HESI Exit Practice Questions and Rationale
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1. Potassium chloride intravenously is prescribed for a client with hypokalemia.
Which actions should the nurse take to plan for preparation and administration
of the potassium? Select all that apply.
1. Obtain an intravenous (IV) infusion pump.
2.Monitor urine output during administration.
3.Prepare the medication for bolus administration.
4.Monitor the IV site for signs of infiltration or phlebitis.
5.Ensure that the medication is diluted in the appropriate volume of fluid.
6.Ensure that the bag is labeled so that it reads the volume of potassium in the
solution.: 1, 2, 4, 5, 6
Potassium chloride administered intravenously must always be diluted in IV fluid and infused via an infusion pump.
Potassium chloride is never given by bolus (IV push). Giving potassium chloride by IV push can result in cardiac arrest.
The nurse should ensure that the potassium is diluted in the appropriate amount of diluent or fluid. The IV bag
containing the potassium chloride should always be labeled with the volume of potassium it contains. The IV site is
monitored closely because potassium chloride is irritating to the veins and there is risk of phlebitis. In addition, the
nurse should monitor for infiltration. The nurse monitors urinary output during administration and contacts the health
care provider if the urinary output is less than 30 mL/hour.
2. A client admitted to the hospital with chest pain and a history of type 2
diabetes mellitus is scheduled for cardiac catheterization. Which medication
would need to be withheld for 24 hours before the procedure and for 48 hours
after the procedure?
1.Glipizide
2.Metformin
3.Repaglinide
4.Regular insulin: 2
Metformin needs to be withheld 24 hours before and for 48 hours after cardiac catheterization because of the injection
of contrast medium during the procedure. If the contrast medium affects kidney function, with metformin in the system
the client would be at increased risk for lactic acidosis. The medications in the remaining options do not need to be
withheld 24 hours before and 48 hours after cardiac catheterization.
3. A client who had cardiac surgery 24 hours ago has had a urine output
averaging 20 mL/hour for 2 hours. The client received a single bolus of 500 mL
of intravenous fluid. Urine output for the subsequent hour was 25 mL. Daily
, HESI Exit Practice Questions and Rationale
Study online at https://quizlet.com/_9bqxy6
laboratory results indicate that the blood urea nitrogen level is 45 mg/dL (16
mmol/L) and the serum creatinine level is 2.2 mg/dL (194 mcmol/L). On the
basis of these findings, the nurse would anticipate that the client is at risk for
which problem?
1. Hypovolemia
2.Acute kidney injury 3.Glomerulonephritis
4.Urinary tract infection: 2
The client who undergoes cardiac surgery is at risk for renal injury from poor perfusion, hemolysis, low cardiac output, or
vasopressor medication therapy. Renal injury is signaled by decreased urine output and increased blood urea nitrogen
(BUN) and creatinine levels. Normal reference levels are BUN, 10-20 mg/dL (3.6-7.1 mmol/L), and creatinine, male,
0.6-1.2 mg/dL (53-106 mcmol/L) and female 0.5-1.1 mg/dL (44-97 mcmol/L). The client may need medications to
increase renal perfusion and possibly could need peritoneal dialysis or hemodialysis. No data in the question indicate
the presence of hypovolemia, glomerulonephritis, or urinary tract infection.
4. The nurse is reviewing an electrocardiogram rhythm strip. The P waves and
QRS complexes are regular. The PR interval is 0.16 seconds, and QRS complexes
measure 0.06 seconds. The overall heart rate is 64 beats/minute. Which action
should the nurse take?
1. Check vital signs.
2.Check laboratory test results. 3.Notify the health care provider. 4.Continue to
monitor for any rhythm change.: 4
Normal sinus rhythm is defined as a regular rhythm, with an overall rate of 60 to 100 beats/minute. The PR and QRS
measurements are normal, measuring between 0.12 and 0.20 seconds and 0.04 and 0.10 seconds, respectively. There
are no irregularities in this rhythm currently, so there is no immediate need to check vital signs or laboratory results, or
to notify the health care provider. Therefore, the nurse would continue to monitor the client for any rhythm change.
