HESI RN Exit Practice Test 1 Answered 2023
ANS: C, D
Excessive vomiting results in the loss of potassium, chloride, and (stomach) acid. This results in the development of hypokalemic, hypochloremic metabolic alkalosis. Therefore, lab results will show a rise in bicarbonate levels (Choice C) a...
HESI RN Exit Practice Test 1 Answered
2023
ANS: C, D
Excessive vomiting results in the loss of potassium, chloride, and (stomach) acid. This results in the
development of hypokalemic, hypochloremic metabolic alkalosis. Therefore, lab results will show a rise
in bicarbonate levels (Choice C) and low chloride levels (Choice D).
Choice A is incorrect because the nurse would expect to see U wave and ST depression on the EKG due
to hypokalemia. Peaked T waves and QRS prolongation are signs of hyperkalemia. Choice B is incorrect
because the PCO2 will be increased (i.e. the client will be hypoventilating) to compensate for the rise in
bicarbonate. Choice E is incorrect because this client is hypokalemic as a result of excess vomiting and
not as a result of renal potassium loss. the kidneys will minimize potassium excretion in an attempt to
raise serum potassium levels.
A pregnant woman with hyperemesis gravidarum has been vomiting excessively and lab results reveal
hypokalemia (serum potassium 3.0 mEq/L). What other abnormalities should the nurse expect to find?
A. Peaked T waves and QRS prolongation on EKG
B. Decreased PCO2
C. Increased serum bicarbonate
D. Decreased serum chloride
E. Increased urinary potassium
ANS: A, D, E
Clients on clear liquid diet can- as the name implies- only consume clear liquids. No solids are included in
this diet. Option A (gelatin), D (tea with honey), and E (broth) are proper choices for a client on a clear
liquid diet.
Choice B is incorrect because pulp cannot be consumed while on a liquid diet. The client is permitted to
drink clear juices such as apple juice or grape juice without pulp. Choice C is incorrect because a
cappuccino contains milk, which is not permitted on a clear liquid diet. The client is permitted to drink a
cup of dark coffee without milk
A clear liquid diet is ordered for a client scheduled for a colonoscopy. Which food selection indicates
that teaching has been effective? (Select all that apply)
A. Gelatin
B. Orange juice with pulp
C. Cappuccino
,D. Tea with honey
E. Broth
ANS: C
The nurse should instruct the graduate nurse to assess location C to see if an air leak is present. Location
C is the air leak meter; bubbling in this location indicates an air leak. In contrast, fluctuation of the fluid
in the air leak chamber and water seal (tube connecting B and C) is normal as a result of pressure
changes during respiration.
Choice A is incorrect because location A is the collection chamber. In this chamber, the drainage from
the chest is collected. It has calibration marks and make it easier to read and document the amount of
drainage. There will be no bubbling in this chamber.
Choice B is incorrect because location B is the high negativity float valve and high negativity relief
chamber. The negativity float valve and negativity relief chamber are safety measures that maintain the
water seal in the event of high negative pressures (which can be caused by coughing, crying, and
stripping of the chest tubes or decreased suctioning).
Choice D is incorrect because location D is the suction control chamber. The amount of suction is
regulated by the height of the column of water in the suction control chamber A suction pressure of -20
cm H2O is typically used. Gentle continuous bubbling in this chamber is normal and does not indicate an
air leak
The nurse is instruction a new graduate on the use of a pleur evac drainage system for a client with a
pleural effusion. In what location should the nurse instruct the new graduate to look if an air leak is
suspected?
A. Location A
B. Location B
C. Location C
D. Location D
ANS: C
Pulmonary function tests (PFTs) consist of a series of tests to measure how well the lungs are
functioning. Typically, spirometer, diffusion studies, and plethysmography are performed to measure
lung volume, capacity, rates of flow, and gas exchange. Client should be instructed to breath through a
mouthpiece connected to a measuring device. Choice C is the correct answer as the PFTs provide
quantification of the damage that is sustained through smoking and provide information on the need for
additional therapies to improve pulmonary function, such as bronchodilators.
Choice A is incorrect because PFTs are not used for the detection of lung cancer. An X-ray or CT scan
should be ordered if lung cancer is suspected.
Choice B is incorrect because the percentage of oxygen in the lungs is dependent on the mixture of air
,that is inhaled regardless of the capacity or condition of the lungs.
Choice D is incorrect because PFTs do not identify interventions to aid the client with smoking cessation.
A client with a 40 pack year history of smoking is scheduled for a pulmonary function test. What should
the nurse explain regarding this diagnostic test?
