HESI E2 HESI Exit Exam - Set 5 - Part 1

Correct Answer: Acute pericarditis

Pleuritic chest pain eased by leaning forward, along with a pericardial friction rub, are hallmark features of pericarditis. Post-MI inflammation, called Dressler syndrome, often produces this pattern within days to weeks after the infarction. Option a is incorrect because recurrent ischemic pain follows a pressure or squeezing pattern, lacks positional relief, and is not paired with a friction rub. Ischemia also responds to nitroglycerin, while inflammatory pericardial pain does not. Option b is incorrect because pulmonary edema brings severe dyspnea, pink frothy sputum, and diffuse crackles. The presentation here lacks fluid overload signs and instead centers on positional pleuritic chest pain consistent with pericardial inflammation. Option d is incorrect because aortic dissection produces sudden tearing pain radiating to the back, often with unequal arm pressures. A scratchy friction rub and reproducible relief on leaning forward point clearly away from a dissecting aorta.

Correct Answer: Place client in high Fowler position

Acute pulmonary congestion demands immediate relief from work of breathing, and high Fowler position reduces venous return while expanding the lungs. This nursing action addresses the breathing impairment before secondary measures such as diuresis or teaching. Option b is incorrect because diagnostic scheduling cannot relieve acute respiratory distress unfolding right now at the bedside. Echocardiography matters for confirming ejection fraction later but offers no help during a worsening congestive episode. Option c is incorrect because patient teaching is inappropriate during acute dyspnea, when the client cannot meaningfully participate in learning. Dietary education belongs to the recovery phase once breathing stabilizes and oxygenation improves overall. Option d is incorrect because home weight monitoring is a long-term self-management strategy that does not relieve the present episode. The hospitalized client needs immediate positioning and oxygenation before any home or discharge

Correct Answer: Aortic dissection

Sudden tearing pain radiating through the chest and back paired with a large pressure gradient between arms strongly suggests aortic dissection. The intimal tear interrupts perfusion to one subclavian artery, producing the asymmetric reading the nurse documents at intake. Option a is incorrect because inferior wall infarction produces pressure-like substernal pain often radiating down the left arm or jaw, not asymmetric arm pressures. A coronary event does not split arterial flow between the upper extremities this way. Option c is incorrect because stable angina is predictable, exertional, and brief, easing with rest or nitroglycerin. The dramatic tearing pain and the unequal arm pressures fall well outside the typical chronic angina presentation by every measure. Option d is incorrect because ruptured varices cause hematemesis, melena, and signs of hemorrhagic shock from gastrointestinal bleeding. They do not produce a tearing chest pain pattern or an arm-to-arm pressure differential

Correct Answer: Inferior wall infarction

ST elevation in leads II, III, and aVF localizes injury to the inferior wall of the left ventricle. The right coronary artery typically supplies this region, so the nurse anticipates careful monitoring for bradycardia and atrioventricular block. Option b is incorrect because lateral wall injury shows in leads I, aVL, V5, and V6. The circumflex artery supplies the lateral wall, and these leads provide the relevant electrical view that the inferior leads cannot show. Option c is incorrect because septal infarction is revealed by changes in leads V1 and V2, which view the interventricular septum. The inferior leads track a separate cardiac territory perfused by a different coronary branch entirely. Option d is incorrect because anterior wall changes appear in the precordial leads V1 through V4, not the inferior leads. Localizing infarction depends on matching the elevation to the lead distribution that the left anterior descending artery perfuses.

Correct Answer: Watch for a persistent dry cough

ACE inhibitors classically produce a persistent dry cough from increased bradykinin and may rarely cause angioedema with facial or tongue swelling. The client should report a cough or swelling promptly because angioedema can compromise the airway quickly. Option a is incorrect because peripheral edema and grapefruit interaction describe calcium channel blockers such as amlodipine. ACE inhibitors act on the renin-angiotensin pathway and do not produce the dependent swelling characteristic of the CCB class. Option b is incorrect because orange body fluid discoloration is a rifampin effect tied to tuberculosis treatment. ACE inhibitor therapy is unrelated to dye-like changes in urine, sweat, or tears that anti-tuberculosis drugs commonly cause in clients. Option d is incorrect because hirsutism and gingival hyperplasia are well-known phenytoin side effects requiring careful oral hygiene. Lisinopril does not target tissue growth the way anticonvulsants do over the long term in clinical pra

