HESI RN CLINICAL JUDGMENT ACCURATE
COMPREHENSIVE PRACTICE EXAM WITH ALL
POSSIBLE APPROVED WELL ELABORATED
PRACTICE QUESTIONS AND 100% CORRECT
VERIFIED ANSWERS WITH DETAILED RATIONALES
PLUS EXPERT ANSWER KEY (100% CORRECT
VERIFIED SOLUTIONS) 2026-2027 CURRENTLY
UPDATED VERSION Q&A GUARANTEED PASS A+
INSTANT DOWNLOAD PDF
1. The nurse is caring for a client who suddenly develops chest pain,
diaphoresis, and shortness of breath. Which action should the nurse take
first?
A. Obtain a 12-lead electrocardiogram
B. Administer sublingual nitroglycerin
C. Notify the healthcare provider
D. Initiate continuous cardiac monitoring
A
Assessing cardiac electrical activity is the priority to determine if
myocardial ischemia or infarction is present before administering
medications or notifying the provider.
2. A client with heart failure has gained 3 pounds overnight and reports
feeling more short of breath. Which assessment finding requires immediate
intervention?
, A. Heart rate 92 beats per minute
B. Crackles in bilateral lung bases
C. Ankle edema of 1+
D. Urine output of 50 mL in the past 2 hours
B
New crackles indicate pulmonary edema and worsening heart failure,
requiring prompt intervention to improve oxygenation and reduce fluid
overload.
3. The nurse is reviewing morning laboratory results for a client with type 1
diabetes. Which value should the nurse address first?
A. Fasting blood glucose of 140 mg/dL
B. Serum potassium of 3.1 mEq/L
C. Hemoglobin A1c of 7.2 percent
D. Urine ketones negative
B
Hypokalemia can lead to life-threatening cardiac dysrhythmias and must
be corrected immediately; blood glucose and A1c require attention but
are less urgent.
4. A client receiving a blood transfusion reports chills and lower back pain.
What should the nurse do first?
A. Slow the transfusion rate
B. Stop the transfusion
C. Administer acetaminophen
D. Notify the blood bank
B
Chills and lower back pain indicate a possible hemolytic transfusion
reaction; the transfusion must be stopped immediately to prevent further
complications.
5. The nurse is assigned to care for four clients. Which client should the nurse
assess first?
A. A client with pneumonia who has an oxygen saturation of 94 percent
B. A client with cirrhosis who has a distended abdomen
C. A client with chronic kidney disease whose serum potassium is 6.2 mEq/L
, D. A client with diabetic ketoacidosis whose urine output is 60 mL per hour
C
A serum potassium of 6.2 mEq/L places the client at high risk for fatal
cardiac dysrhythmias and requires immediate evaluation and
intervention.
6. A client with a history of asthma presents with wheezing and a respiratory
rate of 28 breaths per minute. Which finding indicates the client’s condition
is worsening?
A. Oxygen saturation of 92 percent
B. Diminished breath sounds bilaterally
C. Increased use of accessory muscles
D. Peak expiratory flow rate of 70 percent of personal best
B
Diminished breath sounds in an asthmatic client may indicate severe
airway obstruction and impending respiratory failure, a more critical sign
than wheezing.
7. The nurse is teaching a client about warfarin therapy. Which statement by
the client indicates correct understanding?
A. I will increase my intake of green leafy vegetables
B. I should use an electric razor for shaving
C. I will take aspirin for headaches while on this medication
D. I can stop taking the medication if I have no symptoms
B
Using an electric razor reduces the risk of bleeding from cuts, which is
important for clients on anticoagulant therapy.
8. A postoperative client has a blood pressure of 88/52 mm Hg, heart rate of
118 beats per minute, and urine output of 20 mL over the past hour. Which
condition do these findings most likely indicate?
A. Fluid volume excess
B. Hypovolemic shock
C. Septic shock
D. Cardiogenic shock
B
, Hypotension, tachycardia, and decreased urine output are classic signs of
hypovolemic shock caused by inadequate circulating blood volume.
9. A client with major depressive disorder states, I have a plan to end my life.
Which is the nurse’s priority action?
A. Ask if the client has the means to carry out the plan
B. Place the client on one-to-one observation
C. Encourage the client to verbalize feelings
D. Document the statement in the medical record
B
Ensuring immediate safety through continuous observation is the priority
when a client expresses a suicidal plan.
10. The nurse is preparing to administer digoxin to a client. Which assessment
finding should prompt the nurse to withhold the dose and notify the
provider?
A. Apical pulse of 56 beats per minute
B. Serum potassium of 4.0 mEq/L
C. Digoxin level of 1.2 ng/mL
D. Blood pressure of 110/70 mm Hg
A
An apical pulse below 60 beats per minute may indicate digoxin toxicity or
excessive vagal effect, so the dose should be withheld.
11. A client with a head injury develops a dilated right pupil and becomes
increasingly lethargic. What is the priority nursing action?
A. Administer prescribed pain medication
B. Notify the healthcare provider immediately
C. Perform a full neurological assessment
D. Reassess the client in 15 minutes
B
A dilated pupil with declining level of consciousness indicates increasing
intracranial pressure and possible herniation, requiring immediate
provider notification.
12. The nurse observes a client receiving continuous enteral feedings has a
residual volume of 250 mL. What should the nurse do first?
