HESI Fundamentals - Set 4 - Part 1

Correct Answer: Dry mucous membranes and decreased skin turgor

Dry mucous membranes and decreased skin turgor are classic dehydration findings. The combination reflects intracellular water loss and supports a nursing diagnosis of fluid volume deficit, especially in the older adult during this stay. Option a is incorrect because A bounding pulse and elevated blood pressure better describe fluid volume excess. Dehydration typically presents with weak rapid pulse and lower blood pressure as circulating volume drops below the level needed for stable perfusion. Option b is incorrect because Crackles in the lungs and pitting edema reflect fluid volume excess, often from heart failure. The cues are the opposite of dehydration and would not appear in a patient with reduced fluid intake here. Option d is incorrect because Distended jugular veins and weight gain reflect fluid overload, not deficit. Both findings indicate the body is retaining too much volume and would not appear in a patient losing or restricting fluids.

Correct Answer: Crackles, pitting edema, jugular distention

Crackles in the lungs, pitting edema, and jugular vein distention all reflect excess fluid volume. The cues map directly to the heart failure scenario and support the nursing diagnosis of fluid overload comprehensively. Option b is incorrect because Dry mucous membranes and weak pulse describe dehydration rather than fluid excess. The pattern is the opposite of overload and would appear in a patient who has been losing or restricting fluids over time. Option c is incorrect because Decreased skin turgor and concentrated urine reflect dehydration with intracellular water loss. The cues do not appear in fluid overload, where extracellular fluid expansion produces edema and dilute urine instead. Option d is incorrect because Sunken eyes and rapid weak pulse are also classic dehydration findings. The cluster does not match heart failure with overload, which is associated with the opposite cluster of swelling and venous congestion.

Correct Answer: Encourage oral fluids and monitor intake

Encouraging oral fluids and monitoring intake is the first-line approach for mild dehydration in an alert patient. The intervention is independent, safe, and effective when the patient can swallow without aspiration risk. Option a is incorrect because Restricting oral intake worsens dehydration and contradicts the basic plan of care. The patient needs more fluid, not less, and limiting intake without a clinical reason runs counter to standard nursing practice. Option b is incorrect because Initiating intravenous fluids without an order exceeds nursing scope of practice. The nurse may suggest fluids during communication, but the prescriber writes the order before any infusion can begin at the bedside. Option c is incorrect because Avoiding any encouragement until the provider arrives delays a safe and standard nursing intervention. Oral hydration is independent and well within nursing scope; waiting for orders is unnecessary for routine encouragement of fluids.

Correct Answer: Establish IV access and prepare fluid resuscitation

Hypovolemic shock requires immediate intravenous access and rapid fluid resuscitation to restore circulating volume. The nurse anticipates orders for crystalloid bolus, transfusion if indicated, and monitors response through vital signs, urine output, and mentation. Option a is incorrect because Restricting fluids worsens shock by removing the only path to restore volume. The patient needs aggressive replacement, not restriction, since the cause of the shock is loss of circulating fluid through the gut. Option c is incorrect because Holding all medications until labs return delays time-critical resuscitation. The lab results may guide later decisions, but immediate fluid replacement should not wait for any laboratory turnaround time during the emergency. Option d is incorrect because Reverse Trendelenburg position places the head higher than the feet and worsens hypotension. The patient may benefit from supine positioning with legs elevated, but the priority is intravenous access and f

Correct Answer: Decreased urine output and weight loss

Decreased urine output and weight loss are reliable indicators of dehydration in children. Diaper weight changes, fewer wet diapers, sunken fontanel in infants, and dry mucous membranes all support the assessment promptly. Option a is incorrect because Increased weight contradicts dehydration in a child losing fluids. Weight loss, not gain, accompanies fluid volume deficit, especially in young children where small absolute losses are clinically significant compared to total body weight. Option b is incorrect because A strong steady pulse and warm skin suggest stable circulation rather than dehydration. The picture does not match a child losing fluids, who would more typically show tachycardia and cool skin during fluid loss. Option d is incorrect because A bounding pulse with elevated blood pressure suggests fluid overload rather than dehydration. The pattern is the opposite of the expected findings in a child with vomiting and diarrhea over recent days.

