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correct Answers highlighted) 2025
HESI EXAM 1 (158 Questions with
correct Answers highlighted) 2025
A mother runs into the emergency department with a toddler in her arms and tells the nurse that her child got into some cleaning products. the child smells of chemicals on the hands, face, and on the front of the child's clothes. after ensuring the airway is patent, what action should the nurse implement first? a. Assess the child for altered sensorium b. Determine type of chemical exposure c. Obtain equipment for gastric lavage d. Call poison control emergency number - ✔️ b. Determine type of chemical exposure
Which conditions are most likely to respond to treatment with antihistamines? Select all that apply. a. Bronchitis b. Allergic rhinitis c. Otitis media d. Contact dermatitis e. Myocarditis - ✔️ b. Allergic rhinitis d. Contact dermatitis
An older client's daughter calls the home health nurse and reports that her mother has become forgetful and is very confused at night. The daughter states that her mother's behavior changed suddenly a few days ago and is now getting worse. Which action should the nurse take? Select all that apply. a. Ask if the mother is experiencing any pain with urination b. Encourage increased intake of high protein foods c. Instruct the daughter to check her mother's temperature d. Review the client's current food and medication allergies e. Determine if the mother has recently experienced a fall - ✔️ a. Ask if the mother is experiencing any pain with urination c. Instruct the daughter to check her mother's temperature e. Determine if the mother has recently experienced a fall
The nurse is assessing a male with a history of Addison's disease. The client has flu- like symptoms and nausea with vomiting over the past week. The client's spouse reports that he acted confused and was extremely weak when he awoke this
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morning. The client is febrile and has tachycardia. The health care provider diagnoses acute adrenal insufficiency. Which medication will most likely be prescribed? a. Hypertonic saline solution at 100 ml/hr until all edema disappears b. Hydrocortisone 100 mg IV every six hours until systolic BP reaches 110 mmHg c. Potassium chloride 20 mEq IV to infuse over 2 hours until confusion resolves d. Regular insulin drip to keep blood glucose around 100 mg/dl (5.55 mmol/L) - ✔️ b. Hydrocortisone 100 mg IV every six hours until systolic BP reaches 110 mmHg
A client with a history of mitral valve prolapse is admitted because of fever and dyspnea on exertion, and is diagnosed with acute infective endocarditis. During the admission assessment, the nurse observes multiple areas of petechiae on the client's skin. Which intervention should the nurse include in the client's plan of care? Select all that apply. a. Monitor cardiac rhythm via telemetry b. Report changes in pre-existing murmurs c. Schedule rest periods between activities d. Maintain record of fluid intake and output e. Initiate contact transmission precautions - ✔️ a. Monitor cardiac rhythm via telemetry b. Report changes in pre-existing murmurs e. Initiate contact transmission precautions
The nurse is planning an educational session for new parents on ways to prevent sudden infant death syndrome (SIDS). Which information is most important to provide parents of newborns and infants? a. Remove pillows and soft toys from the crib at bedtime b. Keep a bulb syringe accessible for use for an infant c. Position the infant in a supine position while sleeping d. Do not prop bottles for an infant during naps and bedtime - ✔️ c. Position the infant in a supine position while sleeping
The healthcare provider prescribes methylergonovine maleate for a postpartum client with uterine atony. What findings should indicate to the nurse to withhold the next dose of medication? a. Hypertension b. Difficulty locating the uterine fundus c. Saturation of more than one pad per hour d. Excessive lochia - ✔️ a. Hypertension
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✔️ d. Tell the wife that her husband's neurologist just would know more about alternative treatments to cure Parkinson's
An IV antibiotic is prescribed for a client with a post operative infection. The medication is to be administered in 4 divided doses. What schedule is best for administering this prescription? a. 1000, 1600, 2200, 0400 b. 0800, 1200, 1600, 2000 c. Administer with meals and a bedtime snack d. Given equally divided doses during waking hours - ✔️ a. 1000, 1600, 2200, 0400
