PRECISED HESI EXIT PRACTICE
QUESTIONS AND RATIONALE
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. - CORRECT
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.
A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus fis
fscheduledffor fcardiac fcatheterization. fWhich fmedication fwould fneed fto fbe fwithheld ffor f24 fhours
fbefore fthe fprocedure fand ffor f48 fhours fafter fthe fprocedure?
1.Glipizide
f2.Metformin
f3.Repaglinid
e
4.Regular finsulin f- fCORRECT fANSWER f-2
,Metformin fneeds fto fbe fwithheld f24 fhours fbefore fand ffor f48 fhours fafter fcardiac fcatheterization
fbecausefof fthe finjection fof fcontrast fmedium fduring fthe fprocedure. fIf fthe fcontrast fmedium faffects
fkidney ffunction, fwith fmetformin fin fthe fsystem fthe fclient fwould fbe fat fincreased frisk ffor flactic
facidosis. fThe fmedications fin fthe fremaining foptions fdo fnot fneed fto fbe fwithheld f24 fhours fbefore
fand f48 fhours fafter fcardiac fcatheterization.
A fclient fwho fhad fcardiac fsurgery f24 fhours fago fhas fhad fa furine foutput faveraging f20 fmL/hour ffor f2
fhours.fThe fclient freceived fa fsingle fbolus fof f500 fmL fof fintravenous ffluid. fUrine foutput ffor fthe
fsubsequent fhour fwas f25 fmL. fDaily flaboratory fresults findicate fthat fthe fblood furea fnitrogen flevel fis
f45 fmg/dL f(16 fmmol/L) fand fthe fserum fcreatinine flevel fis f2.2 fmg/dL f(194 fmcmol/L). fOn fthe fbasis
fof fthese ffindings, fthe fnurse fwould fanticipate fthat fthe fclient fis fat frisk ffor fwhich fproblem?
1. Hypovolemia
2.Acute fkidney finjury f3.Glomerulonephritis
f4.Urinary ftract finfection f- fCORRECT fANSWER
f-2
The fclient fwho fundergoes fcardiac fsurgery fis fat frisk ffor frenal finjury ffrom fpoor fperfusion, fhemolysis,
flow fcardiac foutput, for fvasopressor fmedication ftherapy. fRenal finjury fis fsignaled fby fdecreased furine
foutput fand fincreased fblood furea fnitrogen f(BUN) fand fcreatinine flevels. fNormal freference flevels fare
fBUN, f10-20 fmg/dL f(3.6-7.1 fmmol/L), fand fcreatinine, fmale, f0.6-1.2 fmg/dL f(53-106 fmcmol/L) fand
ffemale f0.5-1.1 fmg/dL f(44-97 fmcmol/L). fThe fclient fmay fneed fmedications fto fincrease frenal
fperfusion fand fpossibly fcouldfneed fperitoneal fdialysis for fhemodialysis. fNo fdata fin fthe fquestion
findicate fthe fpresence fof fhypovolemia, fglomerulonephritis, for furinary ftract finfection.
The fnurse fis freviewing fan felectrocardiogram frhythm fstrip. fThe fP fwaves fand fQRS fcomplexes fare
fregular.fThe fPR finterval fis f0.16 fseconds, fand fQRS fcomplexes fmeasure f0.06 fseconds. fThe foverall
fheart frate fis f64 fbeats/minute. fWhich faction fshould fthe fnurse ftake?
1. Check fvital fsigns.
2.Check flaboratory ftest fresults. f3.Notify fthe fhealth fcare fprovider. f4.Continue fto fmonitor ffor fany
frhythmfchange. f- fCORRECT fANSWER f-4
Normal fsinus frhythm fis fdefined fas fa fregular frhythm, fwith fan foverall frate fof f60 fto f100
fbeats/minute. fThe fPR fand fQRS fmeasurements fare fnormal, fmeasuring fbetween f0.12 fand f0.20
fseconds fand f0.04 fand f0.10 fseconds, frespectively. fThere fare fno firregularities fin fthis frhythm
fcurrently, fso fthere fis fno fimmediate fneedfto fcheck fvital fsigns for flaboratory fresults, for fto fnotify fthe
fhealth fcare fprovider. fTherefore, fthe fnurse fwould fcontinue fto fmonitor fthe fclient ffor fany frhythm
fchange.
,A fclient fis fwearing fa fcontinuous fcardiac fmonitor, fwhich fbegins fto fsound fits falarm. fThe fnurse
fsees fnofelectrocardiographic fcomplexes fon fthe fscreen. fWhich fis fthe fpriority fnursing faction?
