HESI 213 PRACTICE EXAM NUR 213
Agiclientgiwithgicardiogenicgishockgiwhogiweighsgi220gipoundsgiisgireceivinggiagisolutiongiofgiDextrosegi5%giingiW
tergi(D5W)gi250gimlgiwithgidopaminegi400gimggiatgithegirategiofgi3gimcg/kg/
minute.giTheginursegishouldgisetgithegiinfusiongipumpgitogidelivergihowgimanygiml/hour?
gi(Enterginumericgivaluegionly.giIfgiroundinggiisgirequired,giroundgitogitheginearestgitenth.)gi-gianswer--11.3
Howgishouldgitheginursegipositiongithegielectrodesgiforgimodifiedgichestgileadgionegi(MCLgiI)gitelemetrygimonito
g?gi-gianswer--
Negativegipolaritygileftgishoulder,gipositivegipolaritygirightgichestginipplegiline,gigroundgileftgichestginipplegiline.
Agi3-week-oldginewborngiisgibroughtgitogithegiclinicgiforgifollow-
upgiaftergiagihomegibirth.giThegimothergireportsgithatgihergichildgibottlegifeedsgiforgi5giminutesgionlygiandgithengifa
giasleep.giTheginursegiauscultatesgiagiloudgimurmurgicharacteristicgiofgiagiventriculargiseptalgidefectgi(VSD),gian
ifindsgitheginewborngiisgiacyanoticgiwithgiagirespiratorygirategiofgi64gibreathsgipergiminute.giWhatgiinstructiongish
ldgitheginursegiprovidegithegimothergitogiensuregithegiinfantgiisgireceivinggiadequategiintake?
gi(Selectgiallgithatgiapply.)gi-gianswer--
NeonatesgiwhogihavegiVSDgimaygifatiguegiquicklygiduringgifeedinggiandgiingestgiinadequategiamounts.giTheyg
ouldgibegimonitoredgiforgiweightgigaingiandgiatgileastgi6giwetgidiapersgipergiday.giAgione-
monthgioldgiinfantgishouldgiingestgi2gitogi4giouncesgi(60-
120mL)giofgiformulagipergifeedinggiandgiprogressgitogiaboutgi30giouncesgi(900mL)gipergidaygibygi4-
monthsgiofgiage.giDuegitogifatigue,githegiinfantgishouldgirest,gibutgifeedgiatgileastgieverygi2gihoursgitogiensuregiade
uategiintake.giAgisoftergi(preemie)ginipplegiorgiagilargergislitgiingitheginipplegihelpsgitogireducegithegisuckinggieffor
ndgienergygiexpenditure,githusgiallowinggithegiinfantgitogiingestgimoregiwithgilessgieffort.giAntibioticgiprophylaxis
sgirecommendedgiforgiinfantsgiwithgiVSDs,gibutgishouldginotgibegimixedgiingiagibottlegiofgiformulagibecausegiitgiisg
fficultgitogiensuregithatgithegitotalgidosegiisgiconsumed.
1-2-3-5
Agi3-year-
oldgiboygiisgibroughtgitogithegiemergencygiroomgibecausegiofgiagipossiblegidiazepamgi(Valium)gioverdose.giHeg
lethargicgiandgiconfused,giandgihisgivitalgisignsgiare:gipulsegirategi100gibeats/
minute,girespiratorygirategi20gibreaths/
minute,giandgibloodgipressuregi70/30.giWhichginursinggiinterventiongihasgithegihighestgipriority?gi-gianswer--
preparationgiforgiendotrachealgiintubationgitogiprotectgithegiairwaygiisgithegiprioritygiinterventiongiatgithisgitime.
Agiclientgiwithgiagi16-
yeargihistorygiofgidiabetesgimellitusgiisgihavinggirenalgifunctiongitestsgibecausegiofgirecentgifatigue,giweakness,
evatedgibloodgiureaginitrogen,giandgiserumgicreatininegilevels.giWhichgifindinggishouldgitheginursegiconcludegia
angiearlygisymptomgiofgirenalgiinsufficiency?gi-gianswer--Nocturia
Asgithegiglomerulargifiltrationgirategidecreasesgiingiearlygirenalgiinsufficiency,gimetabolicgiwastegiproducts,giinc
dinggiurea,gicreatinine,giandgiothergisubstances,gisuchgiphenols,gihormones,gielectrolytes,giaccumulategiingith
blood.giIngithegiearlygistagegiofgirenalgiinsufficiency,gipolyuriagiresultsgifromgithegiinabilitygiofgithegikidneysgitogico
centrategiurinegiandgicontributegitoginocturia.