The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation? a. Continued development of the brain lesion determines the child's outcome b. Brain damage with CP is not progressive but it does have variable course c. CP is one of the most common permanent physical disability in children d. Severe motor dysfunction determines the extent of successful habilitation - ✔️ b. Brain damage with CP is not progressive but it does have variable course
The nurse is preparing a teaching plan for an older female client diagnosed with osteoporosis. Which expected outcome has the highest priority for this client? a. Identifies 2 treatments for constipation due to immobility b. Names 3 home safety hazards to be resolved immediately c. States 4 risk factors for the development of osteoporosis d. Lists five calcium rich foods to be added to her daily diet - ✔️ b. Names 3 home safety hazards to be resolved immediately
A client is recovering in the outpatient surgical unit after an endoscopic carpal tunnel release. The nurse assesses the client's vital signs, pain level, and dressing. Before discharging the client, which intervention should the nurse implement? a. Administer and non-steroidal anti-inflammatory drug for pain b. Check neurovascular status of the distal digits c. Change the dressing if drainage increases d. Position the arm in a sling for discharge - ✔️ b. Check neurovascular status of the distal digits
An older client is admitted in respiratory distress secondary to heart failure (HF), coronary artery disease (CAD), hypertension (HTN), and atrial fibrillation. Which
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nursing problem should the nurse include in the client's plan of care? Select all that apply. a. Fluid volume excess b. Decreased cardiac output c. Altered peripheral tissue perfusion d. Fluid volume deficit e. Fatigue - ✔️ a. Fluid volume excess b. Decreased cardiac output c. Altered peripheral tissue perfusion e. Fatigue
The nurse is providing preoperative education for a Jewish client scheduled to receive a xenograft graft to promote burn healing. Which information should the nurse provide this client? a. As the burn heels, the graft permanently attaches b. Graphs are later removed by a debriding procedure c. Grafting increases the risk for bacterial infections d. The xenograft is taken from non-human sources - ✔️ d. The xenograft is taken from non-human sources
A client is admitted with a severe asthma attack. For the last three hours the client has experienced increasing shortness of breath. Arterial blood gas results are: ph 7.22; paco2 55mmhg; HCO3 25 meq/L (25 mmol/L). Which intervention should the nurse implement? a. Space care to provide periods of rest b. Instruct client to purse lip breathe c. Position client for maximum comfort d. Administer PRN dose of albuterol - ✔️ d. Administer PRN dose of albuterol
After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wish to see the body before it is taken to the funeral home. Which interventions should the nurse take to prepare the body before the family enters the room? Select all that apply. a. Take out dentures and place in a labeled cup b. Apply a body shroud c. Place a small pillow under the head d. Remove resuscitation equipment from the room e. Gently close the eyes - ✔️ c. Place a small pillow under the head
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d. What did the night nurse do that makes you think she is aloof? - ✔️ b. I am happy that you are getting better and will be able to go home
The nurse is caring for a client who has been diagnosed with malnutrition. Which finding supports the medical diagnosis? a. Decrease in the appetite b. Weight of 227 pounds (103 kg) c. Dry mucosal membranes d. Body mass index (BMI) of 17 - ✔️ d. Body mass index (BMI) of 17
The nurse is preparing a client who had a below the knee amputation for discharge to home. Which recommendation should the nurse provide this client? Select all that apply. a. Avoid range of motion exercises b. Use a residual limb shrinker c. Watch the stump with soap and water d. Inspect skin for redness e. Apply alcohol to the stump after bathing - ✔️ b. Use a residual limb shrinker c. Watch the stump with soap and water d. Inspect skin for redness
A client develops urticaria on the trunk and neck shortly after a secondary infusion of piperacillin that is initiated. In what order should the nurse implement these interventions? (arrange the actions in order of priority, with highest priority first, and least priority last or at the bottom.)
