BSN 366 HESI RN EXIT EXAM V1
QUESTIONS AND VERIFIED ANSWERS |
100% CORRECT | GRADE A+
1. A client with Type 1 Diabetes Mellitus is admitted with a blood glucose of 560 mg/dL and
positive ketones in the urine. Which arterial blood gas (ABG) result would the nurse expect to
find?
A. pH 7.48, PaCO2 32, HCO3 20
B. pH 7.28, PaCO2 38, HCO3 18
C. pH 7.52, PaCO2 48, HCO3 30
D. pH 7.30, PaCO2 50, HCO3 26
Answer: B
Conceptual Explanation: Diabetic Ketoacidosis (DKA) results in metabolic acidosis. A pH
below 7.35 and a low bicarbonate level (HCO3 < 22) are characteristic findings.
2. A client is receiving Digoxin for heart failure. Which assessment finding is most indicative of
early Digoxin toxicity?
A. Tachycardia and hypertension
B. Yellow-green visual disturbances
,C. Increased urinary output
D. Anorexia, nausea, and vomiting
Answer: D
Conceptual Explanation: Early signs of Digoxin toxicity include gastrointestinal
symptoms like anorexia, nausea, and vomiting, followed by neurological and visual
changes.
3. A client with a T4 spinal cord injury reports a sudden, severe, pounding headache and is
found to be profusely sweating above the level of injury. What is the priority nursing action?
A. Administer an ordered analgesic for the headache
B. Assess the client’s bladder for distension
C. Place the client in a supine position
D. Lower the head of the bed to increase cerebral perfusion
Answer: B
Conceptual Explanation: These are classic signs of Autonomic Dysreflexia. The priority is
to elevate the head of the bed and identify/remove the stimulus, which is most commonly a
distended bladder.
4. The nurse is monitoring a client receiving Magnesium Sulfate for preeclampsia. Which
finding requires immediate intervention?
A. Respiratory rate of 14 breaths/minute
, B. Absent deep tendon reflexes
C. Urinary output of 40 mL/hour
D. Magnesium level of 6 mg/dL
Answer: B
Conceptual Explanation: Loss of deep tendon reflexes is an early sign of magnesium
toxicity. A therapeutic level is 4-7 mg/dL, and a respiratory rate below 12 or low urine
output would also be concerning.
5. During a fetal heart rate (FHR) monitor assessment, the nurse notes repetitive late
decelerations. Which action should the nurse take first?
A. Increase the rate of the Oxytocin infusion
B. Turn the client onto her left side
C. Perform a sterile vaginal exam
D. Document the findings as normal
Answer: B
Conceptual Explanation: Late decelerations indicate uteroplacental insufficiency. The
priority action is to improve perfusion by repositioning the mother to the side, followed by
oxygen and fluids.
QUESTIONS AND VERIFIED ANSWERS |
100% CORRECT | GRADE A+
1. A client with Type 1 Diabetes Mellitus is admitted with a blood glucose of 560 mg/dL and
positive ketones in the urine. Which arterial blood gas (ABG) result would the nurse expect to
find?
A. pH 7.48, PaCO2 32, HCO3 20
B. pH 7.28, PaCO2 38, HCO3 18
C. pH 7.52, PaCO2 48, HCO3 30
D. pH 7.30, PaCO2 50, HCO3 26
Answer: B
Conceptual Explanation: Diabetic Ketoacidosis (DKA) results in metabolic acidosis. A pH
below 7.35 and a low bicarbonate level (HCO3 < 22) are characteristic findings.
2. A client is receiving Digoxin for heart failure. Which assessment finding is most indicative of
early Digoxin toxicity?
A. Tachycardia and hypertension
B. Yellow-green visual disturbances
,C. Increased urinary output
D. Anorexia, nausea, and vomiting
Answer: D
Conceptual Explanation: Early signs of Digoxin toxicity include gastrointestinal
symptoms like anorexia, nausea, and vomiting, followed by neurological and visual
changes.
3. A client with a T4 spinal cord injury reports a sudden, severe, pounding headache and is
found to be profusely sweating above the level of injury. What is the priority nursing action?
A. Administer an ordered analgesic for the headache
B. Assess the client’s bladder for distension
C. Place the client in a supine position
D. Lower the head of the bed to increase cerebral perfusion
Answer: B
Conceptual Explanation: These are classic signs of Autonomic Dysreflexia. The priority is
to elevate the head of the bed and identify/remove the stimulus, which is most commonly a
distended bladder.
4. The nurse is monitoring a client receiving Magnesium Sulfate for preeclampsia. Which
finding requires immediate intervention?
A. Respiratory rate of 14 breaths/minute
, B. Absent deep tendon reflexes
C. Urinary output of 40 mL/hour
D. Magnesium level of 6 mg/dL
Answer: B
Conceptual Explanation: Loss of deep tendon reflexes is an early sign of magnesium
toxicity. A therapeutic level is 4-7 mg/dL, and a respiratory rate below 12 or low urine
output would also be concerning.
5. During a fetal heart rate (FHR) monitor assessment, the nurse notes repetitive late
decelerations. Which action should the nurse take first?
A. Increase the rate of the Oxytocin infusion
B. Turn the client onto her left side
C. Perform a sterile vaginal exam
D. Document the findings as normal
Answer: B
Conceptual Explanation: Late decelerations indicate uteroplacental insufficiency. The
priority action is to improve perfusion by repositioning the mother to the side, followed by
oxygen and fluids.