Agiclient'sgifamilygiasksgiwhygitheirgimothergiwithgiheartgifailuregineedsgiagipulmonarygiarterygi(PA)gicathetergino
ithatgishegiisgiingithegiintensivegicaregiunitgi(ICU).giWhatgiinformationgishouldgitheginursegiincludegiingithegiexplan
iongitogithegifamily?gi-gianswer--
Pulmonarygiarterygicathetersgiaregiusedgitogimeasuregicentralgipressuresgiandgifluidgibalance.
, Theginursegiisgidesigninggiagibioterrorismgiplangiforgiagicommunity.giWhichgiagentsgiaregitransmittedgipersongit
persongiviagirespiratorygiorgiinhalationgiexposure?gi(Selectgiallgithatgiapply.)gi-gianswer--
Thegipneumonicgiplaguegicangibegitransmittedgipersongitogipersongiviagirespiratorygidroplets.giSmallpoxgicang
oducegiaerosolizedgidropletsgiofgirupturedgipockgimarksgiingithegibuccalgicavity,githusgiaerosolizinggithegivirusg
dgicausinggirespiratorygitransmission.
Agiclientgiisgiadmittedgiforgicomplaintsgiofgichestgipaingiandgiachinggiforgithegipastgi4gidays.giThegiresultsgiforgiser
mgicreatinegikinase-MBgi(CK-
MB)giandgitroponingilevelsgiaregiobtained.giWhatgirationalegishouldgitheginursegiusegitogievaluategithegilaborato
ifindings?gi-gianswer--
4)giAngielevatedgiserumgitroponingihasgibecomegithegicardiacgimarkergiofgichoicegiforgidiagnosinggiangiacutegiM
accordinggithegiAmericangiCollegegiofgiCardiologygi(ACC)giguidelinesgi(2017)giforgiNSTEMI.giAngielevatedgitro
oningiwillgibecomegievidentgiwithingi2-3gihoursgiofgiangiMIgiingicomparisongitogithegiCK-
MBgiandgiothergicardiacgienzymesgithatgicangitakegiupgitogi6-9gihoursgiaftergithegiMIgioccurrence.
Thegiunlicensedgiassistivegipersonnelgi(UAP)gireportsgimorninggivitalgisignsgitogithegiprimaryginurse.giWhichgic
ntgishouldgitheginursegiassessgifirst?giThegiclientgiwhogiisgi-gianswer--4
Theginursegiworkinggiongiagitelemetrygiunitgifindsgiagiclientgiunconsciousgiandgiingipulselessgiventriculargitachyc
diagi(VT).giThegiclientgihasgiangiimplantedgiautomaticgidefibrillator.giWhatgiactiongishouldgitheginursegiimpleme
?gi-gianswer--shock
Agihealthcaregiprovidergiprescribesgiagicontinuousgiinfusiongiofgi0.9%gisodiumgichloridegi250gimlgiwithgipancur
iumgi(Pavulon)gi25gimggiatgiagirategiofgi0.1gimg/kg/
hourgiforgiagiclientgiwithgicoronarygiarterygibypassgigrafting.giThegiclientgiweighsgi78gikg.giTheginursegishouldgipr
ramgithegiinfusiongipumpgitogidelivergihowgimanygiml/hour?
