HESI Exit Exam
What PO2 value indicates respiratory failure in adults? ANS: PO2 < 60 mmHg
What blood value indicates hypercapnia? ANS: PCO2 > 45 mmHg
What condition occurs when the PO2 is < 60 mmHg (acute hypoxemia), the CO2 tension rises > 50
mmHg (acute hypercarbia, hypercapnia) & the pH drops < 7.35, or both? ANS: Acute respiratory failure
What are the S/S of respiratory failure in adults? ANS: Dyspnea, SOB
Tachypnea
Intercostal & sternal retractions
Cyanosis
Tachycardia
Cough that produces sputum
Fatigue
Fever
Crackles, wheezes
Chest pain (especially when trying to deep breathe)
Hypotension
Confusion
Agitation, restlessness
What are the common causes of respiratory failure in peds? ANS: CHD
RDS
Infection, sepsis
NM diseases
,Trauma, burns
Aspiration
FVO & dehydration
Anesthesia & narcotic OD
Structural anomalies resulting in airway obstruction
What percentage of O2 should a child in severe respiratory distress receive? ANS: 100% O2
What is shock? ANS: Widespread, serious reduction of tissue perfusion, which leads to generalized
impairment of cellular function.
What is the most common cause of shock? ANS: Hypovolemia
What causes septic shock? ANS: Release of endotoxins from bacteria, which act on the nerves in
peripheral vascular spaces, causing vascular pooling, reduced venous return, decreased CO & results in
poor systemic perfusion.
What is the goal of tx for hypovolemic shock? ANS: Quick restoration of CO & tissue perfusion.
It's important to differentiate between hypovolemic & cardiogenic shock. How might the RN determine
the existence of cardiogenic shock? ANS: H/o MI with LV failure or possible cardiomyopathy, with S/S of
pulmonary edema.
If a pt is in cardiogenic shock, what might result from administration of volume-expanding fluids, and
what intervention can the RN expect to perform in the event of such an occurrence? ANS: Pulmonary
edema -- administer meds to manage preload, contractility and/or afterload. For example, to decrease
afterload, nitroprusside may be given.
What are 5 assessment findings occur in most shock pt's? ANS: Tachycardia
,Tachypnea
Hypotension
Cool, clammy skin
Decreased urine output
Once circulating volume is restored, vasopressors may be given to increase venous return. What are the
main drugs that are used? ANS: Epi & NE
Dopamine
Dobutamine
Isoproterenol
What is the established minimum renal output per hour? ANS: 30 mL/hr
What are 4 measurable criteria that are the major expected outcomes of a shock crisis? ANS: MAP 80-90
mmHg
PO2 > 50 mmHg
CVP 2-6 mmHg H2O
Urine output ≥ 30 mL/hr
What is DIC? ANS: A coagulation disorder in which there's paradoxical thrombosis & hemorrhage.
What medication is used to tx DIC? ANS: Heparin
The RN assesses a pt with the admitting dx of bipolar affective disorder, mania. Which pt S/S require the
RN's immediate action?
a) Incessant talking & sexual innuendos
, b) Grandiose delusions & poor concentration
c) Outlandish behaviors & inappropriate dress
d) Nonstop physical activity & poor nutritional intake ANS: d) Nonstop physical activity & poor
nutritional intake
Rationale:
Mania is a mood characterized by excitement, euphoria, hyperactivity, excessive energy, decreased
need for sleep, and impaired ability to concentrate or complete a single train of thought. The client's
mood is predominantly elevated, expansive, or irritable. All of the options reflect a client's possible
symptoms. However, the correct option clearly presents a problem that compromises physiological
integrity and needs to be addressed immediately.
The RN is caring for a pt who was involuntarily hospitalized to a mental health unit & is scheduled for
ECT. The RN notes that the informed consent hasn't been obtained for the procedure. Based on this
information, what is the RN's best determination in care planning?
a) The informed consent doesn't need to be obtained.
b) The informed consent would be obtained from the family.
c) The informed consent needs to be obtained from the pt.
d) The PCP will provide informed consent. ANS: c) The informed consent needs to be obtained from the
pt.
Rationale:
Clients who are admitted involuntarily to a mental health unit do not lose their right to informed
consent. Clients must be considered legally competent until they have been declared incompetent
through a legal proceeding. The best determination for the nurse to make is to obtain the informed
consent from the client.
A pt presents to the ED with UGI bleeding & in moderate distress. In care planning, what is the priority
RN action for this pt?
