HESI E2 HESI Exit Exam - Set 4 - Part 2

Correct Answer: Hold furosemide and notify provider

Severe hypokalemia of 2.8 with electrocardiogram changes and muscular symptoms requires immediate intervention. The nurse should hold the loop diuretic, notify the provider, and anticipate cautious potassium replacement with cardiac monitoring because untreated hypokalemia precipitates dangerous dysrhythmias quickly. Option b is incorrect because waiting twelve hours allows electrolyte disturbance and symptoms to worsen toward life-threatening dysrhythmias. The combination of muscle weakness, flat T waves, and emerging U waves indicates cardiac irritability that needs prompt attention. Option c is incorrect because giving additional furosemide compounds potassium loss and intensifies the existing dysrhythmia risk. Aggressive diuresis in a patient already hypokalemic moves the serum value further from the safe range rather than toward balance. Option d is incorrect because the patient is hypokalemic and requires more potassium, not less. Restricting intake misidentifies the imbalance an

Correct Answer: Stop infusion and notify provider

Therapeutic activated partial thromboplastin time during heparin therapy is 1.5 to 2.5 times control, roughly 45 to 100 seconds. A value of 115 is supratherapeutic with serious bleeding risk, so the nurse stops the infusion and notifies the provider. Option a is incorrect because continuing heparin while the activated partial thromboplastin time sits well above the therapeutic ceiling exposes the client to hemorrhage. Maintaining the rate ignores the trigger to pause and recalculate the dose downward. Option b is incorrect because increasing the rate moves the already supratherapeutic level even further from safety. The result calls for de-escalation rather than amplification, and pushing harder converts a recoverable situation into a potentially catastrophic bleed. Option d is incorrect because warfarin requires several days to achieve effect and would not address the immediate bleeding risk from current heparin excess. Switching agents in this moment ignores the active infusion that

Correct Answer: Partially compensated metabolic acidosis

The pH is acidotic, the bicarbonate is low matching the pH direction so the primary problem is metabolic, and the partial pressure of carbon dioxide is low showing respiratory compensation. Hyperventilation, Kussmaul breathing, partially offsets the acid load. Option a is incorrect because the partial pressure of carbon dioxide is low rather than high. A respiratory acidosis would feature elevated carbon dioxide as the primary driver, opposite to the depressed value the laboratory reports for this client. Option c is incorrect because the pH is well below 7.35, identifying acidosis rather than alkalosis. In addition, the oxygen value sits within the normal range, ruling out hypoxemia and contradicting both elements of this interpretation simultaneously. Option d is incorrect because full compensation would return the pH to the normal range while keeping both partial pressure of carbon dioxide and bicarbonate abnormal. With pH still markedly low, compensation is only partial and primary

Correct Answer: Initiate seizure precautions, notify provider

Saunders lists normal magnesium as 1.8 to 2.6 mEq per liter. A value of 1.2 with new tremors and hyperreflexia indicates symptomatic hypomagnesemia, which carries risk for seizures and dysrhythmias. Seizure precautions and provider notification take priority for safety. Option a is incorrect because waiting a full day with symptomatic hypomagnesemia delays replacement and increases seizure and dysrhythmia risk. Documentation alone, without escalation, is appropriate for asymptomatic mild deviations rather than for symptomatic out-of-range values. Option b is incorrect because dietary restriction is the wrong direction when the patient is already deficient. The clinical task is replacement, often intravenous, paired with treating the underlying losses driven by thiazide-induced urinary magnesium wasting. Option d is incorrect because calcium gluconate stabilizes the myocardium during hyperkalemia or magnesium toxicity, not deficiency. Administering calcium for low magnesium misapplies a

Correct Answer: Value supports myocardial injury suspicion

Normal troponin I sits below 0.04 ng per milliliter. Values rise within three to six hours and remain elevated for several days. A value of 0.18 with new chest pain warrants suspicion for myocardial injury and serial measurement. Option a is incorrect because troponin elevation cannot rule out myocardial infarction; it actually strengthens the suspicion. The phrasing reverses the clinical meaning of the test, which is used to confirm rather than exclude myocyte damage. Option b is incorrect because troponin I is highly specific for cardiac muscle, unlike creatine kinase. Skeletal injury elevates aspartate aminotransferase or myoglobin, while troponin I tracks injury to the myocardium itself rather than other muscle groups. Option c is incorrect because 0.18 sits more than four times above the upper reference limit of 0.04. Labeling this value normal would lead to discharge or delay in revascularization for a patient experiencing acute coronary syndrome.