gi(Enterginumericgivaluegionly.giIfgiroundinggiisgirequired,giroundgitogitheginearestgitenth.)gi-gianswer--78
Agiburnedgichildgiisgibroughtgitogithegiemergencygiroom.giIngiestimatinggithegipercentagegiofgithegibodygiburned
heginursegiusesgiagimodifiedgi"RulegiofgiNines."giWhichgipartgiofgiagichild'sgibodygiisgicalculatedgiasgiagilargergipe
entagegiofgitotalgibodygisurfacegithangiangiadult's?gi-gianswer--headgiandgineck
Theginursinggieducationgicoordinatorgiisgicreatinggiemployeegiorientationgimaterialsgiforgistaffginursesgiwhogip
ngitogiworkgiatgiagiclinicgithatgiservesgiagilowergisocioeconomicgineighborhood.giWhatgiinformationgishouldgithe
ducatorgiincludegiregardinggithegiclinic'sgiclientgipopulation?gi(Selectgiallgithatgiapply.)gi-gianswer--1-2-4
AngiIVgiseondarygiinfusiongiofgi0.9%ginormalgisalinegi100gimlgiwithgiinamrinonegi(Inocor)gi0.1gigrams/
100gimlgiisgiprescribedgiforgiclientgiwithgiheartgifailure.giThegimedicationgiisgitogibegideliveredgiatgiagirategiofgi400g
cg/minute.giTheginursegishouldgiprogramgithegiinfusiongipumpgitogidelivergihowgimanygiml/hour?
gi(Enterginumericgivaluegionly.giIfgiroundinggiisgirequired,giroundgitogitheginearestgiwholeginumber.)gi-gianswer--2
Theginursegiisgiconductinggiagiprocessgievaluationgiofgiagipreventiongieducationgiprogramgiforgioldergiadultsgiw
giaregiatgiriskgiforgisubstancegiabuse.giWhichgidatagisourcegiprovidesgithegiinformationgitheginursegineedsgitogico
ductgithisgiprocessgievaluation?gi-gianswer--documentgi
Processgievaluationgiexaminesgiwhethergiorginotgiinterventionsgiweregiimplemented,giandgiaginursinggirecord
uditgi(D)gishouldgiindicategiifgipreventiongieducationgihadgibeengiconducted.gi(AgiandgiB)giindicategiassessmen
butginotgiintervention.gi(C)gidescribesgithegidemographicsgiofgithegipopulation,gibutgidoesginotgicollectgiinforma
ngiaboutgieducationalgiprograms.
AgiclientgiisgiadmittedgitogithegiEmergencygiDepartmentgiwithgiagitensiongipneumothorax.giWhichgiassessmen
houldgitheginursegiexpectgitogiidentify?gi-gianswer--c
Agiclientgiwithgicardiogenicgishockgiwhogiweighsgi220gipoundsgiisgireceivinggiagisolutiongiofgiDextrosegi5%giingiW
tergi(D5W)gi250gimlgiwithgidopaminegi400gimggiatgithegirategiofgi3gimcg/kg/
minute.giTheginursegishouldgisetgithegiinfusiongipumpgitogidelivergihowgimanygiml/hour?
gi(Enterginumericgivaluegionly.giIfgiroundinggiisgirequired,giroundgitogitheginearestgitenth.)gi-gianswer--11.3
Howgishouldgitheginursegipositiongithegielectrodesgiforgimodifiedgichestgileadgionegi(MCLgiI)gitelemetrygimonito
g?gi-gianswer--
Negativegipolaritygileftgishoulder,gipositivegipolaritygirightgichestginipplegiline,gigroundgileftgichestginipplegiline.
Agi3-week-oldginewborngiisgibroughtgitogithegiclinicgiforgifollow-
upgiaftergiagihomegibirth.giThegimothergireportsgithatgihergichildgibottlegifeedsgiforgi5giminutesgionlygiandgithengifa
giasleep.giTheginursegiauscultatesgiagiloudgimurmurgicharacteristicgiofgiagiventriculargiseptalgidefectgi(VSD),gian
ifindsgitheginewborngiisgiacyanoticgiwithgiagirespiratorygirategiofgi64gibreathsgipergiminute.giWhatgiinstructiongish
ldgitheginursegiprovidegithegimothergitogiensuregithegiinfantgiisgireceivinggiadequategiintake?