- Document reaction to the drug
- Initiate an adverse event report
- Contact the health care provider
- Assess vital signs
- Stop the infusion - ✔️ 5. Stop the infusion
- Assess vital signs
- Contact the health care provider
- Document reaction to the drug
- Initiate an adverse event report
The nurse is planning the preoperative teaching plan for a 12-year-old child who is scheduled for surgery. To help reduce this child anxiety, what action is best for the nurse to implement?
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a. Provide dolls and equipment to re-enact feelings associated with painful procedures b. Give the child syringes or hospital masks to play with at home prior to hospitalization c. Provide a family tour of the preoperative unit one week before the surgery is scheduled d. Include the child and play therapy with children who are hospitalized for similar surgery - ✔️ a. Provide dolls and equipment to re-enact feelings associated with painful procedures
A client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing in the tape securing the intravenous (IV) line. The abdominal dressing is no longer occlusive, and the IV insertion site is pink. Which intervention should the nurse implement? a. Replace the IV site with a smaller gauge b. Apply soft bilateral wrist restraints c. Leave the lights on in the room at night d. Redress the abdominal incision - ✔️ d. Redress the abdominal incision
A client is experiencing withdrawal from the benzodiazepine alprazolam is demonstrating severe agitation and tremors. What is the best initial nursing action? a. Administer naloxone per PRN protocol b. Obtain a serum drug screen c. Initiate seizure precautions d. Instruct the family about withdrawal symptoms - ✔️ c. Initiate seizure precautions
A client's morning assessment includes bounding peripheral pulses, weight gain of two pounds (0.91 kg), pitting ankle edema, and moist crackles bilaterally. Which intervention is most important for the nurse to include in this client's plan of care? a. Restrict daily fluid intake to 1500 ml b. Administer prescribed diuretic c. Maintain accurate intake and output d. Weigh client every morning - ✔️ b. Administer prescribed diuretic
The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?
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A client's telemetry monitor indicates ventricular fibrillation (VF). Which action should the nurse implement immediately? a. Administer IV atropine b. Defibrillate with one shock c. Give a dose of amiodarone IV d. Prepare for external pacing - ✔️ b. Defibrillate with one shock
A recently hired nurse who is in orientation is assigned to the medical unit. The charge nurse observes the new nurse prepare to administer a unit of packed red blood cells as seen in the picture. Which action should the charge nurse take? a. Verify that a 22-gauge intravenous catheter is used for the transfusion b. Assist the nurse in changing the intravenous tubing attached to the blood c. Tell the nurse to take the clients vital signs and then start the transfusion d. Assume responsibility for the care of the client during the blood transfusion - ✔️ b. Assist the nurse in changing the intravenous tubing attached to the blood
The home care nurse visits a client who has cancer. The client reports having a good appetite but experiencing nausea when smelling food cooking. What action should the nurse implement? a. Encourage family members to cook meals outdoors and bring the cooked foods inside b. Advise the client to replace cooked foods with a variety of different nutritional supplements c. Assess the clients' mucous membranes and report the findings to the health care provider d. Instruct the client to take an anti-emetic before every meal to prevent excessive vomiting - ✔️ a. Encourage family members to cook meals outdoors and bring the cooked foods inside
The unlicensed assistive personnel (UAP) reports that a client's blood pressure cannot be measured because the client has casts on both arms and is unable to be turned to the prone position for blood pressure measurement in the legs. Which action should the nurse implement? a. Advise the UAP to document the last blood pressure obtained in the client's graphic sheet b. Demonstrate how to palpate the popliteal pulse with a client supine and the knee flexed c. Document why the blood pressure cannot be accurately measured at the present time
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d. Estimate the blood pressure by assessing the pulse volume of the clients' radial pulses - ✔️ b. Demonstrate how to palpate the popliteal pulse with a client supine and the knee flexed