5. A client is wearing a continuous cardiac monitor, which begins to sound its
alarm. The nurse sees no electrocardiographic complexes on the screen. Which
is the priority nursing action?
1. Call a code.
2.Call the health care provider. 3.Check the client's status and lead placement.
4.Press the recorder button on the electrocardiogram console.: 3
Sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly electrode displacement.
, HESI Exit Practice Questions and Rationale
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Accurate assessment of the client and equipment is necessary to determine the cause and identify the appropriate
intervention. The remaining options are secondary to client assessment.
6. The nurse is evaluating a client's response to cardioversion. Which assess-
ment would be the priority?
1. Blood pressure
2.Status of airway
3.Oxygen flow rate
4.Level of consciousness: 2
Nursing responsibilities after cardioversion include maintenance first of a patent airway, and then oxygen administra-
tion, assessment of vital signs and level of consciousness, and dysrhythmia detection.
Cardioversion is a medical procedure that restores a normal heart rhythm in people with certain types of abnormal
heartbeats (arrhythmias)
7. The nurse is caring for a client who has just had implantation of an automatic
internal cardioverter-defibrillator. The nurse should assess which item based
on priority?
1. Anxiety level of the client and family
2.Presence of a MedicAlert card for the client to carry
3. Knowledge of restrictions on postdischarge physical activity
4. Activation status of the device, heart rate cutoff, and number of shocks it is
programmed to deliver: 4
The nurse who is caring for the client after insertion of an automatic internal cardioverter-defibrillator needs to assess
device settings, similar to after insertion of a permanent pacemaker. Specifically, the nurse needs to know whether the
device is activated, the heart rate cutoff above which it will fire, and the number of shocks it is programmed to deliver.
The remaining options are also nursing interventions but are not the priority.
8. A client's electrocardiogram strip shows atrial and ventricular rates of 110
beats/minute. The PR interval is 0.14 seconds, the QRS complex measures
0.08 seconds, and the PP and RR intervals are regular. How should the nurse
correctly interpret this rhythm?
1.Sinus tachycardia
2.Sinus bradycardia
3.Sinus dysrhythmia
4.Normal sinus rhythm: 1
, HESI Exit Practice Questions and Rationale
Study online at https://quizlet.com/_9bqxy6
Sinus tachycardia has the characteristics of normal sinus rhythm, including a regular PP interval and normal-width PR
and QRS intervals; however, the rate is the differentiating factor. In sinus tachycardia, the atrial and ventricular rates are
greater than 100 beats/minute.
9. The nurse is assessing the neurovascular status of a client who returned
to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass
graft. The affected leg is warm, and the nurse notes redness and edema. The
pedal pulse is palpable and unchanged from admission. How should the nurse
correctly interpret the client's neurovascular status?
1. The neurovascular status is normal because of increased blood flow through
the leg.
2. The neurovascular status is moderately impaired, and the surgeon should be
called.
3. The neurovascular status is slightly deteriorating and should be monitored
for another hour.
4. The neurovascular status is adequate from an arterial approach, but venous
complications are arising.: 1
An expected outcome of aortoiliac bypass graft surgery is warmth, redness, and edema in the surgical extremity because
of increased blood flow. The remaining options are incorrect interpretations.
10. The nurse is evaluating the condition of a client after pericardiocentesis
performed to treat cardiac tamponade. Which observation would indicate that
the procedure was effective?
1. Muffled heart sounds
2. A rise in blood pressure
3. Jugular venous distention
4.Client expressions of dyspnea: 2
Following pericardiocentesis, the client usually expresses immediate relief. Heart sounds are no longer muffled or
distant and blood pressure increases. Distended neck veins are a sign of increased venous pressure, which occurs with
cardiac tamponade.
11. A client with variant angina is scheduled to receive an oral calcium channel
blocker twice daily. Which statement by the client indicates the need for further
teaching?
1. "I should notify my doctor if my feet or legs start to swell."
