BSN 246 HESI REVIEW EXAM QUESTIONS AND ANSWERS 100% CORRECT!!!, Exams of Nursing

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BSN 246 HESI REVIEW EXAM QUESTIONS

AND ANSWERS 100% CORRECT!!!

Hypokalemia appearance on EKG - ANSWER - U waves

• inverted T waves
• depressed ST segment

Potassium chloride intravenously is prescribed for a client with heart failure experiencing 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. Obtain an intravenous (IV) infusion pump.
7. Monitor urine output during administration.
8. Monitor the IV site for signs of infiltration or phlebitis.
9. Ensure that the medication is diluted in the appropriate volume of fluid.
10. Ensure that the bag is labeled so that it reads the volume of potassium in the solution.

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 primary health care provider if the urinary output is less than 30 mL/hr.

The nurse is assessing a client with a lactose intolerance disorder for a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client?

1. Twitching
2. Hypoactive bowel sounds
3. Negative Trousseau's sign

3. Hypoparathyroidism
4. Tumor lysis syndrome - ANSWER 1. Malnutrition

The normal serum phosphorus (phosphate) level is 3.0 to 4.5 mg/dL (0.97 to 1. mmol/L). The client is experiencing hypophosphatemia. Causative factors relate to malnutrition or starvation and the use of aluminum hydroxide- based or magnesium-based antacids. Renal insufficiency, hypoparathyroidism, and tumor lysis syndrome are causative factors of hyperphosphatemia.

The nurse is reading a primary health care provider's (PHCP's) progress notes in the client's record and reads that the PHCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse makes a notation that insensible fluid loss occurs through which type of excretion?

1. Urinary output
2. Wound drainage
3. Integumentary output
4. The gastrointestinal tract - ANSWER 3. Integumentary output

Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs. Sensible losses are those of which the person is aware, such as through urination, wound drainage, and gastrointestinal tract losses.

The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit?

1. A client with an ileostomy
2. A client with heart failure
3. A client on long-term corticosteroid therapy
4. A client receiving frequent wound irrigations - ANSWER 1. A client with an ileostomy

A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. A client with heart failure or on long-term corticosteroid therapy or a client receiving frequent wound irrigations is most at risk for fluid volume excess.

Which client is at risk for the development of a potassium level of 5.5 mEq/L (5. mmol/L)?

1. The client with colitis

2. The client with Cushing's syndrome
3. The client who has been overusing laxatives
4. The client who has sustained a traumatic burn - ANSWER 4. The client who has sustained a traumatic burn

The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level higher than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia. Clients who experience cellular shifting of potassium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are at risk for hyperkalemia. The client with Cushing's syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia.

The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Paco2 of 30 mm Hg (30 mm Hg), and HCO3 - of 20 mEq/L (20 mmol/L). The nurse analyzes these results as indicating which condition?

1. Metabolic acidosis, compensated
2. Respiratory alkalosis, compensated
3. Metabolic alkalosis, uncompensated
4. Respiratory acidosis, uncompensated - ANSWER 2. Respiratory alkalosis, compensated

The normal pH is 7.35 to 7.45. In a respiratory condition, an opposite effect will be seen between the pH and the Paco2. In this situation, the pH is at the high end of the normal value and the Pco2 is low. In an alkalotic condition, the pH is elevated. Therefore, the values identified in the question indicate a respiratory alkalosis that is compensated by the kidneys through the renal excretion of bicarbonate. Because the pH has returned to a normal value, compensation has occurred.

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client for manifestations of which disorder that the client is at risk for?

1. Metabolic acidosis
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis - ANSWER 2. Metabolic alkalosis

Metabolic alkalosis is defined as a deficit or loss of hydrogen ions or acids or an excess of base (bicarbonate) that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions resulting in hypovolemia, the loss of gastric fluid, excessive bicarbonate intake, the massive

1. Respirations that are shallow
2. Respirations that are increased in rate
3. Respirations that are abnormally slow
4. Respirations that are abnormally deep
5. Respirations that cease for several seconds - ANSWER 2. Respirations that are increased in rate
6. Respirations that are abnormally deep

Kussmaul's respirations are abnormally deep and increased in rate. These occur as a result of the compensatory action by the lungs. In bradypnea, respirations are regular but abnormally slow. Apnea is described as respirations that cease for several seconds.

