EXIT HESI COMPREHENSIVE EXAM
BSN 366 V2 QUESTIONS AND VERIFIED
ANSWERS | 100% CORRECT | GRADE A+
1. A nurse is caring for a client with a history of heart failure who is receiving digoxin 0.25 mg
daily. Which of the following assessment findings should the nurse identify as a priority to
report to the provider?
A. Apical pulse of 62 beats per minute
B. Reported blurred vision with yellow-green halos
C. Potassium level of 4.2 mEq/L
D. Occasional premature ventricular contractions
Answer: B
Conceptual Explanation: Visual changes such as yellow-green halos or blurred vision are
classic signs of digoxin toxicity and require immediate intervention. A heart rate of 62 is
within normal limits, and a potassium of 4.2 is normal, though low potassium can increase
toxicity risk.
2. A client is admitted to the emergency department with a potassium level of 6.8 mEq/L.
Which of the following prescriptions should the nurse expect to implement first?
A. Administer intravenous calcium gluconate
,B. Initiate a low-potassium diet
C. Administer oral sodium polystyrene sulfonate
D. Prepare the client for emergency hemodialysis
Answer: A
Conceptual Explanation: Calcium gluconate does not lower potassium but is administered
first to stabilize the myocardium and prevent life-threatening arrhythmias caused by
hyperkalemia.
3. The nurse is reviewing the arterial blood gas (ABG) results for a client with respiratory
distress: pH 7.28, PaCO2 52 mm Hg, HCO3 26 mEq/L. How should the nurse interpret these
findings?
A. Metabolic Acidosis
B. Respiratory Acidosis
C. Metabolic Alkalosis
D. Respiratory Alkalosis
Answer: B
Conceptual Explanation: A pH below 7.35 indicates acidosis. A PaCO2 above 45 mm Hg
indicates a respiratory cause, and since the bicarbonate is within the normal range, it is
uncompensated respiratory acidosis.
, 4. Which client should the nurse assess first after receiving the change-of-shift report?
A. A client with a chest tube who has 50 mL of serosanguinous drainage in the last hour
B. A client with type 1 diabetes whose capillary blood glucose is 160 mg/dL
C. A client with a pulmonary embolism who reports sudden-onset shortness of breath and
pleuritic pain
D. A client 2 days post-op from a hip replacement who is requesting pain medication
Answer: C
Conceptual Explanation: Sudden-onset shortness of breath in a client with a known
pulmonary embolism indicates a life-threatening worsening of the condition (ABCs).
5. A nurse is caring for a client receiving a continuous heparin infusion for deep vein
thrombosis. The client’s aPTT is 105 seconds (control 25-35 seconds). Which action should the
nurse take?
A. Increase the infusion rate per protocol
B. Continue the infusion and recheck the aPTT in 4 hours
C. Stop the infusion and prepare to administer protamine sulfate
D. Notify the provider and expect to decrease the infusion rate
Answer: C
BSN 366 V2 QUESTIONS AND VERIFIED
ANSWERS | 100% CORRECT | GRADE A+
1. A nurse is caring for a client with a history of heart failure who is receiving digoxin 0.25 mg
daily. Which of the following assessment findings should the nurse identify as a priority to
report to the provider?
A. Apical pulse of 62 beats per minute
B. Reported blurred vision with yellow-green halos
C. Potassium level of 4.2 mEq/L
D. Occasional premature ventricular contractions
Answer: B
Conceptual Explanation: Visual changes such as yellow-green halos or blurred vision are
classic signs of digoxin toxicity and require immediate intervention. A heart rate of 62 is
within normal limits, and a potassium of 4.2 is normal, though low potassium can increase
toxicity risk.
2. A client is admitted to the emergency department with a potassium level of 6.8 mEq/L.
Which of the following prescriptions should the nurse expect to implement first?
A. Administer intravenous calcium gluconate
,B. Initiate a low-potassium diet
C. Administer oral sodium polystyrene sulfonate
D. Prepare the client for emergency hemodialysis
Answer: A
Conceptual Explanation: Calcium gluconate does not lower potassium but is administered
first to stabilize the myocardium and prevent life-threatening arrhythmias caused by
hyperkalemia.
3. The nurse is reviewing the arterial blood gas (ABG) results for a client with respiratory
distress: pH 7.28, PaCO2 52 mm Hg, HCO3 26 mEq/L. How should the nurse interpret these
findings?
A. Metabolic Acidosis
B. Respiratory Acidosis
C. Metabolic Alkalosis
D. Respiratory Alkalosis
Answer: B
Conceptual Explanation: A pH below 7.35 indicates acidosis. A PaCO2 above 45 mm Hg
indicates a respiratory cause, and since the bicarbonate is within the normal range, it is
uncompensated respiratory acidosis.
, 4. Which client should the nurse assess first after receiving the change-of-shift report?
A. A client with a chest tube who has 50 mL of serosanguinous drainage in the last hour
B. A client with type 1 diabetes whose capillary blood glucose is 160 mg/dL
C. A client with a pulmonary embolism who reports sudden-onset shortness of breath and
pleuritic pain
D. A client 2 days post-op from a hip replacement who is requesting pain medication
Answer: C
Conceptual Explanation: Sudden-onset shortness of breath in a client with a known
pulmonary embolism indicates a life-threatening worsening of the condition (ABCs).
5. A nurse is caring for a client receiving a continuous heparin infusion for deep vein
thrombosis. The client’s aPTT is 105 seconds (control 25-35 seconds). Which action should the
nurse take?
A. Increase the infusion rate per protocol
B. Continue the infusion and recheck the aPTT in 4 hours
C. Stop the infusion and prepare to administer protamine sulfate
D. Notify the provider and expect to decrease the infusion rate
Answer: C