gi(Selectgiallgithatgiapply.)gi-gianswer--
NeonatesgiwhogihavegiVSDgimaygifatiguegiquicklygiduringgifeedinggiandgiingestgiinadequategiamounts.giTheyg
ouldgibegimonitoredgiforgiweightgigaingiandgiatgileastgi6giwetgidiapersgipergiday.giAgione-
monthgioldgiinfantgishouldgiingestgi2gitogi4giouncesgi(60-
120mL)giofgiformulagipergifeedinggiandgiprogressgitogiaboutgi30giouncesgi(900mL)gipergidaygibygi4-
monthsgiofgiage.giDuegitogifatigue,githegiinfantgishouldgirest,gibutgifeedgiatgileastgieverygi2gihoursgitogiensuregiade
uategiintake.giAgisoftergi(preemie)ginipplegiorgiagilargergislitgiingitheginipplegihelpsgitogireducegithegisuckinggieffor
ndgienergygiexpenditure,githusgiallowinggithegiinfantgitogiingestgimoregiwithgilessgieffort.giAntibioticgiprophylaxis
sgirecommendedgiforgiinfantsgiwithgiVSDs,gibutgishouldginotgibegimixedgiingiagibottlegiofgiformulagibecausegiitgiisg
fficultgitogiensuregithatgithegitotalgidosegiisgiconsumed.
1-2-3-5
Agi3-year-
oldgiboygiisgibroughtgitogithegiemergencygiroomgibecausegiofgiagipossiblegidiazepamgi(Valium)gioverdose.giHeg
lethargicgiandgiconfused,giandgihisgivitalgisignsgiare:gipulsegirategi100gibeats/
minute,girespiratorygirategi20gibreaths/
minute,giandgibloodgipressuregi70/30.giWhichginursinggiinterventiongihasgithegihighestgipriority?gi-gianswer--
preparationgiforgiendotrachealgiintubationgitogiprotectgithegiairwaygiisgithegiprioritygiinterventiongiatgithisgitime.
Agiclientgiwithgiagi16-
yeargihistorygiofgidiabetesgimellitusgiisgihavinggirenalgifunctiongitestsgibecausegiofgirecentgifatigue,giweakness,
evatedgibloodgiureaginitrogen,giandgiserumgicreatininegilevels.giWhichgifindinggishouldgitheginursegiconcludegia
angiearlygisymptomgiofgirenalgiinsufficiency?gi-gianswer--Nocturia
Asgithegiglomerulargifiltrationgirategidecreasesgiingiearlygirenalgiinsufficiency,gimetabolicgiwastegiproducts,giinc
dinggiurea,gicreatinine,giandgiothergisubstances,gisuchgiphenols,gihormones,gielectrolytes,giaccumulategiingith
blood.giIngithegiearlygistagegiofgirenalgiinsufficiency,gipolyuriagiresultsgifromgithegiinabilitygiofgithegikidneysgitogico
centrategiurinegiandgicontributegitoginocturia.
Agiclient'sgifamilygiasksgiwhygitheirgimothergiwithgiheartgifailuregineedsgiagipulmonarygiarterygi(PA)gicathetergino
ithatgishegiisgiingithegiintensivegicaregiunitgi(ICU).giWhatgiinformationgishouldgitheginursegiincludegiingithegiexplan
iongitogithegifamily?gi-gianswer--
Pulmonarygiarterygicathetersgiaregiusedgitogimeasuregicentralgipressuresgiandgifluidgibalance.
, Theginursegiisgidesigninggiagibioterrorismgiplangiforgiagicommunity.giWhichgiagentsgiaregitransmittedgipersongit
persongiviagirespiratorygiorgiinhalationgiexposure?gi(Selectgiallgithatgiapply.)gi-gianswer--
Thegipneumonicgiplaguegicangibegitransmittedgipersongitogipersongiviagirespiratorygidroplets.giSmallpoxgicang
oducegiaerosolizedgidropletsgiofgirupturedgipockgimarksgiingithegibuccalgicavity,githusgiaerosolizinggithegivirusg
dgicausinggirespiratorygitransmission.
Agiclientgiisgiadmittedgiforgicomplaintsgiofgichestgipaingiandgiachinggiforgithegipastgi4gidays.giThegiresultsgiforgiser
mgicreatinegikinase-MBgi(CK-
MB)giandgitroponingilevelsgiaregiobtained.giWhatgirationalegishouldgitheginursegiusegitogievaluategithegilaborato
ifindings?gi-gianswer--
4)giAngielevatedgiserumgitroponingihasgibecomegithegicardiacgimarkergiofgichoicegiforgidiagnosinggiangiacutegiM
accordinggithegiAmericangiCollegegiofgiCardiologygi(ACC)giguidelinesgi(2017)giforgiNSTEMI.giAngielevatedgitro
oningiwillgibecomegievidentgiwithingi2-3gihoursgiofgiangiMIgiingicomparisongitogithegiCK-
MBgiandgiothergicardiacgienzymesgithatgicangitakegiupgitogi6-9gihoursgiaftergithegiMIgioccurrence.