The nurse working in the psychiatric clinic has phone messages from several clients. Which cost should the nurse return first? a. A young man with schizophrenia who wants to stop taking his medications b. The mother of a child who was involved in a physical fight at school today c. A client diagnosed with depression who is experiencing sexual dysfunction d. A family member of a client with dementia who has been missing for five hours - ✔️ d. A family member of a client with dementia who has been missing for five hours
A child is diagnosed with acquired aplastic anemia. The nurse knows that this child has the best prognosis with which treatment regimen? a. Chemotherapy b. Immunosuppressive therapy c. Blood transfusions d. Bone marrow transplantation - ✔️ c. Blood transfusions
A client is admitted with possible urosepsis. Which intervention should the nurse perform as soon as possible? a. Teach the client about the side effects of the prescribed anti-infective drug b. Assess the last 24-hour oral and intravenous fluid intake and urine output c. Administer the initial dose of the anti-infective drug as prescribed d. Obtain a urine specimen for a prescribed culture and sensitivity test - ✔️ d. Obtain a urine specimen for a prescribed culture and sensitivity test
Three hours after birth, a newborn becomes jittery and tachypneic. What should the nurse do first? a. Encourage the mother to breastfeed b. Wrap tightly in a warm blanket c. Obtain a capillary glucose level d. Feed 30 ml of 10% dextrose in water - ✔️ c. Obtain a capillary glucose level
The nurse is assigning care of a client with prostatitis to a practical nurse (PN). What instruction should the nurse provide the PN regarding care of this client? a. Restrict oral fluid intake b. Avoid urinary catheterization
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A mother brings her child, who has a history of asthma, to the emergency room. The child is wheezing and speaking one word between each breath. The child is anxious, tachycardic, and has labored respirations. Which assessment is most important for the nurse to obtain? a. Frequency that the child uses a rescue inhaler during the week b. Type of allergen exposure or trigger for the current episode c. Type of inhaler the child typically uses on a regular basis d. Last dose and type of rescue inhaler used by the child - ✔️ a. Frequency that the child uses a rescue inhaler during the week
The nurse is teaching the parents of a child newly diagnosed with a latex allergy. Which information by the parents indicates the need for further teaching? a. A diet of healthy fruits, such as bananas and Kiwis, are best for the child b. Only foil balloons will be used for the child's birthday party c. Rubber-free toys, such as wooden building blocks, are good choices for the child d. An epinephrine auto-injector will be on hand to treat allergic reactions - ✔️ a. A diet of healthy fruits, such as bananas and Kiwis, are best for the child
A client with chronic kidney disease has an arteriovenous (AV) fistula In the left forearm. Which observation by the nurse indicates that the fistula is patent? a. Distended, tortuous veins in the left hand b. Auscultation of a thrill on the left forearm c. The left radial pulses 2+ bounding d. Assessment of a bruit on the left forearm - ✔️ d. Assessment of a bruit on the left forearm
A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose? a. History of intravenous drug abuse b. Conversion of the client's PPD test from negative to positive c. Current diagnosis of hepatitis B d. Length of time of the exposure to tuberculosis - ✔️ c. Current diagnosis of hepatitis B
The nurse instructs and unlicensed assistive personnel (UAP) to turn an immobilized older client with an indwelling urinary catheter every two hours. What additional action should the nurse instruct the UAP to take each time the client is turned? a. Empty the urinary drainage bag b. Assess the breath sounds
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c. Offer the client oral fluids d. Feed the client a snack - ✔️ c. Offer the client oral fluids
A client has had several episodes of clear, watery diarrhea that started yesterday. What action should the nurse implement? a. Check the client's hemoglobin level b. Review the clients current list of medications c. Assess the client for the presence of hemorrhoids d. Administer prescribed PRN anti-emetic - ✔️ b. Review the clients current list of medications
A 15-year-old male client was recently diagnosed with type 1 diabetes mellitus. He tells the nurse that he has difficulty adhering to his meal plan when he is with his friends. What nursing intervention is best for the nurse to implement? a. Advise him to take his own food with him on going to fast food restaurants with his friends b. Encourage him to find activities to do with his friends that do not involve eating c. Assist him in identifying popular fast foods that are within his meal plan for diabetes d. Recommend that he avoid fast food restaurants until he is familiar with his prescribed diet - ✔️ c. Assist him in identifying popular fast foods that are within his meal plan for diabetes