Correct Answer: Defibrillate using 200 joules biphasic

The chaotic pulseless rhythm describes ventricular fibrillation, and unsynchronized defibrillation is the only effective intervention to restore organized electrical activity. Early shock combined with high-quality chest compressions gives the best chance of return of spontaneous circulation. Option b is incorrect because adenosine targets supraventricular tachycardia by blocking AV node conduction in conscious clients. The pulseless ventricular dysrhythmia described requires electrical defibrillation rather than pharmacologic conversion of a supraventricular focus through the AV node. Option c is incorrect because synchronized cardioversion requires an identifiable R wave to time the shock with. A chaotic pulseless rhythm offers no organized R wave for synchronization, so attempting it would only delay the lifesaving unsynchronized shock. Option d is incorrect because antiarrhythmic agents follow the first or second shock during arrest, not replace defibrillation. Drug delivery withou

Correct Answer: Notify provider and prepare for Doppler

Postoperative unilateral calf swelling and warmth signal possible deep vein thrombosis, and venous Doppler ultrasound is the gold standard for confirmation. The nurse must notify the provider before any other action to avoid dislodging a thrombus. Option a is incorrect because manipulating a suspected affected calf can break loose a thrombus and send it to the pulmonary circulation. Nursing care for suspected deep vein thrombosis explicitly prohibits massage in every standard reference text used today. Option b is incorrect because forced ambulation before ruling out DVT may dislodge a thrombus and trigger pulmonary embolism. Heat application also expands vessels and worsens the symptoms without addressing the actual clot that may be present. Option c is incorrect because ace wrapping does not treat an existing clot and can worsen distal circulation. Compression therapy belongs to prevention or post-thrombotic management of leg swelling, not the initial evaluation of new acute swelling

Correct Answer: This prevents stroke during cardioversion

Atrial fibrillation lasting more than 48 hours allows stagnant atrial blood to form clots in the left atrial appendage. Anticoagulation for several weeks before and after cardioversion reduces the risk of embolic stroke when rhythm restores normal flow. Option a is incorrect because electrical cardioversion happens in a controlled setting using synchronized shocks delivered by trained providers. No oral medication delivers an electrical shock, and this misconception requires correction by the nurse before the scheduled procedure proceeds. Option b is incorrect because postprocedure nausea is managed with antiemetics such as ondansetron during recovery in the postanesthesia unit. Anticoagulant therapy serves an entirely different purpose related to thrombus prevention surrounding the planned rhythm reset. Option d is incorrect because rate-controlling agents such as metoprolol or diltiazem slow ventricular response. Apixaban acts as a factor Xa inhibitor and has no direct effect on card

Correct Answer: Initiate large-bore IVs and call surgery

Sudden severe pain with hypotension in a known aneurysm strongly suggests rupture, a surgical emergency requiring rapid action. Establishing two large-bore intravenous lines prepares for fluid resuscitation and immediate transfer to the operating room for repair. Option b is incorrect because oral medication absorption is unreliable in shock, and the client needs surgical control rather than pain pills. The priority shifts entirely toward circulatory support and definitive operative repair of the leaking vessel wall. Option c is incorrect because thermal therapy has no role in vascular emergencies and may mask deteriorating perfusion of the surrounding tissues. Comfort measures take a distant back seat when active bleeding threatens the client's survival in minutes. Option d is incorrect because palpating a suspected ruptured aneurysm risks further dissection or hemorrhage from a fragile vessel wall. Bedside examination of the abdomen is contraindicated in this situation regardles

Correct Answer: Encourage the client to bear down forcefully

Stable supraventricular tachycardia in a conscious client begins with vagal maneuvers such as the Valsalva strain. If maneuvers fail, the nurse administers adenosine 6 mg rapid IV push followed by saline flush as the next step. Option a is incorrect because defibrillation is reserved for pulseless ventricular rhythms, not stable supraventricular tachycardia in a conscious client. Applying an unsynchronized shock to a perfusing rhythm could provoke a far more dangerous ventricular dysrhythmia. Option c is incorrect because compressions are for pulseless arrest, not a perfusing tachycardia with measurable blood pressure. Initiating CPR on a conscious client with a strong pulse causes injury and confuses the actual clinical priority entirely. Option d is incorrect because pacing addresses bradycardia and heart block, not rapid narrow-complex tachycardia. Adding pacing pulses to an already-fast rhythm worsens the clinical situation and does not interrupt the reentrant supraventricular circ