Thegiunlicensedgiassistivegipersonnelgi(UAP)gireportsgimorninggivitalgisignsgitogithegiprimaryginurse.giWhichgic
ntgishouldgitheginursegiassessgifirst?giThegiclientgiwhogiisgi-gianswer--4
Theginursegiworkinggiongiagitelemetrygiunitgifindsgiagiclientgiunconsciousgiandgiingipulselessgiventriculargitachyc
diagi(VT).giThegiclientgihasgiangiimplantedgiautomaticgidefibrillator.giWhatgiactiongishouldgitheginursegiimpleme
?gi-gianswer--shock
Agihealthcaregiprovidergiprescribesgiagicontinuousgiinfusiongiofgi0.9%gisodiumgichloridegi250gimlgiwithgipancur
iumgi(Pavulon)gi25gimggiatgiagirategiofgi0.1gimg/kg/
hourgiforgiagiclientgiwithgicoronarygiarterygibypassgigrafting.giThegiclientgiweighsgi78gikg.giTheginursegishouldgipr
ramgithegiinfusiongipumpgitogidelivergihowgimanygiml/hour?
gi(Enterginumericgivaluegionly.giIfgiroundinggiisgirequired,giroundgitogitheginearestgitenth.)gi-gianswer--78
Agiburnedgichildgiisgibroughtgitogithegiemergencygiroom.giIngiestimatinggithegipercentagegiofgithegibodygiburned
heginursegiusesgiagimodifiedgi"RulegiofgiNines."giWhichgipartgiofgiagichild'sgibodygiisgicalculatedgiasgiagilargergipe
entagegiofgitotalgibodygisurfacegithangiangiadult's?gi-gianswer--headgiandgineck
Theginursinggieducationgicoordinatorgiisgicreatinggiemployeegiorientationgimaterialsgiforgistaffginursesgiwhogip
ngitogiworkgiatgiagiclinicgithatgiservesgiagilowergisocioeconomicgineighborhood.giWhatgiinformationgishouldgithe
ducatorgiincludegiregardinggithegiclinic'sgiclientgipopulation?gi(Selectgiallgithatgiapply.)gi-gianswer--1-2-4
AngiIVgiseondarygiinfusiongiofgi0.9%ginormalgisalinegi100gimlgiwithgiinamrinonegi(Inocor)gi0.1gigrams/
100gimlgiisgiprescribedgiforgiclientgiwithgiheartgifailure.giThegimedicationgiisgitogibegideliveredgiatgiagirategiofgi400g
cg/minute.giTheginursegishouldgiprogramgithegiinfusiongipumpgitogidelivergihowgimanygiml/hour?
gi(Enterginumericgivaluegionly.giIfgiroundinggiisgirequired,giroundgitogitheginearestgiwholeginumber.)gi-gianswer--2
Theginursegiisgiconductinggiagiprocessgievaluationgiofgiagipreventiongieducationgiprogramgiforgioldergiadultsgiw
giaregiatgiriskgiforgisubstancegiabuse.giWhichgidatagisourcegiprovidesgithegiinformationgitheginursegineedsgitogico
ductgithisgiprocessgievaluation?gi-gianswer--documentgi
Processgievaluationgiexaminesgiwhethergiorginotgiinterventionsgiweregiimplemented,giandgiaginursinggirecord
uditgi(D)gishouldgiindicategiifgipreventiongieducationgihadgibeengiconducted.gi(AgiandgiB)giindicategiassessmen
butginotgiintervention.gi(C)gidescribesgithegidemographicsgiofgithegipopulation,gibutgidoesginotgicollectgiinforma
ngiaboutgieducationalgiprograms.
AgiclientgiisgiadmittedgitogithegiEmergencygiDepartmentgiwithgiagitensiongipneumothorax.giWhichgiassessmen
houldgitheginursegiexpectgitogiidentify?gi-gianswer--c