A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Paco2 is 90 mm Hg (90 mm Hg), and is 22 mEq/L ( mmol/L). The nurse interprets the results as indicating which condition?

1. Metabolic acidosis with compensation
2. Respiratory acidosis with compensation
3. Metabolic acidosis without compensation
4. Respiratory acidosis without compensation - ANSWER 4. Respiratory acidosis without compensation

The acid-base disturbance is respiratory acidosis without compensation. The normal pH is 7.35 to 7.45. The normal Paco2 is 35 to 45 mm Hg (35 to 45 mm Hg). In respiratory acidosis the pH is decreased and the Pco2 is elevated. The normal bicarbonate ) level is 21 to 28 mEq/L (21 to 28 mmol/L). Because the bicarbonate is still within normal limits, the kidneys have not had time to adjust for this acid-base disturbance. In addition, the pH is not within normal limits. Therefore, the condition is without compensation. The remaining options are incorrect interpretations.

The nurse notes that a client's arterial blood gas (ABG) results reveal a pH of 7.50 and a Paco2 of 30 mm Hg (30 mm Hg). The nurse monitors the client for which clinical manifestations associated with these ABG results? Select all that apply.

1. Nausea
2. Confusion
3. Bradypnea
4. Tachycardia
5. Hyperkalemia
6. Lightheadedness - ANSWER 1. Nausea
7. Confusion
8. Tachycardia

6. Lightheadedness

Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions that cause overstimulation of the respiratory system. Clinical manifestations of respiratory alkalosis include lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness and tingling of the extremities. Hyperventilation (tachypnea) occurs. Bradypnea describes respirations that are regular but abnormally slow. Hyperkalemia is associated with acidosis.

A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths per minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats per minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding?

1. A decreased pH and an increased Paco
2. An increased pH and a decreased Paco
3. A decreased pH and a decreased HCO3 -
4. An increased pH and an increased HCO3 - - ANSWER 4. An increased pH and an increased HCO3 -

Clients experiencing nausea and vomiting would most likely present with metabolic alkalosis resulting from loss of gastric acid, thus causing the pH and HCO3 - to increase. Symptoms experienced by the client would include a decrease in the respiratory rate and depth, and tachycardia. Option 1 reflects a respiratory acidotic condition. Option 2 reflects a respiratory alkalotic condition, and option 3 reflects a metabolic acidotic condition.

The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas values are pH = 7.53, Pao2 = 72 mm Hg (72 mm Hg), Paco = 32 mm Hg (32 mm Hg), and = 28 mEq/L (28 mmol/L). Which conclusion about the client should the nurse make?

1. The client has acidotic blood.
2. The client is probably overreacting.
3. The client is fluid volume overloaded.
4. The client is probably hyperventilating. - ANSWER 4. The client is probably hyperventilating.

4. Obtain a Spanish-English dictionary and attempt to triage the client. - ANSWER 3. Page an interpreter from the hospital's interpreter services.

The best action is to have a professional hospital-based interpreter translate for the client. English-speaking family members may not appropriately understand what is asked of them and may paraphrase what the client is actually saying. Also, client confidentiality as well as accurate information may be compromised when a family member or a non-health care provider acts as interpreter.

The nurse is performing a neurological assessment on a client and notes a positive Romberg's test. The nurse makes this determination based on which observation?

1. An involuntary rhythmic, rapid, twitching of the eyeballs
2. A dorsiflexion of the great toe with fanning of the other toes
3. A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed
4. A lack of normal sense of position when the client is unable to return extended fingers to a point of reference - ANSWER 3. A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed

In Romberg's test, the client is asked to stand with the feet together and the arms at the sides, and to close the eyes and hold the position; normally the client can maintain posture and balance. A positive Romberg's sign is a vestibular 409 neurological sign that is found when a client exhibits a loss of balance when closing the eyes. This may occur with cerebellar ataxia, loss of proprioception, and loss of vestibular function. A lack of normal sense of position coupled with an inability to return extended fingers to a point of reference is a finding that indicates a problem with coordination. A positive gaze nystagmus evaluation results in an involuntary rhythmic, rapid twitching of the eyeballs. A positive Babinski's test results in dorsiflexion of the great toe with fanning of the other toes; if this occurs in anyone older than 2 years it indicates the presence of central nervous system disease.