Correct Answer: Decompensated heart failure with congestion

A B-type natriuretic peptide above 400 strongly suggests heart failure, and the combination of crackles and edema confirms volume overload. The result helps distinguish cardiac from pulmonary causes of dyspnea and supports starting diuretic therapy with careful electrolyte monitoring. Option b is incorrect because asthma exacerbations show airway narrowing with wheezes, prolonged expiration, and accessory muscle use. The B-type natriuretic peptide typically remains near baseline because asthma does not stretch the ventricles to drive peptide release. Option c is incorrect because pulmonary fibrosis presents with dry crackles, clubbing, and gradual exertional dyspnea over months. Acutely elevated B-type natriuretic peptide with edema and basilar crackles aligns much more with congestive volume overload than fibrotic disease. Option d is incorrect because anxiety hyperventilation drives respiratory alkalosis without elevating B-type natriuretic peptide. The peptide rises with ventricular

Correct Answer: Supratherapeutic, hold dose, notify provider

Therapeutic international normalized ratio for atrial fibrillation is 2 to 3, and 2.5 to 3.5 for mechanical valves. A value of 5.8 with active mucosal bleeding indicates excessive anticoagulation. Hold the dose, notify the provider, and anticipate vitamin K administration. Option a is incorrect because an international normalized ratio of 5.8 sits well above standard therapeutic ranges. Continuing the same dose at this level invites worsening bleeding from already supratherapeutic anticoagulation rather than maintaining a safe therapeutic effect. Option b is incorrect because the international normalized ratio is supratherapeutic, not subtherapeutic. Increasing the warfarin dose moves the patient further into dangerous anticoagulation, the opposite of what the current laboratory value is signaling. Option c is incorrect because protamine sulfate reverses heparin, not warfarin. The partial thromboplastin time is normal, ruling out heparin overdose, and the appropriate reversal agent for

Correct Answer: Hold dose and notify provider

Therapeutic digoxin sits between 0.5 and 2 ng per milliliter. A value of 2.6 with classic features like visual halos, nausea, fatigue, and bradycardia indicates toxicity, so the nurse holds the dose, notifies the provider, and monitors rhythm. Option b is incorrect because administering more digoxin when the serum level is already above the therapeutic ceiling deepens the toxicity. Continuing the dose worsens bradycardia, perception changes, and risk of life-threatening dysrhythmias instead of any benefit. Option c is incorrect because potassium intake is unrelated to digoxin serum elevation and may dangerously raise potassium when used reflexively. Hypokalemia, not hyperkalemia, increases digoxin toxicity risk, so the action confuses management principles entirely. Option d is incorrect because delaying the response normalizes a dangerous value and allows continued toxicity. The clear constellation of bradycardia, gastrointestinal symptoms, and visual halos requires immediate clinical

Correct Answer: Blood cultures, light blue, lavender

Order of draw begins with blood cultures to maintain sterility, then light blue tubes for coagulation studies, followed by lavender for the complete blood count. The mnemonic Boys Love Ravishing Girls Like Sex preserves the correct sequence at the bedside. Option a is incorrect because drawing the light blue tube before blood cultures risks contaminating the culture and the coagulation specimen. The culture must always come first to preserve sterility, after which additive tubes follow in their established order. Option c is incorrect because the lavender tube belongs after the coagulation tube, not before the cultures. Reversing this order would permit ethylenediaminetetraacetic acid carryover that distorts coagulation results and compromises culture sterility together. Option d is incorrect because the lavender tube must follow the light blue tube. Placing it ahead of coagulation studies risks ethylenediaminetetraacetic acid contamination that falsely prolongs clotting times and erod

Correct Answer: Draw two sets before antibiotics begin

Two sets from two different peripheral sites improves sensitivity and helps distinguish contamination from true bacteremia. Cultures must be obtained before antibiotics begin to preserve the chance of identifying the causative organism and tailoring therapy precisely with sensitivities. Option a is incorrect because antibiotics given before cultures sharply reduce growth yield and obscure the causative organism. The bundle requires drawing cultures first whenever clinically feasible to keep diagnostic accuracy intact for downstream antibiotic narrowing. Option b is incorrect because a single site cannot reliably distinguish skin contamination from true infection. Two sets from two different sites improve sensitivity and help interpret growth patterns when results return from the microbiology laboratory. Option d is incorrect because drawing only from a central line increases the risk of identifying colonization rather than true bloodstream infection. Peripheral draws are preferred, wit