What PO2 value indicates respiratory failure in adults? ANS: PO2 < 60 mmHg
What blood value indicates hypercapnia? ANS: PCO2 > 45 mmHg
What condition occurs when the PO2 is < 60 mmHg (acute hypoxemia), the CO2 tension rises > 50
mmHg (acute hypercarbia, hypercapnia) & the pH drops < 7.35, or both? ANS: Acute respiratory failure
What are the S/S of respiratory failure in adults? ANS: Dyspnea, SOB
Tachypnea
Intercostal & sternal retractions
Cyanosis
Tachycardia
Cough that produces sputum
Fatigue
Fever
Crackles, wheezes
Chest pain (especially when trying to deep breathe)
Hypotension
Confusion
Agitation, restlessness
What are the common causes of respiratory failure in peds? ANS: CHD
RDS
Infection, sepsis
NM diseases
,Trauma, burns
Aspiration
FVO & dehydration
Anesthesia & narcotic OD
Structural anomalies resulting in airway obstruction
What percentage of O2 should a child in severe respiratory distress receive? ANS: 100% O2
What is shock? ANS: Widespread, serious reduction of tissue perfusion, which leads to generalized
impairment of cellular function.
What is the most common cause of shock? ANS: Hypovolemia
What causes septic shock? ANS: Release of endotoxins from bacteria, which act on the nerves in
peripheral vascular spaces, causing vascular pooling, reduced venous return, decreased CO & results in
poor systemic perfusion.
What is the goal of tx for hypovolemic shock? ANS: Quick restoration of CO & tissue perfusion.
It's important to differentiate between hypovolemic & cardiogenic shock. How might the RN determine
the existence of cardiogenic shock? ANS: H/o MI with LV failure or possible cardiomyopathy, with S/S of
pulmonary edema.
If a pt is in cardiogenic shock, what might result from administration of volume-expanding fluids, and
what intervention can the RN expect to perform in the event of such an occurrence? ANS: Pulmonary
edema -- administer meds to manage preload, contractility and/or afterload. For example, to decrease
afterload, nitroprusside may be given.
What are 5 assessment findings occur in most shock pt's? ANS: Tachycardia
,Tachypnea
Hypotension
Cool, clammy skin
Decreased urine output
Once circulating volume is restored, vasopressors may be given to increase venous return. What are the
main drugs that are used? ANS: Epi & NE
Dopamine
Dobutamine
Isoproterenol
What is the established minimum renal output per hour? ANS: 30 mL/hr
What are 4 measurable criteria that are the major expected outcomes of a shock crisis? ANS: MAP 80-90
mmHg
PO2 > 50 mmHg
CVP 2-6 mmHg H2O
Urine output ≥ 30 mL/hr
What is DIC? ANS: A coagulation disorder in which there's paradoxical thrombosis & hemorrhage.
What medication is used to tx DIC? ANS: Heparin
The RN assesses a pt with the admitting dx of bipolar affective disorder, mania. Which pt S/S require the
RN's immediate action?
a) Incessant talking & sexual innuendos
, b) Grandiose delusions & poor concentration
c) Outlandish behaviors & inappropriate dress
d) Nonstop physical activity & poor nutritional intake ANS: d) Nonstop physical activity & poor
nutritional intake
Rationale:
Mania is a mood characterized by excitement, euphoria, hyperactivity, excessive energy, decreased
need for sleep, and impaired ability to concentrate or complete a single train of thought. The client's
mood is predominantly elevated, expansive, or irritable. All of the options reflect a client's possible
symptoms. However, the correct option clearly presents a problem that compromises physiological
integrity and needs to be addressed immediately.
The RN is caring for a pt who was involuntarily hospitalized to a mental health unit & is scheduled for
ECT. The RN notes that the informed consent hasn't been obtained for the procedure. Based on this
information, what is the RN's best determination in care planning?
a) The informed consent doesn't need to be obtained.
b) The informed consent would be obtained from the family.
c) The informed consent needs to be obtained from the pt.
d) The PCP will provide informed consent. ANS: c) The informed consent needs to be obtained from the
pt.
Rationale:
Clients who are admitted involuntarily to a mental health unit do not lose their right to informed
consent. Clients must be considered legally competent until they have been declared incompetent
through a legal proceeding. The best determination for the nurse to make is to obtain the informed
consent from the client.
A pt presents to the ED with UGI bleeding & in moderate distress. In care planning, what is the priority
RN action for this pt?
