HESI Exit Comprehensive Assessment
Final Exam 2026 | 200 Questions with
Verified Answers and Rationales |
Graded A+ Premium Study Guide
Q1
The nurse is caring for a client with a deep vein thrombosis (DVT) who
is receiving a continuous intravenous heparin infusion. The client’s
activated partial thromboplastin time (aPTT) is 105 seconds. Which
action should the nurse take first?
A. Increase the heparin infusion rate by 100 units/hour.
B. Maintain the current infusion rate and reassess in 4 hours.
C. Stop the heparin infusion immediately and notify the healthcare
provider.
D. Administer Vitamin K intramuscularly as prescribed.
EXPLANATION: The normal therapeutic range for aPTT while on
heparin therapy is typically 1.5 to 2.5 times the normal control value
, (about 45 to 70 seconds). An aPTT of 105 seconds indicates excessive
anticoagulation, placing the client at a critical risk for severe
hemorrhage. The infusion must be stopped immediately to protect
safety, and the provider must be notified. Vitamin K is the antidote for
warfarin, not heparin (protamine sulfate is the antidote for heparin).
Q2
A client with a history of severe cirrhosis is admitted with suspected
hepatic encephalopathy. Which laboratory result requires the most
immediate intervention by the nurse?
A. Serum albumin of 2.8 g/dL.
B. Serum ammonia of 135 mcg/dL.
C. Prothrombin time (PT) of 16 seconds.
D. Total bilirubin of 3.2 mg/dL.
EXPLANATION: Increased serum ammonia levels are directly
responsible for the neurotoxic manifestations of hepatic
encephalopathy, including confusion, asterixis, and progressive coma.
Lactulose is routinely given to lower this level. Elevated PT, low
albumin, and elevated bilirubin are expected baseline signs of chronic
liver failure but do not cause acute mental status changes as rapidly as
hyperammonemia.
, Q3
The nurse is caring for a pregnant client at 34 weeks' gestation who
presents with severe epigastric pain, a headache, and blurred vision. The
blood pressure is 172/114 mmHg. Which medication does the nurse
anticipate administering first?
A. Oxytocin.
B. Magnesium sulfate.
C. Terbutaline.
D. Methylergonovine.
EXPLANATION: The client is exhibiting signs of severe preeclampsia,
including severe hypertension, neurological symptoms (headache,
blurred vision), and epigastric pain (suggesting liver involvement).
Magnesium sulfate is the drug of choice to prevent tonic-clonic seizures
(eclampsia). Oxytocin is used for induction, terbutaline is a tocolytic to
stop contractions, and methylergonovine is oxytocic and
contraindicated in severe hypertension.
Q4
, A 4-year-old child with a known history of tetralogy of Fallot becomes
acutely agitated, cyanotic, and dyspneic while crying. Which position
should the nurse immediately place the child in?
A. High-Fowler's position with legs extended.
B. Prone position with the head turned to the side.
C. Knee-chest position.
D. Supine position with the feet elevated.
EXPLANATION: This child is experiencing a hypercyanotic spell ("tet
spell"). Placing the child in a knee-chest position increases systemic
vascular resistance, which forces more blood out of the right ventricle
into the pulmonary artery rather than through the ventricular septal
defect, improving systemic oxygenation.
Q5
A client with an acute exacerbation of bipolar I disorder is pacing back
and forth in the dayroom, yelling loudly at other clients, and refusing to
sit down for meals. Which nursing intervention is most appropriate?
A. Restrict the client to their bedroom until behavior improves.
B. Provide portable, high-calorie finger foods and juices.
C. Schedule the client for an immediate group therapy session.
D. Administer a sedative and place the client in mechanical restraints.
Final Exam 2026 | 200 Questions with
Verified Answers and Rationales |
Graded A+ Premium Study Guide
Q1
The nurse is caring for a client with a deep vein thrombosis (DVT) who
is receiving a continuous intravenous heparin infusion. The client’s
activated partial thromboplastin time (aPTT) is 105 seconds. Which
action should the nurse take first?
A. Increase the heparin infusion rate by 100 units/hour.
B. Maintain the current infusion rate and reassess in 4 hours.
C. Stop the heparin infusion immediately and notify the healthcare
provider.
D. Administer Vitamin K intramuscularly as prescribed.
EXPLANATION: The normal therapeutic range for aPTT while on
heparin therapy is typically 1.5 to 2.5 times the normal control value
, (about 45 to 70 seconds). An aPTT of 105 seconds indicates excessive
anticoagulation, placing the client at a critical risk for severe
hemorrhage. The infusion must be stopped immediately to protect
safety, and the provider must be notified. Vitamin K is the antidote for
warfarin, not heparin (protamine sulfate is the antidote for heparin).
Q2
A client with a history of severe cirrhosis is admitted with suspected
hepatic encephalopathy. Which laboratory result requires the most
immediate intervention by the nurse?
A. Serum albumin of 2.8 g/dL.
B. Serum ammonia of 135 mcg/dL.
C. Prothrombin time (PT) of 16 seconds.
D. Total bilirubin of 3.2 mg/dL.
EXPLANATION: Increased serum ammonia levels are directly
responsible for the neurotoxic manifestations of hepatic
encephalopathy, including confusion, asterixis, and progressive coma.
Lactulose is routinely given to lower this level. Elevated PT, low
albumin, and elevated bilirubin are expected baseline signs of chronic
liver failure but do not cause acute mental status changes as rapidly as
hyperammonemia.
, Q3
The nurse is caring for a pregnant client at 34 weeks' gestation who
presents with severe epigastric pain, a headache, and blurred vision. The
blood pressure is 172/114 mmHg. Which medication does the nurse
anticipate administering first?
A. Oxytocin.
B. Magnesium sulfate.
C. Terbutaline.
D. Methylergonovine.
EXPLANATION: The client is exhibiting signs of severe preeclampsia,
including severe hypertension, neurological symptoms (headache,
blurred vision), and epigastric pain (suggesting liver involvement).
Magnesium sulfate is the drug of choice to prevent tonic-clonic seizures
(eclampsia). Oxytocin is used for induction, terbutaline is a tocolytic to
stop contractions, and methylergonovine is oxytocic and
contraindicated in severe hypertension.
Q4
, A 4-year-old child with a known history of tetralogy of Fallot becomes
acutely agitated, cyanotic, and dyspneic while crying. Which position
should the nurse immediately place the child in?
A. High-Fowler's position with legs extended.
B. Prone position with the head turned to the side.
C. Knee-chest position.
D. Supine position with the feet elevated.
EXPLANATION: This child is experiencing a hypercyanotic spell ("tet
spell"). Placing the child in a knee-chest position increases systemic
vascular resistance, which forces more blood out of the right ventricle
into the pulmonary artery rather than through the ventricular septal
defect, improving systemic oxygenation.
Q5
A client with an acute exacerbation of bipolar I disorder is pacing back
and forth in the dayroom, yelling loudly at other clients, and refusing to
sit down for meals. Which nursing intervention is most appropriate?
A. Restrict the client to their bedroom until behavior improves.
B. Provide portable, high-calorie finger foods and juices.
C. Schedule the client for an immediate group therapy session.
D. Administer a sedative and place the client in mechanical restraints.
