HESI Exit Practice Questions and
Rationale / Study Guide
Questions & Correct Answers.
Quiz____?
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. -
Answer✓✓
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.
Quiz____?
Page 1 of 90
,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 -
Answer✓✓
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.
Quiz____?
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 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 -
Answer✓✓
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
Page 2 of 90
,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.
Quiz____?
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. -
Answer✓✓
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.
Quiz____?
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. -
Page 3 of 90
, Answer✓✓
3
Sudden loss of electrocardiographic complexes indicates ventricular
asystole or possibly electrode displacement. 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.
Quiz____?
The nurse is evaluating a client's response to cardioversion. Which
assessment would be the priority?
1. Blood pressure
2.Status of airway
3.Oxygen flow rate
4.Level of consciousness -
Answer✓✓
2
Nursing responsibilities after cardioversion include maintenance first of a
patent airway, and then oxygen administration, 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)
Quiz____?
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
Page 4 of 90
Rationale / Study Guide
Questions & Correct Answers.
Quiz____?
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. -
Answer✓✓
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.
Quiz____?
Page 1 of 90
,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 -
Answer✓✓
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.
Quiz____?
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 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 -
Answer✓✓
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
Page 2 of 90
,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.
Quiz____?
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. -
Answer✓✓
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.
Quiz____?
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. -
Page 3 of 90
, Answer✓✓
3
Sudden loss of electrocardiographic complexes indicates ventricular
asystole or possibly electrode displacement. 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.
Quiz____?
The nurse is evaluating a client's response to cardioversion. Which
assessment would be the priority?
1. Blood pressure
2.Status of airway
3.Oxygen flow rate
4.Level of consciousness -
Answer✓✓
2
Nursing responsibilities after cardioversion include maintenance first of a
patent airway, and then oxygen administration, 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)
Quiz____?
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
Page 4 of 90