A. "This test is used to assess your risk for lung cancer"
B. "This test is used to determine the percentage of oxygen that is in your lungs with every breath"
C. "This test shows if you would benefit from medication to improve your breathing"
D. "This test identifies the best interventions to help you quit smoking"
ANS: A, B
The laboratory results indicate that the client is experience in severe hypothyroidism (high TSH, very low
T3, T4) as well as respiratory acidosis, which is a manifestation of hypothyroidism due to
hypoventilation. Other symptoms associated with severe hypothyroidism include mental status changes
such as drowsiness (Choice A) and decreased body temperature (choice B).
Choices C, D, and E are incorrect because these symptoms are seen in clients with hyperthyroidism. The
client is likely to have bradycardia and hypotension, as well as hypoventilation (of which respiratory
acidosis is a manifestation)
The nurse is evaluating laboratory results of a client with thyroid dysfunction. Based on the provided
information, the nurse would expect to see what findings when assessing the client? (Select all that
apply)
A. Drowsiness
B. Decreased body temperature
C. Increased heart rate
D. Hyperventilation
E. Hypertension
ANS: B
All clients have the legal right to be fullly informed about their medical condition as well as any
purposed treatments. Informed consent is defined as the client's choice to undergo a treatment or
procedure based on their full understanding of the risks and benefits as well as any potential
alternatives. In order to provide informed consent, the client must be an adult with the mental ability to
make decisions. For this reason, Option B, a 16-year-old client with an acetaminophen allergy, is correct
because this client is a minor and would require informed consent from a legal guardian such as a
parent. For most states, a client must be 17 years of age or older in order to provide informed consent
for treatment or a procedure. There are certain exceptions to this such as treatment for a sexually
transmitted disease or if they are legally married. Option A, a 54-year-old client with a hand tremor is
incorrect because the client is of legal age and is competent to consent to care. Although their signature
may be shaky, the nurse is verifying their understanding of the procedure and not their ability to write
, legibly. Option C, a 32-year-old client who is legally blind, is incorrect because this client is still
competent to provide consent despite their injury. If a client is unable to see or to read the consent, the
nurse can read the information to them or provide an alternative text, such as large print or braille Their
ability to understand is not affected by their inability to see the text on the consent form. Option D, a
72-year-old client whose primary language is Russian, is incorrect because this client's ability to
understand the procedure is not affected because his primary language is Russian. It is a client's right to
receive written oral medical information in their primary language. Many computer programs will offer
translations of consent forms or the nurse may use a trained translator. The nurse should use a trained
medical translator, rather than available family members, to ensure that the information is
communicated correctly and that confidential medical information is kept private.
A perioperative nurse is preparing to obtain consents from a group of clients that are scheduled for
outpatient surgery today. Which client requires informed consent from next of kin?
A. A 54 year old client with a hand tremor
B. A 16 year old client with acetaminophen allergy
C. A 32 year old client who is legally blind
D. A 72 year old client whose primary language is Russian
ANS: B
Clients taking sedating medications are at increased fall risk. Nursing care should focus on providing a
safe and injury free environment. Education should be provided to ensure that the client is aware of
their limitations and follows safety protocols. In the situation described in the question, the client
followed the correct process by signaling the nurse with the call light for assistance with ambulating to
the bathroom. When no assistance was provided in a timely manner, the client got up and attempted to
walk to the bathroom by themselves. This behavior does not constitute the need for a vest or wrist
restraints, but demonstrates inadequate care on the part of the nursing staff, both in providing timely
care to the client and by applying restraints without a medical indication. The nurse manager should
reprimand the staff nurse for violating this client's rights and review that restraints can only be applied if
the client is a risk for self or others and less invasive measures fail to resolve the situation.
Choice A is incorrect because there is no medical indication for restraints and the client's restraints
should be lifted as soon as possible. Proper nursing care and falll prevention that do not violate the
client's rights should be implemented. Note that a physician's order is required before the
implementation of any type of restraint.
Choice C is an appropriate action but fails to address the more important issue of the violation of the
client's rights.
Choice D is incorrect because a bed alarm is considered a form of restraint and requires a physician's
order. Rather than using a bed alarm to restrict the client's movement, the nursing team should come
up with ways to address client needs in a more timely manner. Filing a "near-miss" report is an
appropriate action as the client could have sustained a fall. A Near Miss is an unplanned event that did
not result in injury, illness, or damage - but had the potential to do so. The reason for filing a near miss
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