HESI E2 HESI Exit Exam - Set 3 - Part 3

Correct Answer: Therapeutic; continue current infusion

The therapeutic range for activated partial thromboplastin time during heparin therapy is one and a half to two and a half times control. With a value at twice control and no bleeding, the client is therapeutic. Option a is incorrect because the activated partial thromboplastin time is already within the therapeutic range, not below it. Increasing the dose would push the client into supratherapeutic territory and unnecessarily raise the risk of new bleeding complications. Option c is incorrect because a value at twice control is at the upper portion of the desired range, not above it. Stopping a therapeutic infusion would leave the underlying pulmonary embolism inadequately treated and risk new clot formation. Option d is incorrect because protamine sulfate is reserved for clinically significant bleeding or marked overdose. With no bleeding and a value still inside the therapeutic window, an antidote would cause unwanted reversal of needed anticoagulation.

Correct Answer: Hold lithium, notify the provider

Therapeutic lithium ranges from zero point six to one point two milliequivalents per liter. A level of one point eight with neurologic symptoms indicates toxicity, and low sodium intake further raises levels. The nurse holds the dose. Option a is incorrect because giving lithium in the toxic range would worsen tremor and confusion and could trigger seizures or arrhythmia. The drug must be held while the team treats toxicity and identifies adjustments to dose or dietary sodium. Option b is incorrect because, although hydration matters, plain water alone does not treat established lithium toxicity that produces neurologic symptoms. The provider may order intravenous saline or even hemodialysis depending on the severity of toxicity present. Option c is incorrect because restricting fluids worsens lithium retention and elevates the serum level further. Dehydration is a known precipitant of toxicity, so the nurse should never deliberately limit fluid intake during an episode of lithium toxi

Correct Answer: Reassess the penicillin allergy details

Cephalosporins share structural features with penicillins, so some cross-reactivity is possible. The nurse should reassess the nature and severity of the penicillin reaction before infusion, giving the prescribing team data needed to weigh risk and monitor for hypersensitivity. Option a is incorrect because, although baseline vital signs are useful, they do not address the immediate safety concern raised by a penicillin allergy. Verifying the allergy details takes priority and could prompt a change in the prescribed antibiotic. Option b is incorrect because simply repeating the documentation does not actively explore reaction history. The nurse must clarify whether the reaction was a mild rash or anaphylaxis, since these carry different cross-reactivity implications for cephalosporin use. Option d is incorrect because renal function does inform cefazolin dosing but ranks behind confirming allergy risk. An allergic reaction can occur even with appropriate renal dosing, so the allergy as

Correct Answer: Avoid the herb; serotonin syndrome risk

St. John's wort has serotonergic activity, and combining it with a selective serotonin reuptake inhibitor can trigger serotonin syndrome. The client should avoid the supplement entirely and review any new herbal product with the prescriber before adding to current therapy. Option a is incorrect because combining a serotonin reuptake inhibitor with another serotonergic agent can cause agitation, hyperthermia, tremor, and dangerous autonomic instability. Reassurance that this combination is safe could lead the client into a life-threatening drug reaction. Option b is incorrect because timing the supplement to weekends does not prevent the additive serotonergic effect. Serotonin syndrome can develop with even a single dose when added to ongoing antidepressant therapy, regardless of the day of the week. Option c is incorrect because abruptly stopping a serotonin reuptake inhibitor causes discontinuation syndrome and risks relapse of depression. The plan should focus on avoiding the da

Correct Answer: Extend infusion to at least sixty minutes

Vancomycin flushing syndrome, previously called red man syndrome, results from histamine release with rapid infusion. Extending administration to at least sixty minutes lowers the rate enough to limit histamine release and minimize associated flushing, itching, and hypotension during dosing. Option a is incorrect because shortening the infusion increases the rate of vancomycin delivery and triggers more histamine release. Faster administration is consistently linked with worse flushing syndrome, not improved tolerance to the medication during the initial dose. Option b is incorrect because intravenous vancomycin is never given as a rapid push. The drug requires dilution and slow infusion, and a five-minute push would almost certainly cause severe flushing, hypotension, and possible cardiac instability in the client. Option d is incorrect because reducing the diluent volume raises the concentration without changing the rate that triggers histamine release. The key intervention is slowin