Correct Answer: Status asthmaticus with respiratory failure

Rising carbon dioxide, falling oxygen, and a silent chest in an exhausted asthmatic indicate the client is no longer moving air effectively. The nurse must prepare for intubation while continuing aggressive bronchodilator and corticosteroid therapy for status asthmaticus. Option a is incorrect because hyperventilation produces respiratory alkalosis with low carbon dioxide, while this client retains CO2 and shows acidosis. Verbal reassurance alone cannot reverse a failing respiratory pump in dire need of mechanical ventilation support. Option b is incorrect because a normalizing carbon dioxide in a previously hyperventilating asthmatic actually signals deterioration, not improvement. True recovery would include audible breath sounds, alert mentation, and rising oxygenation values together as recovery markers. Option c is incorrect because mild bronchospasm presents with audible wheezing and adequate gas exchange. A silent chest combined with acidosis and hypoxemia describes a far more d

Correct Answer: Nasal cannula at 2 liters per minute

Low-flow oxygen titrated to a saturation of 88 to 92 percent supports oxygenation without suppressing the hypoxic drive in chronic CO2 retainers. Starting low and reassessing avoids carbon dioxide narcosis while still relieving the client's hypoxemia safely. Option a is incorrect because high-flow oxygen in chronic carbon dioxide retainers can blunt the respiratory drive and precipitate respiratory failure. Reserving non-rebreathers for clients without compensatory mechanisms keeps therapy aligned with each person's underlying physiology and risk. Option b is incorrect because BiPAP is reserved for moderate to severe respiratory acidosis or worsening hypercapnia despite low-flow oxygen. An initial saturation of 89 percent does not yet meet the clinical threshold for noninvasive positive pressure ventilation. Option d is incorrect because withholding supplemental oxygen when saturation falls below target leaves the client hypoxic. Breathing exercises may complement oxygen ther

Correct Answer: Inspect all chest tube connections

Continuous bubbling in the water seal chamber indicates an air leak in the system, and loose connections are the most common reversible cause. Tightening each junction from patient to unit may resolve the air leak immediately at the bedside. Option a is incorrect because clamping a chest tube while air leaks remain can trap pleural air and cause a tension pneumothorax. Standard practice prohibits clamping outside of specific protocols ordered explicitly by the provider for known reasons. Option b is incorrect because aggressive stripping of chest tube tubing generates dangerous negative pressure that can injure pleural tissue. Most facilities moved away from routine stripping practice based on current evidence pointing to harm from the maneuver. Option c is incorrect because the nurse must first attempt simple bedside troubleshooting before calling the provider. Identifying a loose junction in the tubing can correct the problem instantly without imaging or unnecessary escalation of car

Correct Answer: This is expected with rifampin therapy

Rifampin causes a harmless reddish-orange discoloration of urine, sweat, saliva, and tears throughout the treatment period. Teaching clients about this expected change before therapy begins helps prevent unnecessary alarm and supports medication adherence over many months of treatment. Option a is incorrect because stopping anti-tuberculosis medications for a benign side effect risks resistance development and treatment failure. The four-drug regimen must continue throughout the full prescribed course to fully eradicate the organism from the lungs and body. Option c is incorrect because urinary tract infection brings dysuria, frequency, and cloudy foul urine rather than uniform orange-red discoloration. Misattributing this expected effect to infection delays correct teaching and erodes the client's trust in the nurse over time. Option d is incorrect because hepatotoxicity from these agents presents with abdominal pain, nausea, jaundice, and elevated enzymes on labs. Orange-red uri

Correct Answer: Increased pulmonary secretions in the airway

High-pressure alarms reflect resistance to airflow from secretions, biting, coughing, bronchospasm, or kinked tubing. After ruling out circuit issues, accumulating mucus in the airway is a common cause that the nurse can quickly relieve by suctioning. Option a is incorrect because disconnection from the circuit produces a low-pressure or low-minute-volume alarm rather than high-pressure activation. The alarm pattern described points toward an obstructed flow path inside the patient, not a leak in the system. Option b is incorrect because cuff leaks reduce delivered tidal volume and trigger low-pressure or low-volume alarms instead. Audible air around the upper airway accompanies this picture, which does not fit a sudden high-pressure alarm event on the monitor. Option d is incorrect because dislodgement of the endotracheal tube produces severe loss of pressure rather than a sharp rise. The clinical picture of an extubated client also includes immediate respiratory distress without posi