Correct Answer: Cleanse front to back, midstream catch

The midstream technique begins with antiseptic cleansing from front to back to limit perineal flora, then initial voiding into the toilet to flush the urethra, followed by midstream collection into the sterile cup before completing the void. Option a is incorrect because voiding into the cup from the start captures urethral and perineal flora rather than urine that has flushed the meatus. The initial stream collects contaminants that lead to false-positive growth on culture results. Option c is incorrect because the first portion of urine carries the highest concentration of contaminants from the urethra and perineum. Submitting this segment increases the chance of misleading bacterial growth that does not reflect bladder infection. Option d is incorrect because catheterization should be avoided when a clean-catch specimen is feasible. Routinely catheterizing introduces unnecessary infection risk and conflicts with current efforts to limit catheter-associated urinary tract infection ra

Correct Answer: Notify provider, discuss premedication options

A documented hypersensitivity to iodinated contrast warrants provider discussion regarding corticosteroid and antihistamine premedication or alternative imaging. The team weighs benefit and risk, plans monitoring, and identifies emergency interventions including epinephrine should anaphylaxis occur during scanning. Option b is incorrect because documentation alone does not prevent a repeat reaction in a client with prior contrast hypersensitivity. The client needs corticosteroid and antihistamine premedication or an alternative imaging study, not just a noted allergy and caution. Option c is incorrect because a 24-hour fast is excessive and unnecessary for contrast scanning. Standard preparation involves a short fast or none at all, with hydration to support renal clearance rather than prolonged restriction of intake. Option d is incorrect because beta blockers do not prevent contrast hypersensitivity and may worsen outcomes by blunting epinephrine response if anaphylaxis develops. Pre

Correct Answer: Stop process, notify radiology team

A pacemaker that is not magnetic resonance imaging conditional is an absolute contraindication, as the magnetic field can damage the device, dislodge leads, or cause cardiac harm. The nurse stops the process and notifies radiology to discuss alternatives. Option a is incorrect because routine safety applies only to devices specifically certified as magnetic resonance imaging conditional. Pacemakers without that designation can be heated, reprogrammed, or damaged within the strong magnetic field generated by the scanner. Option b is incorrect because removing a pacemaker is a surgical procedure with substantial risk and is not undertaken to enable elective imaging. The appropriate path is alternative imaging or coordination with cardiology before proceeding with any scan. Option c is incorrect because lead shielding does not block the magnetic field that drives magnetic resonance imaging. Such shields apply to ionizing radiation, while magnetic resonance imaging interactions involve mag

Correct Answer: Clear liquids two hours; solids six

Adult preprocedure fasting allows clear liquids until two hours before sedation, with light meals stopped six hours before and heavy or fatty meals stopped eight hours before. These intervals support gastric emptying and reduce the chance of aspiration under sedation. Option a is incorrect because a 24-hour fast is excessive and contributes to dehydration without added safety benefit. Modern guidelines allow clear fluids up to two hours preoperatively, reflecting evidence that gastric emptying does not require such prolonged restriction. Option b is incorrect because permitting breakfast on the morning of the procedure violates the six-to-eight hour solid food restriction. Doing so increases aspiration risk during sedation when the patient loses protective airway reflexes during the examination. Option d is incorrect because mealtime medication continuation conflicts with the fasting plan. Some medications are taken with a sip of water per anesthesia guidance, but routine administratio

Correct Answer: Platelets at 38,000 per cubic mm

Liver biopsy carries significant bleeding risk. A platelet count below 50,000 raises concern and often warrants transfusion before the procedure. The nurse alerts the provider so platelets can be ordered or the biopsy postponed until coagulation parameters are improved. Option b is incorrect because an international normalized ratio of 0.9 falls inside the normal range of 0.81 to 1.20. This value does not indicate coagulopathy and would not warrant any delay or provider notification before the biopsy is performed. Option c is incorrect because a hemoglobin of 12.4 is within normal limits for adults and does not raise bleeding concerns by itself. There is no indication for transfusion or postponement based on this single hematologic value before the procedure. Option d is incorrect because the white blood cell count of 7,200 sits in the normal range and reflects no acute infectious or hematologic concern. This value does not influence preprocedure bleeding risk and does not warrant noti