Study online at https://quizlet.com/_9bqxy6
1. Potassium chloride intravenously is prescribed for a client with hypokalemia.
Which actions should the nurse take to plan for preparation and administration
of the potassium? Select all that apply.
1. Obtain an intravenous (IV) infusion pump.
2.Monitor urine output during administration.
3.Prepare the medication for bolus administration.
4.Monitor the IV site for signs of infiltration or phlebitis.
5.Ensure that the medication is diluted in the appropriate volume of fluid.
6.Ensure that the bag is labeled so that it reads the volume of potassium in the
solution.: 1, 2, 4, 5, 6
Potassium chloride administered intravenously must always be diluted in IV fluid and infused via an infusion pump.
Potassium chloride is never given by bolus (IV push). Giving potassium chloride by IV push can result in cardiac arrest.
The nurse should ensure that the potassium is diluted in the appropriate amount of diluent or fluid. The IV bag
containing the potassium chloride should always be labeled with the volume of potassium it contains. The IV site is
monitored closely because potassium chloride is irritating to the veins and there is risk of phlebitis. In addition, the
nurse should monitor for infiltration. The nurse monitors urinary output during administration and contacts the health
care provider if the urinary output is less than 30 mL/hour.
2. A client admitted to the hospital with chest pain and a history of type 2
diabetes mellitus is scheduled for cardiac catheterization. Which medication
would need to be withheld for 24 hours before the procedure and for 48 hours
after the procedure?
1.Glipizide
2.Metformin
3.Repaglinide
4.Regular insulin: 2
Metformin needs to be withheld 24 hours before and for 48 hours after cardiac catheterization because of the injection
of contrast medium during the procedure. If the contrast medium affects kidney function, with metformin in the system
the client would be at increased risk for lactic acidosis. The medications in the remaining options do not need to be
withheld 24 hours before and 48 hours after cardiac catheterization.
3. A client who had cardiac surgery 24 hours ago has had a urine output
averaging 20 mL/hour for 2 hours. The client received a single bolus of 500 mL
of intravenous fluid. Urine output for the subsequent hour was 25 mL. Daily
, HESI Exit Practice Questions and Rationale
Study online at https://quizlet.com/_9bqxy6
laboratory results indicate that the blood urea nitrogen level is 45 mg/dL (16
mmol/L) and the serum creatinine level is 2.2 mg/dL (194 mcmol/L). On the
basis of these findings, the nurse would anticipate that the client is at risk for
which problem?
1. Hypovolemia
2.Acute kidney injury 3.Glomerulonephritis
4.Urinary tract infection: 2
The client who undergoes cardiac surgery is at risk for renal injury from poor perfusion, hemolysis, low cardiac output, or
vasopressor medication therapy. Renal injury is signaled by decreased urine output and increased blood urea nitrogen
(BUN) and creatinine levels. Normal reference levels are BUN, 10-20 mg/dL (3.6-7.1 mmol/L), and creatinine, male,
0.6-1.2 mg/dL (53-106 mcmol/L) and female 0.5-1.1 mg/dL (44-97 mcmol/L). The client may need medications to
increase renal perfusion and possibly could need peritoneal dialysis or hemodialysis. No data in the question indicate
the presence of hypovolemia, glomerulonephritis, or urinary tract infection.
4. The nurse is reviewing an electrocardiogram rhythm strip. The P waves and
QRS complexes are regular. The PR interval is 0.16 seconds, and QRS complexes
measure 0.06 seconds. The overall heart rate is 64 beats/minute. Which action
should the nurse take?
1. Check vital signs.
2.Check laboratory test results. 3.Notify the health care provider. 4.Continue to
monitor for any rhythm change.: 4
Normal sinus rhythm is defined as a regular rhythm, with an overall rate of 60 to 100 beats/minute. The PR and QRS
measurements are normal, measuring between 0.12 and 0.20 seconds and 0.04 and 0.10 seconds, respectively. There
are no irregularities in this rhythm currently, so there is no immediate need to check vital signs or laboratory results, or
to notify the health care provider. Therefore, the nurse would continue to monitor the client for any rhythm change.