Correct Answer: Zero point nine percent normal saline

Zero point nine percent saline is isotonic and stays in the extracellular space to expand circulating volume. The fluid is commonly used for hypovolemia, before blood transfusion, and for general volume support in adults. Option b is incorrect because Three percent saline is hypertonic and pulls fluid out of cells into the vascular space. The solution is used in select severe hyponatremia cases and is not a first-line isotonic resuscitation fluid for most patients. Option c is incorrect because Zero point forty-five percent saline is hypotonic and shifts fluid into cells. The solution is useful for cellular dehydration but is not appropriate when the priority is expanding extracellular volume during resuscitation efforts. Option d is incorrect because Ten percent dextrose is hypertonic and used for specific indications like hypoglycemia management. The fluid is not chosen for routine volume expansion and would be inappropriate as a basic isotonic resuscitation choice.

Correct Answer: Stop infusion, remove line, elevate the limb

Stopping the infusion, removing the catheter, and elevating the limb addresses infiltration. The nurse applies a cool or warm compress per policy, monitors the site, and starts a new line at a different location. Option a is incorrect because Increasing the rate forces more fluid into the surrounding tissue and worsens infiltration. The action damages tissue and risks compartment syndrome rather than restoring proper intravenous flow into the vein. Option b is incorrect because Continuing the infusion despite swelling and pallor allows ongoing tissue injury. The findings are signals that the catheter is no longer in the vein, and continuing the flow harms the surrounding tissue significantly. Option c is incorrect because Applying heat to the swelling without first stopping the infusion does not solve the underlying problem. The fluid continues to enter the tissue while heat is applied, worsening the situation rather than resolving it.

Correct Answer: Discontinue line and start new site

Phlebitis presents with warmth, redness, and tenderness along the vein. The nurse discontinues the line, starts a new one at a different site, applies warm compress per policy, and documents the findings clearly. Option a is incorrect because Increasing the infusion rate worsens vein irritation and prolongs phlebitis. The intervention can also cause infiltration if the inflamed vein begins to leak under increased pressure during the higher flow. Option b is incorrect because Covering the site with an adhesive dressing alone does not address the inflammation. The line remains in a compromised vein, and infusion through the irritated vessel continues to harm the patient and worsen findings. Option d is incorrect because Massaging an inflamed vein can dislodge clots and risks embolization to the lungs. The technique is contraindicated in phlebitis and should never be used to treat the inflammation in any patient at any time.

Correct Answer: Drop factor varies by tubing set used

Drop factor varies by tubing set, with macrodrip sets typically ten, fifteen, or twenty drops per milliliter and microdrip sets at sixty drops per milliliter. The nurse confirms the factor before calculating any drip rate. Option b is incorrect because Drop factor is not identical across tubing; manufacturers print the value on each set. Treating all tubing as the same produces incorrect drip rates and either underdoses or overdoses the patient during the infusion. Option c is incorrect because Drop factor does not depend on patient size, only on the tubing used. Patient factors influence the prescribed rate, but not the conversion between milliliters and drops, which is mechanical to the tubing. Option d is incorrect because Room temperature does not change the drop factor. The number is a fixed property of the tubing manufacturer, and environmental conditions have no role in calculating drops per minute during gravity infusion.

Correct Answer: Use chlorhexidine-based skin antisepsis

Chlorhexidine-based skin antisepsis is part of the central line bundle for insertion and care. The bundle also includes hand hygiene, maximal sterile barriers, dedicated insertion checklist, and daily review of necessity for the line. Option a is incorrect because Avoiding hand hygiene contradicts the bundle and raises infection risk. Hand hygiene before any catheter contact is one of the most important elements of central line care and is required every time. Option c is incorrect because Dressings are changed on a regular schedule and whenever they become damp or loose, not only at discharge. Routine dressing changes maintain a clean intact occlusive barrier over the insertion site for protection. Option d is incorrect because Manipulating ports without disinfection introduces pathogens directly into the bloodstream. The nurse scrubs the hub for the recommended duration with an alcohol or chlorhexidine product before each access of the line.