Correct Answer: Prepare naloxone and call for help

Respiratory rate of 7 with hypoxia and difficulty arousing indicates opioid-induced respiratory depression. The nurse calls for help, supports the airway and ventilation, administers oxygen, and prepares to give titrated naloxone per protocol to reverse the depressant effect rapidly. Option a is incorrect because simply increasing oxygen masks worsening respiratory depression without addressing the cause. Waiting ten minutes while the client continues to hypoventilate allows hypercarbia and hypoxia to progress toward respiratory arrest before reversal. Option b is incorrect because administering more opioid in the setting of respiratory depression accelerates harm. The clinical findings clearly indicate excessive opioid effect, so additional dosing would deepen the very depression that already requires reversal action. Option d is incorrect because pain relief that comes with respiratory rate of 7, hypoxia, and impaired arousal is not safe analgesia. Documenting this as adequate respon

Correct Answer: Notify surgeon for additional clarification

Informed consent requires understanding. The surgeon is responsible for explaining the procedure, alternatives, risks, and benefits. When the client expresses uncertainty, the nurse pauses, notifies the surgeon, and supports the client's right to additional information before signing the consent. Option a is incorrect because witnessing the signature when the client has voiced confusion violates the principle of informed consent. The nurse's signature confirms that the client understood and signed voluntarily, neither of which is true here. Option b is incorrect because the nurse cannot substitute for the provider's responsibility to explain the procedure, alternatives, and risks. Reading the form aloud may reinforce information but does not satisfy the legal requirement for provider-led informed consent. Option c is incorrect because canceling an elective surgery weeks into the future overreaches when a brief conversation with the surgeon often resolves the gap. The nur

Correct Answer: Prevents atelectasis by deep inspiration

Incentive spirometry encourages sustained deep inspiration that opens collapsed alveoli and helps prevent atelectasis after surgery. The nurse teaches slow inhalation through the mouthpiece, holding for three to five seconds, then exhaling and following with a productive cough. Option a is incorrect because the device does not function as a secretion-clearing tool. While deep breaths help mobilize secretions and a follow-up cough may clear them, the primary mechanism is alveolar reopening rather than upper airway cleansing. Option c is incorrect because the device emphasizes slow deep inhalation rather than forceful exhalation. Forceful expiration is the technique used in peak flow monitoring, which serves a different purpose for monitoring airway obstruction in asthma. Option d is incorrect because incentive spirometry complements rather than replaces ambulation. Walking remains essential to prevent venous thromboembolism, ileus, urinary retention, and pulmonary complications, so the

Correct Answer: Apply pressure, notify surgeon urgently

A sudden saturation with bright red blood suggests active arterial bleeding. The nurse applies direct manual pressure, reinforces the dressing rather than removing it, monitors vital signs closely, and notifies the surgeon immediately so hemostatic interventions can begin. Option b is incorrect because removing the original dressing disturbs the clot and may worsen bleeding. The accepted practice is to reinforce the dressing while applying direct pressure and obtain urgent surgical evaluation rather than uncovering the active site. Option c is incorrect because nurses do not initiate fluid boluses without an order in routine postoperative care. While supportive measures may be needed, escalating volume resuscitation requires provider input after pressure is applied and the team is notified. Option d is incorrect because documenting and waiting an hour ignores active hemorrhage that can rapidly destabilize a fresh surgical patient. The expected timeframe for response is immediate, not d

Correct Answer: Cover with saline gauze; low Fowler's

Evisceration requires immediate covering of exposed bowel with sterile saline-soaked gauze to keep tissue moist. Position in low Fowler's with knees flexed to reduce abdominal tension. The nurse calls the surgeon, keeps the client NPO, and monitors for shock. Option a is incorrect because attempting to push exposed bowel back into the abdomen risks tissue injury, contamination, and pain. Reintroduction of viscera requires surgical conditions and sterile technique, not a bedside maneuver during initial emergency response. Option b is incorrect because ambulation increases abdominal pressure, tension, and the chance of further tissue extrusion. The patient must remain still in low Fowler's position with knees flexed to minimize strain on the dehisced incision and exposed viscera. Option c is incorrect because dry gauze allows the exposed bowel to desiccate quickly, causing additional injury. Saline-moistened sterile dressings are the standard until surgical reduction and defini