Correct Answer: Cluster care and elevate the head

Maintaining the head of bed at thirty degrees with the head midline promotes venous drainage and reduces intracranial pressure. Clustering nursing activities limits repeated stimulation that could otherwise spike pressures during routine care like turning or oral care. Option b is incorrect because neck flexion compresses the jugular veins and obstructs cerebral venous outflow, raising intracranial pressure further. Keeping the head neutral and midline preserves the venous drainage pathway that the swollen brain depends on for outflow. Option c is incorrect because prolonged suctioning passes longer than ten seconds drive intracranial pressure sharply higher through coughing and hypoxia. Suctioning is performed only when truly needed and limited in duration for this neurologically vulnerable population. Option d is incorrect because head-down positioning increases cerebral blood volume and worsens elevated intracranial pressure. The basic principle of gravity-assisted venous return req

Correct Answer: Intravenous alteplase within the window

An ischemic stroke confirmed by negative CT and presenting within the four and a half hour window qualifies the client for tissue plasminogen activator. Alteplase given quickly can dissolve the clot and restore cerebral perfusion before permanent damage sets in. Option a is incorrect because prophylactic heparin is contraindicated during the acute ischemic stroke phase due to bleeding conversion risk. Anticoagulation may follow days later for specific indications, but it is not the immediate emergency treatment in the door-to-needle period. Option c is incorrect because surgical evacuation applies to hemorrhagic stroke with mass effect or large hematomas. The negative CT scan rules out blood, so the indication for craniotomy is absent in this acute presentation of an ischemic stroke event. Option d is incorrect because acute ischemic stroke requires admission to a stroke unit for monitoring, not outpatient management. Aspirin enters the regimen but is held for twenty-four hours after t

Correct Answer: Protect head and turn client laterally

Protecting the head from injury and placing the client in a lateral position keeps the airway clear of secretions. The nurse stays with the client and times the event while avoiding restraint that could cause musculoskeletal harm. Option a is incorrect because inserting objects between the teeth can break teeth, lodge in the airway, and injure soft tissues. Standard seizure care has long abandoned this dangerous practice in favor of safe airway positioning and head protection instead. Option b is incorrect because forceful restraint during convulsions can cause fractures and dislocations as muscles contract powerfully. The nurse uses minimal touch to keep the client safe without trying to oppose the involuntary motor activity that is happening. Option d is incorrect because attempting to lift a seizing client risks falls and injury to both the client and the staff. The safer practice is to ease the client to the floor where no further fall can happen.

Correct Answer: Sit upright and assess for bladder distention

Autonomic dysreflexia from a noxious stimulus below the injury demands an upright position to use gravity for blood pressure reduction. The nurse then locates and removes the trigger, most commonly a full bladder, to interrupt the dangerous sympathetic reflex. Option a is incorrect because shock positioning raises blood pressure further by promoting venous return to the central circulation. Elevating the feet in autonomic dysreflexia worsens the dangerous hypertensive emergency and increases the risk of stroke during the event. Option b is incorrect because insulin lowers blood glucose, not blood pressure, and has no role in autonomic dysreflexia management. Confusing these emergencies could delay correct intervention while the client remains at high risk for hypertensive crisis injury. Option c is incorrect because environmental modifications matter for general comfort but do not eliminate the underlying noxious stimulus. The headache and severe hypertension persist until the trigger

Correct Answer: Take medication before high-protein meals

Dietary protein competes with levodopa for absorption across the intestinal wall and the blood-brain barrier. Taking the dose at least thirty minutes before meals optimizes drug delivery while still permitting balanced nutrition throughout the rest of the day. Option a is incorrect because pairing levodopa with high protein blocks absorption and reduces symptom control significantly. Clients often notice worsening tremor and rigidity when they ignore this critical timing principle that governs the medication's effectiveness throughout each day. Option c is incorrect because grapefruit juice inhibits cytochrome enzymes that affect calcium channel blockers and statins. Levodopa absorption issues center on amino acid competition rather than enzyme-mediated drug interactions seen with citrus juice consumption. Option d is incorrect because complete avoidance of green vegetables concerns clients on warfarin due to vitamin K content. Carbidopa-levodopa does not interact with leafy green