A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention should the nurse implement? Select all that apply. a. Report serum albumin and globulin levels b. Provide diet low in phosphorus c. Increase oral fluid intake to 1500 ml daily d. Note signs of swelling and edema e. Monitor abdominal girth - ✔️ a. Report serum albumin and globulin levels d. Note signs of swelling and edema e. Monitor abdominal girth
The nurse request a food tray for a client who follows Mormon beliefs and who is on a clear liquid diet following abdominal surgery. Which menu items should the nurse request for this client? Select all that apply. a. Chicken broth b. Apple juice
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c. Decrease wine consumption d. Decrease coffee consumption - ✔️ b. Increase calcium intake
During discharge teaching, a male client recently diagnosed with malignant hypertension tells the nurse that he really enjoys downhill skiing and asks if he can continue with this sport. Which is the best response by the nurse? a. "It should be alright as long as you can find your skiing to the easier trails." b. "Go for it. Skiing should provide you with a terrific aerobic workout." c. "Cold weather may constrict your blood vessels raising your blood pressure'" d. "Skiing might produce too much exertion. How about sledding?" - ✔️ c. "Cold weather may constrict your blood vessels raising your blood pressure'"
A client with acute renal failure (ARF) is admitted for uncontrolled type one diabetes mellitus and hyperkalemia. The nurse administers and IV dose of regular insulin per sliding scale. Which intervention is most important for the nurse to include in this clients plan of care? A. Evaluate hourly urine output for return of normal renal function B. Assess glucose via fingerstick every four to six hours C. Monitor the client's cardiac activity via telemetry D. Maintain venous access with an infusion of normal saline - ✔️ C. Monitor the client's cardiac activity via telemetry
What is the primary goal when planning nursing care for a client with degenerative joint disease (DJD)? a. Obtain adequate rest and sleep b. Reduce risk for infection c. Improve stress management skills d. Achieve satisfactory pain control - ✔️ d. Achieve satisfactory pain control
What might the nurse suggest to a client with fibrocystic breasts in the attempt to help relieve her symptoms? a. "Increase high calcium foods in your diet b. "Eat a low carbohydrate, high protein diet" c. "Eliminate caffeine from your diet" d. "Avoid vigorous physical exercise immediately after your menstrual period" - ✔️ c. "Eliminate caffeine from your diet"
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Client with end stage renal disease (ESRD) is refusing all treatment and requests that no life saving measures be implemented. The health care provider refuses to write do not resuscitate instructions. Which action should the nurse take? a. Initiate a review of the situation by the hospital's ethics committee b. Remind the client that new treatments are being developed daily c. Facilitate a palliative care meeting with the client and health care provider d. Provide the health care provider with a copy of the clients Bill of Rights - ✔️ d. Provide the health care provider with a copy of the clients Bill of Rights
A client with chronic obstructive pulmonary disease (COPD) is experiencing worsening dyspnea and low oxygen levels. Vital signs are: temperature 99.6 degrees F, Heart rate 98 beats/minute, respirations 28 breaths/minute, blood pressure 140/ mmHg and oxygen saturation 88%. Which action should the nurse implement? a. Prepare client for endotracheal intubation b. Place the client in a forward-leaning position c. Apply a non-rebreather mask at 100% oxygen d. Obtain a sputum sample for culture and sensitivity - ✔️ a. Prepare client for endotracheal intubation
A client is admitted with an exacerbation of heart failure secondary to COPD. Which observations for the nurse require immediate intervention to reduce the likelihood of harm to this client? Select all that apply. a. A bedside commode is positioned near the bed b. A full pitcher of water is on the bedside table c. A low sodium diet tray was brought to the room d. The client is lying in the supine position in bed e. A saline lock is present in the right forearm - ✔️ b. A full pitcher of water is on the bedside table d. The client is lying in the supine position in bed