Correct Answer: Cardiac dysrhythmia with peaked T waves

Severe hyperkalemia causes peaked T waves, prolonged conduction, and ventricular dysrhythmia. The nurse places the patient on a cardiac monitor, holds potassium-raising medications, notifies the provider, and prepares for emergency interventions. Option a is incorrect because Mild headache and dry mouth are not the priority concerns of hyperkalemia. The cardiac risks dominate, and the nurse focuses on rhythm and conduction rather than minor symptoms during this critical electrolyte imbalance. Option b is incorrect because Increased appetite and weight gain are not features of hyperkalemia. The misidentification distracts from the immediate cardiac threat that defines this electrolyte emergency in any patient with renal impairment present. Option c is incorrect because Mild ankle swelling is not specific to hyperkalemia. Edema can have many causes, and the nurse focuses on the cardiac risk that the elevated potassium creates rather than peripheral findings unrelated to rhythm.

Correct Answer: Cardiac dysrhythmia and U waves on ECG

Hypokalemia causes flattened T waves, U waves, and cardiac dysrhythmia. The nurse places the patient on a monitor, plans potassium replacement per orders, and assesses other electrolytes since magnesium often drops alongside potassium clinically. Option a is incorrect because Bounding peripheral pulses do not characterize hypokalemia. The pattern is more associated with fluid overload or hyperdynamic states, while hypokalemia tends to produce weakness rather than vivid peripheral perfusion findings. Option b is incorrect because Hypokalemia decreases rather than increases deep tendon reflexes in most patients. The neuromuscular pattern of low potassium includes hyporeflexia and weakness, opposite to what the option describes during the assessment today. Option d is incorrect because Profound hypertension with tremor is not characteristic of hypokalemia. The classic picture is weakness, cramps, and cardiac changes; hypertension is not part of the typical low-potassium presentation in ad

Correct Answer: Never give intravenous potassium as a push

Intravenous potassium is never given by direct push because rapid administration can cause fatal cardiac arrest. The nurse uses an infusion pump, follows dilution and rate limits, and monitors the patient during the entire infusion. Option b is incorrect because Pushing potassium over any duration is unsafe; the medication is given as a controlled infusion. The mistake is one of the most dangerous medication errors and is the reason the high-alert rules exist. Option c is incorrect because Bolus pushes of potassium have no place in routine practice. The medication requires dilution, infusion pump delivery, and rate limits to prevent cardiac arrest in any patient receiving the medication. Option d is incorrect because Concentration and dilution rules apply strictly to intravenous potassium. The nurse must follow specific limits and avoid concentrated solutions outside specific monitored settings to keep the patient safe during therapy.

Correct Answer: Confusion, seizure risk, cerebral edema

Hyponatremia causes water to shift into brain cells, producing confusion, headache, seizures, and cerebral edema. The nurse implements seizure precautions, monitors neurologic status closely, and follows orders for careful sodium correction. Option a is incorrect because Hyperthermia and severe dehydration do not characterize hyponatremia. The condition involves excess water relative to sodium, and the cluster described would be more consistent with hypernatremia and volume deficit. Option b is incorrect because Strong reflexes and rapid speech do not match hyponatremia. The neurologic picture is one of sluggishness and confusion as brain cells swell, not heightened reflexes or accelerated speech in any patient. Option c is incorrect because Increased appetite and urine output do not match hyponatremia. The disorder typically reflects either fluid retention or sodium loss, and increased appetite is not a feature of the condition at all.

Correct Answer: Hypocalcemia from parathyroid disturbance

Hypocalcemia after thyroidectomy can occur if parathyroid glands are damaged or removed. Tingling around the mouth and a positive Chvostek sign signal low calcium, and the nurse anticipates calcium replacement after notifying the provider. Option a is incorrect because Hypernatremia does not cause perioral tingling and Chvostek sign. The clinical picture aligns with low calcium rather than altered sodium and would not be the primary post-thyroidectomy concern in this patient. Option b is incorrect because Hyperkalemia produces muscle weakness and cardiac findings rather than perioral tingling and Chvostek sign. The picture does not match elevated potassium, which is also not a typical thyroidectomy complication after the procedure. Option d is incorrect because Hypermagnesemia produces decreased reflexes rather than the heightened neuromuscular irritability seen here. The clinical scenario does not match elevated magnesium, which would not be expected after thyroidectomy in this case.

