SCRUTINIZED HESI EXIT
EXAM
PRACTICE QUESTIONS
AND ANSWERS
A client presents at the ED complaining of a raspy voice, cold intolerance, and fatigue. Lab
tests indicate an elevated TSH and low T3 and T4 levels. After the client is admitted to the
telemetry unit, which intervention is most important for the nurse to implement?
A) Assess for presence of non-pitting edema.
B) Administer the prescribed dose of levothyroxine.
C)Offer additional blankets and a warm drink.
D) Note client's most recent hemoglobin levels. - CORRECT ANSWER -B) Administer the
prescribed dose of levothyroxine.
Rationale: In the negative feedback mechanism of hypothyroidism, a low level of thyroid
hormone stimulates TSH production by the hypothalamus and results in an elevated TSH level,
but the thyroid gland does not respond with adequate production of T3 and T4 to regulate basal
metabolic rate. These serum hormone levels indicate the need to administer supplementary
thyroid hormone as soon as possible to avert possible myxedema 9coma. 9Non-pitting 9edema
9is 9seen 9in 9chronic 9hypothyroidism 9and 9assessment 9of 9the 9presence 9and 9location 9of
9the 9edema 9(A) 9is 9not 9a 9top 9priority. 9Providing 9warmth 9(C) 9is 9beneficial 9but 9of 9less
9priority 9than 9(B). 9Anemia 9is 9common 9in 9hypothyroidism, 9but 9(D) 9is 9of 9lower 9priority
9than 9initiating 9treatment 9to 9prevent 9myxedema 9coma.
The 9nurse 9suspects 9that 9a 9client 9might 9be 9hemorrhaging 9internally. 9Which 9findings 9of
9an 9orthostatic 9tilt 9test 9are 9a 9most 9likely 9indication 9of 9a 9major 9bleed 9(> 91000 9ml)?
A) A 9decrease 9in 9the 9systolic 9BP 9of 910 9mm 9Hg 9with 9a 9corresponding 9increase 9in 9the 9HR
9of 920.
,B) A 9decrease 9in 9the 9systolic 9BP 9of 910 9mm 9Hg 9with 9a 9corresponding 9decrease 9in 9the
9HR 9of 920.
C)A 9decrease 9in 9the 9systolic 9BP 9of 920 9mm 9Hg 9with 9a 9corresponding 9decrease 9in 9the
9HR 9of 910.
D) A 9decrease 9in 9the 9systolic 9BP 9of 920 9mm 9Hg 9with 9a 9corresponding 9increase 9in 9the
9HR 9of 910. 9- 9CORRECT 9ANSWER 9-Ans: 9A) 9A 9decrease 9in 9the 9systolic 9BP 9of 910 9mm
9Hg 9with 9a 9corresponding 9increase 9in 9the 9HR 9of 920.
Rationale: 9The 9loss 9of 9circulatory 9volume 9results 9in 9a 910 9mm 9Hg 9drop 9in 9the 9systolic
9pressure, 9while 9the 9HR 9increases 9by 920 9% 9above 9normal 9as 9a 9compensatory
9response 9to 9the 9low 9pressure.
When 9conducting 9diet 9teaching 9for 9a 9client 9who 9is 9on 9a 9postoperative 9full 9liquid 9diet,
9which 9foods 9should 9the 9nurse 9encourage 9the 9client 9to 9eat? 9SATA.
A) Canned 9fruit 9cocktail
B) Creamy 9peanut 9butter
C)Vegetable 9juice
D) Vanilla 9frozen 9yogurt
E)Clear 9beef 9broth 9- 9CORRECT 9ANSWER 9-Ans: 9C, 9D, 9E
A 9full 9liquid 9diet 9includes 9all 9liquids 9that 9are 9not 9clear 9such 9as 9vegetable 9juice 9and
9frozen 9yogurt, 9as 9well 9as 9clear 9liquids. 9Pieces 9of 9fruit 9as 9found 9in 9fruit 9cocktail 9and
9peanut 9butter 9are 9not 9considered 9liquids.
