HESI E2 HESI Exit Exam - Set 4 - Part 3

Correct Answer: Progressive shock requiring rapid response

Rising heart rate with falling blood pressure and declining urine output indicates progression from compensated to decompensated shock. The nurse activates rapid response, assesses for postoperative hemorrhage at dressings and drains, ensures large-bore access, and prepares blood products. Option a is incorrect because progressive tachycardia, falling pressure, and declining urine output represent active deterioration rather than stable recovery. Mistaking this picture for normal healing would delay the rescue measures the trajectory clearly demands at this hour. Option b is incorrect because dehydration from preoperative fasting tends to produce mild tachycardia and orthostatic changes that respond to maintenance fluids. The dramatic continuous trend described exceeds simple volume depletion and points toward acute hemorrhage instead. Option d is incorrect because effective opioid analgesia generally slows heart rate and respiratory rate without driving progressive hypotension and oli

Correct Answer: Open airway, prepare bag-mask ventilation

A flat capnography waveform indicates apnea. Pulse oximetry lags by 30 to 60 seconds, particularly on supplemental oxygen, so saturation will fall imminently. The nurse opens the airway with jaw thrust and prepares bag-mask ventilation while calling for help. Option a is incorrect because a normal pulse oximetry value temporarily masks dangerous apnea detected first by capnography. Waiting for desaturation lets hypoxia worsen and shrinks the window for safe airway rescue during sedation procedures. Option c is incorrect because flumazenil addresses benzodiazepine effect but cannot replace immediate airway support during apnea. Even if reversal is needed, the airway and breathing must be supported first to prevent further deterioration during onset. Option d is incorrect because supplemental oxygen flow does nothing for an apneic patient who is not moving air. Without ventilation, additional oxygen simply sits in the cannula while carbon dioxide accumulates and saturation eventually fal

Correct Answer: Score 9, vitals stable, ambulating safely

An Aldrete score of 9 or greater with stable vital signs, return to baseline mental status, ability to maintain the airway, and ambulating safely indicates readiness for discharge from the postanesthesia care unit per standard criteria today. Option a is incorrect because a score of 7 with sleepy consciousness fails to meet the standard threshold for safe discharge. Continued recovery is needed until the patient is more alert and oriented and the score reaches at least 9. Option b is incorrect because a score of 5 with airway support equipment in place signals deep sedation that is incompatible with safe transfer. The patient requires ongoing observation, airway interventions, and recovery before any discharge can be considered. Option d is incorrect because requiring four liters of supplemental oxygen to maintain saturation falls short of the criteria. A patient still dependent on significant oxygen support is not yet stable enough to leave the postanesthesia care unit.

Correct Answer: Apply while in bed before standing

Antiembolism stockings should be applied before getting out of bed, with the legs elevated. This prevents venous pooling before compression takes effect. The stockings must be smooth, free of wrinkles, and worn continuously during the day with planned removal. Option a is incorrect because walking before applying stockings allows venous pooling and reduces the prevention benefit. The stockings work best when applied before gravity has caused fluid to accumulate in the lower extremities during standing or ambulation. Option c is incorrect because rolling stockings down creates a tourniquet effect that constricts circulation and increases the risk of venous obstruction. Stockings must be pulled smoothly along the leg without folds, rolls, or wrinkles to remain safe. Option d is incorrect because nighttime-only use leaves the patient unprotected during the day when prolonged sitting or limited activity drives venous stasis. Continuous daytime wear with planned removal for hygiene is requi

Correct Answer: Inferior wall

Leads II, III, and aVF view the inferior wall of the heart, typically supplied by the right coronary artery. Inferior infarcts can involve the right ventricle, so the nurse anticipates bradycardia and avoids nitroglycerin due to preload sensitivity here. Option a is incorrect because anterior wall infarcts produce changes in leads V3 and V4, supplied by the left anterior descending artery. Inferior leads II, III, and aVF would not show the diagnostic shift expected with anterior involvement seen here. Option b is incorrect because septal infarcts manifest in leads V1 and V2 rather than the inferior leads identified in this electrocardiogram. The reciprocal pattern of changes associated with septal events does not match the inferior pattern described. Option d is incorrect because lateral wall infarcts produce changes in leads I, aVL, V5, and V6. ST elevation confined to II, III, and aVF reflects the inferior territory rather than the lateral wall area of the left ventricle.