1. Call fa fcode.
2.Call fthe fhealth fcare fprovider. f3.Check fthe fclient's fstatus fand flead fplacement.
f4.Press fthe frecorder fbutton fon fthe felectrocardiogram fconsole. f- fCORRECT
fANSWER f-3
Sudden floss fof felectrocardiographic fcomplexes findicates fventricular fasystole for fpossibly felectrode
fdisplacement. fAccurate fassessment fof fthe fclient fand fequipment fis fnecessary fto fdetermine fthe
fcause fand fidentify fthe fappropriate fintervention. fThe fremaining foptions fare fsecondary fto fclient
fassessment.
The fnurse fis fevaluating fa fclient's fresponse fto fcardioversion. fWhich fassessment fwould fbe fthe fpriority?
1. fBlood fpressure
f2.Status fof
fairway f3.Oxygen
fflow frate
4.Level fof fconsciousness f- fCORRECT fANSWER f-2
Nursing fresponsibilities fafter fcardioversion finclude fmaintenance ffirst fof fa fpatent fairway, fand fthen
foxygen fadministration, fassessment fof fvital fsigns fand flevel fof fconsciousness, fand fdysrhythmia
fdetection.
Cardioversion fis fa fmedical fprocedure fthat frestores fa fnormal fheart frhythm fin fpeople fwith fcertain
ftypes foffabnormal fheartbeats f(arrhythmias)
The fnurse fis fcaring ffor fa fclient fwho fhas fjust fhad fimplantation fof fan fautomatic finternal
fcardioverter-fdefibrillator. fThe fnurse fshould fassess fwhich fitem fbased fon fpriority?
1. Anxiety flevel fof fthe fclient fand ffamily
2.Presence fof fa fMedicAlert fcard ffor fthe fclient fto fcarry
3. Knowledge fof frestrictions fon fpostdischarge fphysical factivity
4. Activation fstatus fof fthe fdevice, fheart frate fcutoff, fand fnumber fof fshocks fit fis fprogrammed fto
fdeliver f-fCORRECT fANSWER f-4
The fnurse fwho fis fcaring ffor fthe fclient fafter finsertion fof fan fautomatic finternal fcardioverter-
defibrillatorfneeds fto fassess fdevice fsettings, fsimilar fto fafter finsertion fof fa fpermanent fpacemaker.
, fSpecifically, fthe fnurse fneeds fto fknow fwhether fthe fdevice fis factivated, fthe fheart frate fcutoff
fabove fwhich fit fwill ffire, fand
QUESTIONS AND RATIONALE
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. - CORRECT
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.
A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus fis
fscheduledffor fcardiac fcatheterization. fWhich fmedication fwould fneed fto fbe fwithheld ffor f24 fhours
fbefore fthe fprocedure fand ffor f48 fhours fafter fthe fprocedure?
1.Glipizide
f2.Metformin
f3.Repaglinid
e
4.Regular finsulin f- fCORRECT fANSWER f-2
,Metformin fneeds fto fbe fwithheld f24 fhours fbefore fand ffor f48 fhours fafter fcardiac fcatheterization
fbecausefof fthe finjection fof fcontrast fmedium fduring fthe fprocedure. fIf fthe fcontrast fmedium faffects
fkidney ffunction, fwith fmetformin fin fthe fsystem fthe fclient fwould fbe fat fincreased frisk ffor flactic
facidosis. fThe fmedications fin fthe fremaining foptions fdo fnot fneed fto fbe fwithheld f24 fhours fbefore
fand f48 fhours fafter fcardiac fcatheterization.
A fclient fwho fhad fcardiac fsurgery f24 fhours fago fhas fhad fa furine foutput faveraging f20 fmL/hour ffor f2
fhours.fThe fclient freceived fa fsingle fbolus fof f500 fmL fof fintravenous ffluid. fUrine foutput ffor fthe
fsubsequent fhour fwas f25 fmL. fDaily flaboratory fresults findicate fthat fthe fblood furea fnitrogen flevel fis
f45 fmg/dL f(16 fmmol/L) fand fthe fserum fcreatinine flevel fis f2.2 fmg/dL f(194 fmcmol/L). fOn fthe fbasis
fof fthese ffindings, fthe fnurse fwould fanticipate fthat fthe fclient fis fat frisk ffor fwhich fproblem?