A 9client 9is 9receiving 9ophthalmic 9drops 9preoperatively 9for 9a 9cataract 9extraction 9and 9asks
9the 9nurse 9why 9he 9is 9prescribed 9all 9these 9medications? 9SATA.
A) One 9of 9the 9medications 9is 9used 9to 9anesthetize 9the 9corneal 9surface.
B) The 9iris 9must 9be 9paralyzed 9during 9the 9surgery 9to 9prevent 9it 9from 9reacting 9to 9light.
C)Medication 9is 9used 9to 9induce 9sleep 9during 9the 9procedure.
D) Pupillary 9dilation 9is 9necessary 9to 9access 9the 9eye 9chamber 9for 9lens 9removal.
,E)These 9meds 9assist 9in 9obstructing 9the 9client's 9vision 9during 9the 9surgery. 9- 9CORRECT
9ANSWER 9-Ans: 9A, 9B, 9D
Cataract 9surgery 9is 9accessed 9through 9the 9cornea 9using 9eyelid 9retractors 9while 9the 9client
9is 9awake. 9It 9is 9necessary 9to 9anesthetize 9the 9corneal 9surface 9(A), 9paralyze 9the 9ciliary
9body 9(B), 9and 9provide 9pupil 9dilation 9(D)(mydriasis) 9to 9facilitate 9access 9to 9the 9lens 9which
9ties 9behind 9the 9iris 9(posterior 9chamber 9of 9the 9anterior 9cavity). 9A 9sedative 9may 9be
9administered 9to 9reduce 9anxiety 9but 9it 9is 9not 9used 9to 9induce 9sleep. 9(C) 9Cloudy 9vision
9may 9be 9a 9side 9effect 9of 9these 9agents, 9but 9the 9client 9will 9still 9be 9able 9to 9see 9during
9the 9surgery 9(E).
When 9assessing 9an 9IV 9site 9that 9is 9sued 9for 9fluid 9replacement 9and 9medication
9administration, 9the 9client 9complains 9of 9the 9tenderness 9when 9the 9arm 9is 9touched 9above
9the 9site. 9Which 9additional 9assessment 9warrants 9immediate 9intervention 9by 9the 9nurse?
A) Sluggish 9blood 9return
B) Client 9uses 9the 9arm 9cautiously
C)Spot 9of 9dried 9blood 9at 9the 9insertion 9site
D) Red 9streak 9tracking 9the 9vein 9- 9CORRECT 9ANSWER 9-Ans: 9D
A 9red 9streak 9(D) 9indicates 9vein 9irritation 9and 9necessitates 9discontinuing 9the 9IV 9at 9the
9present 9site. 9A, 9B, 9and 9C 9are 9indications 9for 9relocating 9the 9IV 9site 9or 9other
9immediate 9intervention.
A 9client 9with 9a 9liver 9abscess 9develops 9septic 9shock. 9A 9sepsis 9resuscitation 9bundle
9protocol 9is 9initiated 9and 9the 9client 9receives 9a 9bolus 9of 9IV 9fluids. 9Which 9parameter
9should 9the 9nurse 9monitor 9to 9assess 9effectiveness 9of 9the 9fluid 9bolus?
A) Blood 9cultures.
B) Oxygen 9saturation.
C)White 9blood 9count.
D) Mean 9arterial 9pressure 9(MAP). 9- 9CORRECT 9ANSWER 9-D) 9Mean 9arterial 9pressure
9(MAP)
The 9cornerstone 9of 9initial 9sepsis 9resuscitation 9is 9fluid 9volume 9administration 9to 9restore
9and 9then 9maintain 9MAP 9of 9at 9least 965 9mmHg.
