which assessment finding is
most consistent with this diagnosis?
A. Crackles in the lungs
B. Pink frothy sputum
C. Dyspnea and orthopnea
D. Peripheral edema and jugular venous distention
Answer: D
Conceptual Explanation: Right-sided heart failure causes blood to back up into the
systemic circulation, leading to peripheral edema, hepatomegaly, and JVD.
6. Which dietary instruction is most important for a patient newly prescribed Lithium
carbonate for bipolar disorder?
A. Restrict fluid intake to 1 liter per day