The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse should expect to note which finding?

1. Rhythmic respirations with periods of apnea
2. Regular rapid and deep, sustained respirations
3. Totally irregular respiration in rhythm and depth
4. Irregular respirations with pauses at the end of inspiration and expiration - ANSWER
5. Rhythmic respirations with periods of apnea

Cheyne-Stokes respirations are rhythmic respirations with periods of apnea and can indicate a metabolic dysfunction in the cerebral hemisphere or basal ganglia. Neurogenic hyperventilation is a regular, rapid and deep, sustained respiration that can indicate a dysfunction in the low midbrain and middle pons. Ataxic respirations are totally irregular in rhythm and depth and indicate a dysfunction in the medulla. Apneustic respirations are irregular respirations with pauses at the end of inspiration and expiration and can indicate a dysfunction in the middle or caudal pons.

The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse's findings?

1. pH 7.25, Paco2 50 mm Hg (50 mm Hg)
2. pH 7.35, Paco2 40 mm Hg (40 mm Hg)
3. pH 7.50, Paco2 52 mm Hg (52 mm Hg)
4. pH 7.52, Paco2 28 mm Hg (28 mm Hg) - ANSWER 1. pH 7.25, Paco2 50 mm Hg ( mm Hg)

Atelectasis is a condition characterized by the collapse of alveoli, preventing the respiratory exchange of oxygen and carbon dioxide in a part of the lungs. The normal pH is 7.35 to 7.45. The normal Paco2 is 35 to 45 mm Hg (35 to 45 mm Hg). In respiratory acidosis, the pH is decreased and the Paco2 is elevated. Option 2 identifies normal values. Option 3 identifies an alkalotic condition, and option 4 identifies respiratory alkalosis.

A client diagnosed with conductive hearing loss asks the nurse to explain the cause of the hearing problem. The nurse plans to explain to the client that this condition is caused by which problem?

1. A defect in the cochlea
2. A defect in cranial nerve VIII
3. A physical obstruction to the transmission of sound waves
4. A defect in the sensory fibers that lead to the cerebral cortex - ANSWER 3. A physical obstruction to the transmission of sound waves

A conductive hearing loss occurs as a result of a physical obstruction to the transmission of sound waves. A sensorineural hearing loss occurs as a result of a pathological process in the inner ear, a defect in cranial nerve VIII, or a defect of the sensory fibers that lead to the cerebral cortex.

The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptoms develop? Select all that apply.

1. Polyuria
2. Shakiness
3. Palpitations
4. Blurred vision
5. Lightheadedness
6. Fruity breath odor - ANSWER 2. Shakiness
7. Palpitations
8. Lightheadedness

The nurse is monitoring a client newly diagnosed with diabetes mellitus for signs of complications. Which sign or symptom, if frequently exhibited in the client, indicates that the client is at risk for chronic complications of diabetes if the blood glucose is not adequately managed?

1. Polyuria
2. Diaphoresis
3. Pedal edema
4. Decreased respiratory rate - ANSWER 1. Polyuria

The nurse is preparing a plan of care for a client with diabetes mellitus who has hyperglycemia. The nurse places priority on which client problem?

1. Lack of knowledge
2. Inadequate fluid volume
3. Compromised family coping
4. Inadequate consumption of nutrients - ANSWER 2. Inadequate fluid volume

The nurse is caring for a client after hypophysectomy and notes clear nasal drainage from the client's nostril. The nurse should take which initial action? 1. Lower the head of the bed.

2. Test the drainage for glucose.
3. Obtain a culture of the drainage.
4. Continue to observe the drainage. - ANSWER 2. Test the drainage for glucose.