, When 9attempting 9to 9establish 9risk 9reduction 9strategies 9in 9a 9community, 9the 9nurse 9notes
9that 9regional 9studies 9indicate 9a 9high 9number 9of 9persons 9with 9growth 9stunting 9and
9irreversible 9mental 9deficiencies 9(cretinism) 9caused 9by 9hypothyroidism. 9The 9nurse 9should
9seek 9funding 9to 9implement 9which 9screening 9measure?
A) T4 9levels 9in 9newborns.
B) TSH 9levels 9in 9women 9over 945.
C) T3 9levels 9in 9school-aged 9children
D) Iodine 9levels 9in 9all 9persons 9over 960. 9- 9CORRECT 9ANSWER 9-A) 9T4 9levels 9in
9newborns.
Screening 9for 9low 9T4 9levels 9in 9newborns 9with 9follow-up 9treatment 9can 9reduce 9the 9risk 9for
9irreversible 9growth 9stunting 9and 9mental 9deficiencies 9caused 9by 9congenital 9hypothyroidism.
For 9the 9past 924 9hours, 9an 9antidiarrheal 9agent, 9diphenoxylate, 9has 9been 9administered 9to
9a 9bedridden, 9older 9client 9with 9infectious 9gastroenteritis. 9Which 9finding 9requires 9the
9nurse 9to 9take 9further 9action?
A) Loss 9of 9appetite
B) Serum 9K+ 94.0 9mEq/L 9or 9mmol/L 9(SI)
C)Loose, 9runny 9stools.
D) Tented 9skin 9turgor. 9- 9CORRECT 9ANSWER 9-D) 9Tented 9skin 9turgor.
Indicates 9dehydration, 9a 9serious 9complication 9following 9prolonged 9diarrhea 9that 9requires
9further 9intervention 9by 9the 9nurse.
A 9male 9client 9with 9ulcerative 9colitis 9received 9an 9Rx 9for 9a 9corticosteroid 9last 9month 9but
9because 9of 9the 9S/E, 9he 9stopped 9taking 9the 9medications 96 9days 9ago. 9Which 9finding
9warrants 9immediate 9intervention 9by 9the 9nurse?
A) Fluid 9retention
EXAM
PRACTICE QUESTIONS
AND ANSWERS
A client presents at the ED complaining of a raspy voice, cold intolerance, and fatigue. Lab
tests indicate an elevated TSH and low T3 and T4 levels. After the client is admitted to the
telemetry unit, which intervention is most important for the nurse to implement?
A) Assess for presence of non-pitting edema.
B) Administer the prescribed dose of levothyroxine.
C)Offer additional blankets and a warm drink.
D) Note client's most recent hemoglobin levels. - CORRECT ANSWER -B) Administer the
prescribed dose of levothyroxine.
Rationale: In the negative feedback mechanism of hypothyroidism, a low level of thyroid
hormone stimulates TSH production by the hypothalamus and results in an elevated TSH level,
but the thyroid gland does not respond with adequate production of T3 and T4 to regulate basal
metabolic rate. These serum hormone levels indicate the need to administer supplementary
thyroid hormone as soon as possible to avert possible myxedema 9coma. 9Non-pitting 9edema
9is 9seen 9in 9chronic 9hypothyroidism 9and 9assessment 9of 9the 9presence 9and 9location 9of
9the 9edema 9(A) 9is 9not 9a 9top 9priority. 9Providing 9warmth 9(C) 9is 9beneficial 9but 9of 9less
9priority 9than 9(B). 9Anemia 9is 9common 9in 9hypothyroidism, 9but 9(D) 9is 9of 9lower 9priority
9than 9initiating 9treatment 9to 9prevent 9myxedema 9coma.
The 9nurse 9suspects 9that 9a 9client 9might 9be 9hemorrhaging 9internally. 9Which 9findings 9of
9an 9orthostatic 9tilt 9test 9are 9a 9most 9likely 9indication 9of 9a 9major 9bleed 9(> 91000 9ml)?
A) A 9decrease 9in 9the 9systolic 9BP 9of 910 9mm 9Hg 9with 9a 9corresponding 9increase 9in 9the 9HR
9of 920.