COMPREHENSIVE PRACTICE EXAM WITH ALL
POSSIBLE APPROVED WELL ELABORATED
PRACTICE QUESTIONS AND 100% CORRECT
VERIFIED ANSWERS WITH DETAILED RATIONALES
PLUS EXPERT ANSWER KEY (100% CORRECT
VERIFIED SOLUTIONS) 2026-2027 CURRENTLY
UPDATED VERSION Q&A GUARANTEED PASS A+
INSTANT DOWNLOAD PDF
1. The nurse is caring for a client who suddenly develops chest pain,
diaphoresis, and shortness of breath. Which action should the nurse take
first?
A. Obtain a 12-lead electrocardiogram
B. Administer sublingual nitroglycerin
C. Notify the healthcare provider
D. Initiate continuous cardiac monitoring
A
Assessing cardiac electrical activity is the priority to determine if
myocardial ischemia or infarction is present before administering
medications or notifying the provider.
2. A client with heart failure has gained 3 pounds overnight and reports
feeling more short of breath. Which assessment finding requires immediate
intervention?
, A. Heart rate 92 beats per minute
B. Crackles in bilateral lung bases
C. Ankle edema of 1+
D. Urine output of 50 mL in the past 2 hours
B
New crackles indicate pulmonary edema and worsening heart failure,
requiring prompt intervention to improve oxygenation and reduce fluid
overload.
3. The nurse is reviewing morning laboratory results for a client with type 1
diabetes. Which value should the nurse address first?
A. Fasting blood glucose of 140 mg/dL
B. Serum potassium of 3.1 mEq/L
C. Hemoglobin A1c of 7.2 percent
D. Urine ketones negative
B
Hypokalemia can lead to life-threatening cardiac dysrhythmias and must
be corrected immediately; blood glucose and A1c require attention but
are less urgent.
4. A client receiving a blood transfusion reports chills and lower back pain.
What should the nurse do first?
A. Slow the transfusion rate
B. Stop the transfusion
C. Administer acetaminophen
D. Notify the blood bank
B
Chills and lower back pain indicate a possible hemolytic transfusion
reaction; the transfusion must be stopped immediately to prevent further
complications.
5. The nurse is assigned to care for four clients. Which client should the nurse
assess first?
A. A client with pneumonia who has an oxygen saturation of 94 percent
B. A client with cirrhosis who has a distended abdomen
C. A client with chronic kidney disease whose serum potassium is 6.2 mEq/L
, D. A client with diabetic ketoacidosis whose urine output is 60 mL per hour
C
A serum potassium of 6.2 mEq/L places the client at high risk for fatal
cardiac dysrhythmias and requires immediate evaluation and
intervention.
6. A client with a history of asthma presents with wheezing and a respiratory
rate of 28 breaths per minute. Which finding indicates the client’s condition
is worsening?
A. Oxygen saturation of 92 percent
B. Diminished breath sounds bilaterally
C. Increased use of accessory muscles
D. Peak expiratory flow rate of 70 percent of personal best
B
Diminished breath sounds in an asthmatic client may indicate severe
airway obstruction and impending respiratory failure, a more critical sign
than wheezing.
7. The nurse is teaching a client about warfarin therapy. Which statement by
the client indicates correct understanding?
A. I will increase my intake of green leafy vegetables
B. I should use an electric razor for shaving
C. I will take aspirin for headaches while on this medication
D. I can stop taking the medication if I have no symptoms
B
Using an electric razor reduces the risk of bleeding from cuts, which is
important for clients on anticoagulant therapy.
8. A postoperative client has a blood pressure of 88/52 mm Hg, heart rate of
118 beats per minute, and urine output of 20 mL over the past hour. Which
condition do these findings most likely indicate?
A. Fluid volume excess
B. Hypovolemic shock
C. Septic shock
D. Cardiogenic shock
B
, Hypotension, tachycardia, and decreased urine output are classic signs of
hypovolemic shock caused by inadequate circulating blood volume.
9. A client with major depressive disorder states, I have a plan to end my life.
Which is the nurse’s priority action?
A. Ask if the client has the means to carry out the plan
B. Place the client on one-to-one observation
C. Encourage the client to verbalize feelings
D. Document the statement in the medical record
B
Ensuring immediate safety through continuous observation is the priority
when a client expresses a suicidal plan.
10. The nurse is preparing to administer digoxin to a client. Which assessment
finding should prompt the nurse to withhold the dose and notify the
provider?
A. Apical pulse of 56 beats per minute
B. Serum potassium of 4.0 mEq/L
C. Digoxin level of 1.2 ng/mL
D. Blood pressure of 110/70 mm Hg
A
An apical pulse below 60 beats per minute may indicate digoxin toxicity or
excessive vagal effect, so the dose should be withheld.
11. A client with a head injury develops a dilated right pupil and becomes
increasingly lethargic. What is the priority nursing action?
A. Administer prescribed pain medication
B. Notify the healthcare provider immediately
C. Perform a full neurological assessment
D. Reassess the client in 15 minutes
B
A dilated pupil with declining level of consciousness indicates increasing
intracranial pressure and possible herniation, requiring immediate
provider notification.
12. The nurse observes a client receiving continuous enteral feedings has a
residual volume of 250 mL. What should the nurse do first?