The nurse is admitting a client who is diagnosed with syndrome of inappropriate antidiuretic hormone secretion (SIADH) and has serum sodium of 118 mEq/L ( mmol/L). Which primary health care provider prescriptions should the nurse anticipate receiving? Select all that apply.

1. Initiate an infusion of 3% NaCl.
2. Administer intravenous furosemide.
3. Restrict fluids to 800 mL over 24 hours.
4. Elevate the head of the bed to high-Fowler's.
5. Administer a vasopressin antagonist as prescribed. - ANSWER 1. Initiate an infusion of 3% NaCl.
6. Restrict fluids to 800 mL over 24 hours.
7. Administer a vasopressin antagonist as prescribed.

The nurse is completing an assessment on a client who is being admitted for a diagnostic workup for primary hyperparathyroidism. Which client complaints would be characteristic of this disorder? Select all that apply.

1. Polyuria
2. Headache
3. Bone pain
4. Nervousness
5. Weight gain - ANSWER 1. Polyuria
6. Bone pain

The healthcare provider is caring for a patient with a diagnosis of hypomagnesemia and a QT interval of 0.50 seconds. Which of these, if noted on the cardiac monitor, is an indication the patient's condition is worsening?

1. A polymorphic ventricular tachycardia
2. Premature ventricular contractions
3. Narrow QRS complexes
4. An R-R interval of 1 second - ANSWER 1. A polymorphic ventricular tachycardia

The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse should expect to note which finding?

1. Rhythmic respirations with periods of apnea
2. Regular rapid and deep, sustained respirations
3. Totally irregular respiration in rhythm and depth
4. Irregular respirations with pauses at the end of inspiration and expiration - ANSWER
5. Rhythmic respirations with periods of apnea

The nurse is performing an assessment on a client with pheochromocytoma. Which assessment data would indicate a potential complication associated with this disorder?

1. A urinary output of 50 mL/hr
2. A coagulation time of 5 minutes

5. Confusion

A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? Select all that apply.

1. Diarrhea
2. Black, tarry stools
3. Hyperactive bowel sounds
4. Gray-blue color at the flank
5. Abdominal guarding and tenderness
6. Left upper quadrant pain with radiation to the back - ANSWER 4. Gray-blue color at the flank
7. Abdominal guarding and tenderness
8. Left upper quadrant pain with radiation to the back

A client with a diagnosis of addisonian crisis is being admitted to the intensive care unit. Which findings will the interprofessional health care team focus on? Select all that apply.

1. Hypotension
2. Leukocytosis
3. Hyperkalemia
4. Hypercalcemia
5. Hypernatremia - ANSWER 1. Hypotension
6. Hyperkalemia

The nurse is monitoring a client who was diagnosed with type 1 diabetes mellitus and is being treated with NPH and regular insulin. Which manifestations would alert the nurse to the presence of a possible hypoglycemic reaction? Select all that apply.

1. Tremors
2. Anorexia
3. Irritability
4. Nervousness
5. Hot, dry skin
6. Muscle cramps - ANSWER 1. Tremors
7. Irritability
8. Nervousness

A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding?

1. Malaise
2. Dark stools

3. Weight gain
4. Left upper quadrant discomfort - ANSWER 1. Malaise (discomfort)

The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations support this diagnosis? Select all that apply.

1. Fever
2. Positive Cullen's sign
3. Complaints of indigestion
4. Palpable mass in the left upper quadrant
5. Pain in the upper right quadrant after a fatty meal
6. Vague lower right quadrant abdominal discomfort - ANSWER 1. Fever
7. Complaints of indigestion
8. Pain in the upper right quadrant after a fatty meal

A client is diagnosed with viral hepatitis, complaining of "no appetite" and "losing my taste for food." What instruction should the nurse give the client to provide adequate nutrition?

1. Select foods high in fat.
2. Increase intake of fluids, including juices.
3. Eat a good supper when anorexia is not as severe.
4. Eat less often, preferably only 3 large meals daily. - ANSWER 2. Increase intake of fluids, including juices.