,B) A 9decrease 9in 9the 9systolic 9BP 9of 910 9mm 9Hg 9with 9a 9corresponding 9decrease 9in 9the
9HR 9of 920.
C)A 9decrease 9in 9the 9systolic 9BP 9of 920 9mm 9Hg 9with 9a 9corresponding 9decrease 9in 9the
9HR 9of 910.
D) A 9decrease 9in 9the 9systolic 9BP 9of 920 9mm 9Hg 9with 9a 9corresponding 9increase 9in 9the
9HR 9of 910. 9- 9CORRECT 9ANSWER 9-Ans: 9A) 9A 9decrease 9in 9the 9systolic 9BP 9of 910 9mm
9Hg 9with 9a 9corresponding 9increase 9in 9the 9HR 9of 920.
Rationale: 9The 9loss 9of 9circulatory 9volume 9results 9in 9a 910 9mm 9Hg 9drop 9in 9the 9systolic
9pressure, 9while 9the 9HR 9increases 9by 920 9% 9above 9normal 9as 9a 9compensatory
9response 9to 9the 9low 9pressure.
When 9conducting 9diet 9teaching 9for 9a 9client 9who 9is 9on 9a 9postoperative 9full 9liquid 9diet,
9which 9foods 9should 9the 9nurse 9encourage 9the 9client 9to 9eat? 9SATA.
A) Canned 9fruit 9cocktail
B) Creamy 9peanut 9butter
C)Vegetable 9juice
D) Vanilla 9frozen 9yogurt
E)Clear 9beef 9broth 9- 9CORRECT 9ANSWER 9-Ans: 9C, 9D, 9E
A 9full 9liquid 9diet 9includes 9all 9liquids 9that 9are 9not 9clear 9such 9as 9vegetable 9juice 9and
9frozen 9yogurt, 9as 9well 9as 9clear 9liquids. 9Pieces 9of 9fruit 9as 9found 9in 9fruit 9cocktail 9and
9peanut 9butter 9are 9not 9considered 9liquids.
A 9client 9is 9receiving 9ophthalmic 9drops 9preoperatively 9for 9a 9cataract 9extraction 9and 9asks
9the 9nurse 9why 9he 9is 9prescribed 9all 9these 9medications? 9SATA.
A) One 9of 9the 9medications 9is 9used 9to 9anesthetize 9the 9corneal 9surface.
B) The 9iris 9must 9be 9paralyzed 9during 9the 9surgery 9to 9prevent 9it 9from 9reacting 9to 9light.
C)Medication 9is 9used 9to 9induce 9sleep 9during 9the 9procedure.
D) Pupillary 9dilation 9is 9necessary 9to 9access 9the 9eye 9chamber 9for 9lens 9removal.
,E)These 9meds 9assist 9in 9obstructing 9the 9client's 9vision 9during 9the 9surgery. 9- 9CORRECT
9ANSWER 9-Ans: 9A, 9B, 9D
Cataract 9surgery 9is 9accessed 9through 9the 9cornea 9using 9eyelid 9retractors 9while 9the 9client
9is 9awake. 9It 9is 9necessary 9to 9anesthetize 9the 9corneal 9surface 9(A), 9paralyze 9the 9ciliary
9body 9(B), 9and 9provide 9pupil 9dilation 9(D)(mydriasis) 9to 9facilitate 9access 9to 9the 9lens 9which
9ties 9behind 9the 9iris 9(posterior 9chamber 9of 9the 9anterior 9cavity). 9A 9sedative 9may 9be
9administered 9to 9reduce 9anxiety 9but 9it 9is 9not 9used 9to 9induce 9sleep. 9(C) 9Cloudy 9vision
9may 9be 9a 9side 9effect 9of 9these 9agents, 9but 9the 9client 9will 9still 9be 9able 9to 9see 9during
9the 9surgery 9(E).