Correct Answer: Notify surgeon and anesthesiologist immediately

Eating within the preoperative fasting window risks aspiration during induction. The nurse stops, notifies the surgeon and anesthesiologist, and prepares for likely postponement of elective surgery to allow adequate gastric emptying before anesthetic agents are administered safely. Option a is incorrect because proceeding while the stomach contains food creates aspiration risk during anesthesia. Loss of airway protective reflexes allows gastric contents to enter the lungs, a complication that elective surgery should never accept when delay is possible. Option b is incorrect because nasogastric decompression does not fully empty the stomach and is not used as a workaround for broken fasting. The procedure is uncomfortable and does not replace the proven safety of an adequate preoperative interval. Option c is incorrect because antiemetic medication addresses postoperative nausea, not the aspiration risk created by recent food intake. Substituting an antiemetic for the established fastin

Correct Answer: Compensated to early decompensated deterioration

Trending shows rising heart rate, rising respiratory rate, and falling blood pressure, the classic shift from compensation toward decompensation. Respiratory rate climbing above 27 doubles the risk of cardiac arrest, so the nurse escalates with rapid response activation and reassessment. Option a is incorrect because recovery from illness usually shows vital signs returning toward baseline, not progressively deteriorating. Mistaking continued worsening for healing represents a serious interpretation error that delays needed escalation and intervention by the team. Option c is incorrect because the values are not stable; they are moving away from baseline in a recognizable pattern of shock. Treating the changes as routine variability misses the early warning that the patient's compensatory reserve is collapsing. Option d is incorrect because oral diuretic effect produces gradual volume loss with possible orthostatic changes, not a sweeping rise in heart rate and respiratory rate pa

Correct Answer: Mark distal pulses, document baseline status

Marking pedal pulses and documenting baseline neurovascular status before catheterization gives a reference for postprocedure comparison. Diminished pulses, pallor, paresthesia, or coolness afterward may signal arterial thrombus, hematoma, or pseudoaneurysm requiring immediate provider notification and possible intervention. Option a is incorrect because warm compresses do not contribute to preparation for catheterization and may dilate vessels unnecessarily before puncture. The standard preparation focuses on documentation, fasting, consent, and intravenous access rather than topical thermal application to the groin. Option b is incorrect because beta blockers are typically continued for cardiac patients to maintain rate control and prevent rebound effects. Routinely withholding the dose without an order can destabilize heart rate and rhythm during the procedure. Option c is incorrect because a full meal three hours before catheterization violates fasting requirements designed to limi

Correct Answer: Blood glucose every four to six hours

Total parenteral nutrition delivers high concentrations of dextrose that can drive hyperglycemia, particularly early in therapy. Frequent glucose checks every four to six hours guide insulin coverage and prevent dangerous spikes. Electrolytes, liver enzymes, and triglycerides are also tracked routinely. Option b is incorrect because complete blood counts are usually checked daily rather than every shift in stable patients on total parenteral nutrition. They are valuable but do not match glucose monitoring frequency, which directly drives immediate insulin titration decisions. Option c is incorrect because cholesterol monitoring belongs to lipid management and chronic risk assessment rather than daily total parenteral nutrition surveillance. The clinically pressing parameter early in therapy is dextrose-related glucose control rather than cholesterol trending. Option d is incorrect because bilirubin tracking helps identify hepatic dysfunction over weeks of therapy, not in the early hour

Correct Answer: Respiratory rate climbing 16 to 28

A steadily rising respiratory rate is the most sensitive early predictor of clinical deterioration, including impending cardiac arrest when above 27 breaths per minute. The nurse investigates underlying causes such as hypoxia, sepsis, pulmonary embolism, or shock and escalates care. Option a is incorrect because a heart rate stable at 78 for hours reflects a normal pattern rather than concerning trend. There is no signal to chase, and intervention would distract from the patient whose trajectory is changing meaningfully. Option c is incorrect because a steady temperature of 98.4 sits within the normal range and shows no escalating pattern. Stable thermal status does not warrant priority intervention compared with the rising respiratory rate found in another patient. Option d is incorrect because blood pressure unchanged at 124 over 78 reflects stable hemodynamics over the period assessed. No deterioration trend exists, so this finding does not compete for priority with the climbing res