5. A client is wearing a continuous cardiac monitor, which begins to sound its
alarm. The nurse sees no electrocardiographic complexes on the screen. Which
is the priority nursing action?
1. Call a code.
2.Call the health care provider. 3.Check the client's status and lead placement.
4.Press the recorder button on the electrocardiogram console.: 3
Sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly electrode displacement.
, HESI Exit Practice Questions and Rationale
Study online at https://quizlet.com/_9bqxy6
Accurate assessment of the client and equipment is necessary to determine the cause and identify the appropriate
intervention. The remaining options are secondary to client assessment.
6. The nurse is evaluating a client's response to cardioversion. Which assess-
ment would be the priority?
1. Blood pressure
2.Status of airway
3.Oxygen flow rate
4.Level of consciousness: 2
Nursing responsibilities after cardioversion include maintenance first of a patent airway, and then oxygen administra-
tion, assessment of vital signs and level of consciousness, and dysrhythmia detection.
Cardioversion is a medical procedure that restores a normal heart rhythm in people with certain types of abnormal
heartbeats (arrhythmias)
7. The nurse is caring for a client who has just had implantation of an automatic
internal cardioverter-defibrillator. The nurse should assess which item based
on priority?
1. Anxiety level of the client and family
2.Presence of a MedicAlert card for the client to carry
3. Knowledge of restrictions on postdischarge physical activity
4. Activation status of the device, heart rate cutoff, and number of shocks it is
programmed to deliver: 4
The nurse who is caring for the client after insertion of an automatic internal cardioverter-defibrillator needs to assess
device settings, similar to after insertion of a permanent pacemaker. Specifically, the nurse needs to know whether the
device is activated, the heart rate cutoff above which it will fire, and the number of shocks it is programmed to deliver.
The remaining options are also nursing interventions but are not the priority.
8. A client's electrocardiogram strip shows atrial and ventricular rates of 110
beats/minute. The PR interval is 0.14 seconds, the QRS complex measures
0.08 seconds, and the PP and RR intervals are regular. How should the nurse
correctly interpret this rhythm?
1.Sinus tachycardia
2.Sinus bradycardia
3.Sinus dysrhythmia
4.Normal sinus rhythm: 1
, HESI Exit Practice Questions and Rationale
Study online at https://quizlet.com/_9bqxy6
Sinus tachycardia has the characteristics of normal sinus rhythm, including a regular PP interval and normal-width PR
and QRS intervals; however, the rate is the differentiating factor. In sinus tachycardia, the atrial and ventricular rates are
greater than 100 beats/minute.
9. The nurse is assessing the neurovascular status of a client who returned
to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass
graft. The affected leg is warm, and the nurse notes redness and edema. The
pedal pulse is palpable and unchanged from admission. How should the nurse
correctly interpret the client's neurovascular status?
1. The neurovascular status is normal because of increased blood flow through
the leg.
2. The neurovascular status is moderately impaired, and the surgeon should be
called.
3. The neurovascular status is slightly deteriorating and should be monitored
for another hour.
4. The neurovascular status is adequate from an arterial approach, but venous
complications are arising.: 1
An expected outcome of aortoiliac bypass graft surgery is warmth, redness, and edema in the surgical extremity because
of increased blood flow. The remaining options are incorrect interpretations.
10. The nurse is evaluating the condition of a client after pericardiocentesis
performed to treat cardiac tamponade. Which observation would indicate that
the procedure was effective?
1. Muffled heart sounds
2. A rise in blood pressure
3. Jugular venous distention
4.Client expressions of dyspnea: 2
Following pericardiocentesis, the client usually expresses immediate relief. Heart sounds are no longer muffled or
distant and blood pressure increases. Distended neck veins are a sign of increased venous pressure, which occurs with
cardiac tamponade.
11. A client with variant angina is scheduled to receive an oral calcium channel
blocker twice daily. Which statement by the client indicates the need for further
teaching?
1. "I should notify my doctor if my feet or legs start to swell."