Correct Answer: Respiratory acidosis without compensation

Low pH with elevated carbon dioxide and a normal bicarbonate defines uncompensated respiratory acidosis. The pattern is common in conditions that impair ventilation, including chronic obstructive pulmonary disease, opioid use, or neuromuscular weakness. Option a is incorrect because Metabolic acidosis would show a low bicarbonate. The bicarbonate sits within normal limits at twenty-four, so the abnormality is respiratory in origin rather than metabolic from the laboratory results provided here. Option c is incorrect because Metabolic alkalosis would show a high pH and high bicarbonate. The pH is acidic and the bicarbonate is normal, so neither value matches the pattern of metabolic alkalosis at this point. Option d is incorrect because Respiratory alkalosis would show a high pH and low carbon dioxide. The pH is acidic and the carbon dioxide is high, opposing the expected pattern for respiratory alkalosis at every point in the analysis.

Correct Answer: Metabolic acidosis with respiratory compensation

Low pH with low bicarbonate defines metabolic acidosis. A low carbon dioxide reflects respiratory compensation through hyperventilation, which is the body's effort to blow off acid and partially correct the pH back toward normal. Option b is incorrect because Metabolic alkalosis would show a high pH and high bicarbonate. Neither finding is present, since both pH and bicarbonate are decreased in the diabetic ketoacidosis pattern noted in this laboratory result. Option c is incorrect because Respiratory acidosis would show a high carbon dioxide as the primary problem. The carbon dioxide here is low, marking the respiratory finding as compensation rather than the cause of the acid-base shift. Option d is incorrect because Respiratory alkalosis as a primary problem would have a high pH from low carbon dioxide. The pH here is acidic, so the respiratory pattern is compensation for a metabolic process rather than the primary disturbance.

Correct Answer: Respiratory alkalosis from hyperventilation

Hyperventilation blows off carbon dioxide and creates respiratory alkalosis. Tingling and lightheadedness reflect the resulting alkalemia and reduced ionized calcium effect on nerve conduction, which produces the classic perioral and digital tingling. Option a is incorrect because Metabolic acidosis is unrelated to acute hyperventilation from anxiety. The mechanism described does not match a metabolic disturbance, so the option misidentifies the type of acid-base shift occurring during the episode. Option b is incorrect because Respiratory acidosis arises from carbon dioxide retention, not hyperventilation. Rapid breathing decreases carbon dioxide, producing alkalosis rather than acidosis, so the option contradicts the basic physiology in play. Option c is incorrect because Metabolic alkalosis develops from non-respiratory causes like vomiting or diuretic use. The mechanism here is purely respiratory, so the option misclassifies the body system responsible for the shift in pH.

Correct Answer: Metabolic alkalosis from acid loss

Vomiting loses gastric hydrochloric acid and produces metabolic alkalosis. The pH is high, bicarbonate is elevated, and carbon dioxide rises mildly through respiratory compensation as the body retains acid to balance the loss. Option a is incorrect because Respiratory acidosis is not the primary disturbance from vomiting. Carbon dioxide is only mildly elevated as compensation, and the pH would be low rather than high if this were a respiratory acidosis pattern. Option b is incorrect because Metabolic acidosis would show a low pH and low bicarbonate. The values are the opposite, with high pH and elevated bicarbonate, so the option misidentifies the direction of the acid-base shift. Option d is incorrect because Respiratory alkalosis would show a low carbon dioxide. The carbon dioxide here is mildly elevated as compensation rather than the cause, so the option misclassifies the system driving the acid-base abnormality found here.

Correct Answer: pH first, then primary cause, then compensation

The standard order is to check pH first, then identify whether respiratory or metabolic is primary, then assess compensation. The systematic approach prevents misclassification, especially in mixed disorders or partial compensation across systems. Option b is incorrect because Starting with bicarbonate before pH skips the foundation for classification. The pH establishes whether the patient is acidotic or alkalotic, and that determination directs the rest of the interpretation across systems. Option c is incorrect because Skipping the pH eliminates the anchor for the entire interpretation. Without identifying acidosis or alkalosis, the nurse cannot determine which value is primary or whether compensation is partial or full at this point. Option d is incorrect because Bicarbonate alone is insufficient because it cannot distinguish primary metabolic processes from compensation. The carbon dioxide and pH together complete the interpretation and prevent missing key elements of the disturba