A newly hired unlicensed assisted personnel (UAP) is assigned to a home health care team along with two experienced UAPs. Which intervention should the home health nurse implement to ensure adequate care for all clients? a. Evaluate the newly hired UAP's level of competency by observing the UAP deliver care b. Assign the newly hired UAP to clients who require the least complex level of care c. Ask the most experienced UAP on the team to partner with the newly hired UAP d. Review the UAP's skills checklist and experience with the person who hired the UAP - ✔️ a. Evaluate the newly hired UAP's level of competency by observing the UAP deliver care
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A school nurse is preparing a presentation for elementary school teachers to inform them about when a child should be referred to the school clinic for further follow up. The teacher should be instructed to report which situations to the school nurse? Select all that apply. a. Thirst and frequent requests for bathroom breaks b. Shaking that changes the child's handwriting legibility c. Bruises on both knees after the weekend d. Refuses to complete written homework assignments e. Sunburn with blisters on the face, arms, and hands - ✔️ a. Thirst and frequent requests for bathroom breaks b. Shaking that changes the child's handwriting legibility e. Sunburn with blisters on the face, arms, and hands
The mother of a 12 month old with cystic fibrosis reports that her child is experiencing increasing congestion despite the use of chest physical therapy (CPT) twice a day, and has also experienced a loss of appetite. Which instruction should the nurse provide? a. Perform CPT only in the morning, but increase frequency when appetite improves b. Perform CPT after meals to increase appetite and improve food intake c. CPT should be performed more frequently, but at least an hour before meals d. Stop using CPT during the daytime until the child has regained and appetite - ✔️ c. CPT should be performed more frequently, but at least an hour before meals
The healthcare provider prescribes a low fiber diet for a client with ulcerative colitis. Which food selection indicates to the nurse that the client understands the prescribed diet? a. Roasted pork, fresh strawberries b. Pancakes, whole grain cereals c. Baked potato with skin, raw carrots d. Roasted Turkey, canned vegetables - ✔️ d. Roasted Turkey, canned vegetables
A client with atrial fibrillation receives a new prescription for dabigatran etexilate. Which instruction is important for the nurse to emphasize when teaching the client about this medication? a. Check your pulse rate every day b. Report unusual bruising or bleeding c. Monitor your blood pressure regularly d. Elevate your feet if swelling occurs - ✔️ b. Report unusual bruising or bleeding
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The nurse is preparing to give fentanyl 0.075 mg IM to a client who is scheduled for a colonoscopy. The medication is labeled 50 mcg/ml. How many ml Should the nurse administer? - ✔️ 1.
The home care nurse provided self-care instructions for a client with chronic venous insufficiency caused by deep vein thrombosis. Which instruction should the nurse include in the client's discharge teaching plan? Select all that apply. a. Cross legs at knee but not at ankle b. Maintain the bed flat while sleeping c. Continue wearing compression stockings d. Avoid prolonged standing or sitting e. Use recliner for long periods of sitting - ✔️ c. Continue wearing compression stockings d. Avoid prolonged standing or sitting e. Use recliner for long periods of sitting
Dopamine 5 mcg/kg/minute IV is prescribed for a client who weighs 132 pounds. The pharmacy dispenses of 500 ml IV solution of 0.9% normal saline with dopamine 1600 mg. The nurse should program the infusion pump to deliver how many ml/hr? - ✔️ 5.
During discharge teaching, and overweight client with heart failure is asked to make a grocery list for the nurse to review period which food choices included in the clients less should the nurse encourage? Select all that apply. a. Natural whole almonds b. Cheddar cheese cubes c. Lightly salted potato chips d. Plain, air-popped popcorn e. Canned fruit in heavy syrup - ✔️ a. Natural whole almonds d. Plain, air-popped popcorn
The husband of an older woman, diagnosed with pernicious anemia calls the clinic to report that his wife still has memory loss and some confusion since she received the first dose of nasal cyanocobalamin two days ago. He tells the nurse that he is worried that she may be getting Alzheimer's disease. What action should the nurse take? a. Encourage the husband to bring the client to the clinic for a complete blood count b. Determine if the client is taking iron and folic acid supplements