1. Hypovolemia
2.Acute fkidney finjury f3.Glomerulonephritis
f4.Urinary ftract finfection f- fCORRECT fANSWER
f-2
The fclient fwho fundergoes fcardiac fsurgery fis fat frisk ffor frenal finjury ffrom fpoor fperfusion, fhemolysis,
flow fcardiac foutput, for fvasopressor fmedication ftherapy. fRenal finjury fis fsignaled fby fdecreased furine
foutput fand fincreased fblood furea fnitrogen f(BUN) fand fcreatinine flevels. fNormal freference flevels fare
fBUN, f10-20 fmg/dL f(3.6-7.1 fmmol/L), fand fcreatinine, fmale, f0.6-1.2 fmg/dL f(53-106 fmcmol/L) fand
ffemale f0.5-1.1 fmg/dL f(44-97 fmcmol/L). fThe fclient fmay fneed fmedications fto fincrease frenal
fperfusion fand fpossibly fcouldfneed fperitoneal fdialysis for fhemodialysis. fNo fdata fin fthe fquestion
findicate fthe fpresence fof fhypovolemia, fglomerulonephritis, for furinary ftract finfection.
The fnurse fis freviewing fan felectrocardiogram frhythm fstrip. fThe fP fwaves fand fQRS fcomplexes fare
fregular.fThe fPR finterval fis f0.16 fseconds, fand fQRS fcomplexes fmeasure f0.06 fseconds. fThe foverall
fheart frate fis f64 fbeats/minute. fWhich faction fshould fthe fnurse ftake?
1. Check fvital fsigns.
2.Check flaboratory ftest fresults. f3.Notify fthe fhealth fcare fprovider. f4.Continue fto fmonitor ffor fany
frhythmfchange. f- fCORRECT fANSWER f-4
Normal fsinus frhythm fis fdefined fas fa fregular frhythm, fwith fan foverall frate fof f60 fto f100
fbeats/minute. fThe fPR fand fQRS fmeasurements fare fnormal, fmeasuring fbetween f0.12 fand f0.20
fseconds fand f0.04 fand f0.10 fseconds, frespectively. fThere fare fno firregularities fin fthis frhythm
fcurrently, fso fthere fis fno fimmediate fneedfto fcheck fvital fsigns for flaboratory fresults, for fto fnotify fthe
fhealth fcare fprovider. fTherefore, fthe fnurse fwould fcontinue fto fmonitor fthe fclient ffor fany frhythm
fchange.
,A fclient fis fwearing fa fcontinuous fcardiac fmonitor, fwhich fbegins fto fsound fits falarm. fThe fnurse
fsees fnofelectrocardiographic fcomplexes fon fthe fscreen. fWhich fis fthe fpriority fnursing faction?
1. Call fa fcode.
2.Call fthe fhealth fcare fprovider. f3.Check fthe fclient's fstatus fand flead fplacement.
f4.Press fthe frecorder fbutton fon fthe felectrocardiogram fconsole. f- fCORRECT
fANSWER f-3
Sudden floss fof felectrocardiographic fcomplexes findicates fventricular fasystole for fpossibly felectrode
fdisplacement. fAccurate fassessment fof fthe fclient fand fequipment fis fnecessary fto fdetermine fthe
fcause fand fidentify fthe fappropriate fintervention. fThe fremaining foptions fare fsecondary fto fclient
fassessment.
The fnurse fis fevaluating fa fclient's fresponse fto fcardioversion. fWhich fassessment fwould fbe fthe fpriority?
1. fBlood fpressure
f2.Status fof
fairway f3.Oxygen
fflow frate
4.Level fof fconsciousness f- fCORRECT fANSWER f-2
Nursing fresponsibilities fafter fcardioversion finclude fmaintenance ffirst fof fa fpatent fairway, fand fthen
foxygen fadministration, fassessment fof fvital fsigns fand flevel fof fconsciousness, fand fdysrhythmia
fdetection.
Cardioversion fis fa fmedical fprocedure fthat frestores fa fnormal fheart frhythm fin fpeople fwith fcertain
ftypes foffabnormal fheartbeats f(arrhythmias)
The fnurse fis fcaring ffor fa fclient fwho fhas fjust fhad fimplantation fof fan fautomatic finternal
fcardioverter-fdefibrillator. fThe fnurse fshould fassess fwhich fitem fbased fon fpriority?
1. Anxiety flevel fof fthe fclient fand ffamily
2.Presence fof fa fMedicAlert fcard ffor fthe fclient fto fcarry
3. Knowledge fof frestrictions fon fpostdischarge fphysical factivity
4. Activation fstatus fof fthe fdevice, fheart frate fcutoff, fand fnumber fof fshocks fit fis fprogrammed fto
fdeliver f-fCORRECT fANSWER f-4
The fnurse fwho fis fcaring ffor fthe fclient fafter finsertion fof fan fautomatic finternal fcardioverter-
defibrillatorfneeds fto fassess fdevice fsettings, fsimilar fto fafter finsertion fof fa fpermanent fpacemaker.
, fSpecifically, fthe fnurse fneeds fto fknow fwhether fthe fdevice fis factivated, fthe fheart frate fcutoff
fabove fwhich fit fwill ffire, fand