Correct Answer: Headache, constipation, QT prolongation

Ondansetron commonly causes headache and constipation and can prolong the QT interval. Amiodarone also prolongs QT, so the combination raises the risk of torsades de pointes. The nurse alerts the client to palpitations or syncope and supports cardiac monitoring. Option a is incorrect because ondansetron is not associated with sedation or respiratory depression. The drug is favored over older antiemetics like promethazine partly because it lacks the deep central nervous system depressant effects described in this answer choice. Option c is incorrect because ondansetron actually slows gastrointestinal motility and tends to cause constipation rather than diarrhea. Severe diarrhea would prompt evaluation for other causes such as infection or the underlying chemotherapy regimen rather than ondansetron. Option d is incorrect because weight gain and fluid retention are not characteristic of ondansetron therapy. Such findings are more typical of corticosteroids or specific cardiac medications

Correct Answer: Give glargine alone and rotate sites

Insulin glargine is a long-acting insulin that is never mixed with any other insulin and is given subcutaneously at the same time each day. Rotating sites within one area prevents lipodystrophy from repeated injection in the same exact spot. Option a is incorrect because mixing glargine with rapid-acting insulin changes the pH and absorption profile, blunting the long-acting effect. Even within the same syringe, glargine must remain separate from other insulin preparations at every step of preparation. Option b is incorrect because insulin glargine is given subcutaneously, not intramuscularly. Injecting into muscle would speed absorption unpredictably and remove the flat twenty-four-hour profile that makes this preparation useful for steady basal coverage. Option c is incorrect because freezing destroys insulin proteins and renders the dose ineffective or unsafe for use. Unopened vials and pens belong in the refrigerator, and the in-use supply may stay at room temperature for the label

Correct Answer: Calcium gluconate given intravenously

Calcium gluconate is the antidote for magnesium sulfate toxicity. Low respirations, absent deep tendon reflexes, and reduced urine output indicate dangerous magnesium levels. The nurse stops the infusion, gives intravenous calcium gluconate as ordered, supports respirations, and monitors closely. Option a is incorrect because naloxone reverses opioid effects, not magnesium toxicity. Although both situations involve respiratory depression, the mechanism differs, and naloxone has no effect on the neuromuscular blockade caused by elevated magnesium levels. Option b is incorrect because protamine sulfate is the antidote for heparin overdose. The medication binds heparin but plays no role in correcting the cardiac, respiratory, or reflex changes caused by magnesium accumulating beyond the therapeutic range. Option d is incorrect because vitamin K is the antidote for warfarin overdose, helping the liver resume clotting factor production. Vitamin K does nothing to counter the neuromuscular an

Correct Answer: Stop the infusion immediately

Pale, cool, edematous skin with no blood return signals extravasation of a vesicant. Stopping the infusion immediately prevents further tissue damage from dopamine, which causes severe necrosis through alpha-adrenergic vasoconstriction at the site. Option b is incorrect because applying warmth belongs with a non-vesicant infiltration, where it helps reabsorb fluid into the tissue. Dopamine extravasation needs cold compresses if anything, but the first step is halting the drug to limit ongoing injury. Option c is incorrect because pushing more drug into a leaking catheter forces additional vesicant into surrounding tissue. Increasing the rate worsens the burn, expands the necrotic zone, and may require surgical debridement once the damage spreads. Option d is incorrect because moving the arm does nothing to address vasoactive drug pooling under the skin. Repositioning may even spread the infiltrate along fascial planes, and the catheter still keeps delivering dopamine until the infusion

Correct Answer: Serum potassium two point eight

Furosemide promotes potassium loss, and a serum potassium of two point eight indicates pre-existing hypokalemia that the dose would worsen. Profound hypokalemia raises the risk of dangerous arrhythmias, so the nurse holds and contacts the provider for orders. Option a is incorrect because a heart rate of eighty falls within the normal adult resting range. Loop diuretics do not have a heart-rate boundary that triggers holding, and a normal pulse signals adequate perfusion at baseline. Option c is incorrect because a standing pressure of one twenty over seventy shows the client tolerates upright position without significant orthostatic drop. Diuresis is appropriate at that pressure and would not prompt holding the scheduled dose. Option d is incorrect because a one-kilogram daily weight loss reflects the expected response to therapy in a fluid-overloaded client. That finding actually supports continuing furosemide rather than holding it, since diuresis is producing the targeted volume re