When 9assessing 9an 9IV 9site 9that 9is 9sued 9for 9fluid 9replacement 9and 9medication
9administration, 9the 9client 9complains 9of 9the 9tenderness 9when 9the 9arm 9is 9touched 9above
9the 9site. 9Which 9additional 9assessment 9warrants 9immediate 9intervention 9by 9the 9nurse?
A) Sluggish 9blood 9return
B) Client 9uses 9the 9arm 9cautiously
C)Spot 9of 9dried 9blood 9at 9the 9insertion 9site
D) Red 9streak 9tracking 9the 9vein 9- 9CORRECT 9ANSWER 9-Ans: 9D
A 9red 9streak 9(D) 9indicates 9vein 9irritation 9and 9necessitates 9discontinuing 9the 9IV 9at 9the
9present 9site. 9A, 9B, 9and 9C 9are 9indications 9for 9relocating 9the 9IV 9site 9or 9other
9immediate 9intervention.
A 9client 9with 9a 9liver 9abscess 9develops 9septic 9shock. 9A 9sepsis 9resuscitation 9bundle
9protocol 9is 9initiated 9and 9the 9client 9receives 9a 9bolus 9of 9IV 9fluids. 9Which 9parameter
9should 9the 9nurse 9monitor 9to 9assess 9effectiveness 9of 9the 9fluid 9bolus?
A) Blood 9cultures.
B) Oxygen 9saturation.
C)White 9blood 9count.
D) Mean 9arterial 9pressure 9(MAP). 9- 9CORRECT 9ANSWER 9-D) 9Mean 9arterial 9pressure
9(MAP)
The 9cornerstone 9of 9initial 9sepsis 9resuscitation 9is 9fluid 9volume 9administration 9to 9restore
9and 9then 9maintain 9MAP 9of 9at 9least 965 9mmHg.
, When 9attempting 9to 9establish 9risk 9reduction 9strategies 9in 9a 9community, 9the 9nurse 9notes
9that 9regional 9studies 9indicate 9a 9high 9number 9of 9persons 9with 9growth 9stunting 9and
9irreversible 9mental 9deficiencies 9(cretinism) 9caused 9by 9hypothyroidism. 9The 9nurse 9should
9seek 9funding 9to 9implement 9which 9screening 9measure?
A) T4 9levels 9in 9newborns.
B) TSH 9levels 9in 9women 9over 945.
C) T3 9levels 9in 9school-aged 9children
D) Iodine 9levels 9in 9all 9persons 9over 960. 9- 9CORRECT 9ANSWER 9-A) 9T4 9levels 9in
9newborns.
Screening 9for 9low 9T4 9levels 9in 9newborns 9with 9follow-up 9treatment 9can 9reduce 9the 9risk 9for
9irreversible 9growth 9stunting 9and 9mental 9deficiencies 9caused 9by 9congenital 9hypothyroidism.
For 9the 9past 924 9hours, 9an 9antidiarrheal 9agent, 9diphenoxylate, 9has 9been 9administered 9to
9a 9bedridden, 9older 9client 9with 9infectious 9gastroenteritis. 9Which 9finding 9requires 9the
9nurse 9to 9take 9further 9action?
A) Loss 9of 9appetite
B) Serum 9K+ 94.0 9mEq/L 9or 9mmol/L 9(SI)
C)Loose, 9runny 9stools.
D) Tented 9skin 9turgor. 9- 9CORRECT 9ANSWER 9-D) 9Tented 9skin 9turgor.
Indicates 9dehydration, 9a 9serious 9complication 9following 9prolonged 9diarrhea 9that 9requires
9further 9intervention 9by 9the 9nurse.
A 9male 9client 9with 9ulcerative 9colitis 9received 9an 9Rx 9for 9a 9corticosteroid 9last 9month 9but
9because 9of 9the 9S/E, 9he 9stopped 9taking 9the 9medications 96 9days 9ago. 9Which 9finding
9warrants 9immediate 9intervention 9by 9the 9nurse?
A) Fluid 9retention
