HESI 5 Comprehensive Exam 2026/2027 |
HESI / Elsevier | Nursing Test Bank |
Management of Care, Safety, Pharmacology,
Clinical Judgment | Q&A with Answers &
Rationales
1. A nurse is caring for four clients. Which client should the nurse assess first?
A. Client with COPD requesting a breathing treatment
B. Client 2 days post-op with sudden calf pain and shortness of breath
C. Client requesting pain medication for a headache
D. Client awaiting discharge instructions
Answer: B
Rationale: Sudden calf pain with SOB suggests DVT/PE — a life-threatening
emergency. ABCs and acute/unstable status take priority over comfort or routine
needs.
2. Which task is appropriate for the RN to delegate to a UAP?
A. Administering oral medications
B. Evaluating a client's response to pain medication
C. Obtaining vital signs on a stable client
D. Teaching a client about a new diet
Answer: C
Rationale: UAPs may perform routine, stable tasks like vital signs. Medication
administration, evaluation, and teaching require an RN (or LPN for some meds,
per state scope).
3. A client on heparin has a PTT of 95 seconds. Which action is priority?
A. Continue the infusion
B. Hold heparin and prepare protamine sulfate
C. Administer vitamin K
D. Increase the infusion rate
Answer: B
Rationale: Therapeutic PTT is roughly 1.5–2.5× control (~60–80 sec). 95 sec is
,supratherapeutic; hold and be ready to reverse with protamine sulfate. Vitamin K
reverses warfarin, not heparin.
4. Which client requires airborne precautions?
A. Influenza
B. MRSA
C. Active pulmonary tuberculosis
D. C. difficile
Answer: C
Rationale: TB requires airborne precautions (N95, negative-pressure room). Flu =
droplet; MRSA and C. diff = contact.
5. A nurse is teaching a client about warfarin. Which statement indicates correct
understanding?
A. "I should increase my vitamin K intake."
B. "I will use a soft toothbrush and electric razor."
C. "I can take aspirin for headaches."
D. "I will double my dose if I miss one."
Answer: B
Rationale: Bleeding precautions are essential. Vitamin K intake should be
consistent, not increased; aspirin increases bleeding risk; doses are never
doubled.
6. Which finding is the priority concern for a client receiving digoxin?
A. Heart rate of 58 bpm
B. Nausea and visual halos
C. Blood pressure 118/76
D. Mild ankle edema
Answer: B
Rationale: Nausea and visual disturbances (yellow/green halos) are signs of
digoxin toxicity. Hold and notify the provider; check the digoxin level.
7. A client with a new colostomy is being taught. Which statement shows need
for further teaching?
A. "I will empty the pouch when it is 1/3 full."
B. "I will use a skin barrier around the stoma."
C. "I should avoid all high-fiber foods forever."
, D. "I will clean the skin with warm water."
Answer: C
Rationale: Most foods can eventually be reintroduced; only gas/odor-producing
foods may need moderation. Avoidance "forever" is incorrect.
8. Which client is at greatest risk for falls?
A. Client on bed rest
B. Client taking furosemide and oxycodone
C. Client with a casted arm
D. Client 1 day post-appendectomy
Answer: B
Rationale: Diuretics (urinary urgency) plus opioids (sedation, dizziness) greatly
increase fall risk.
9. A nurse receives an order for potassium IV push. What should the nurse do?
A. Administer as ordered
B. Clarify the order — potassium is never given IV push
C. Dilute and give slowly
D. Give IM instead
Answer: B
Rationale: IV push potassium can cause fatal cardiac arrest. It must be diluted and
infused via pump at a controlled rate.
10. Which action best prevents central line–associated bloodstream infection
(CLABSI)?
A. Changing the dressing daily
B. Scrubbing the hub before accessing
C. Flushing with sterile water
D. Using clean gloves for dressing changes
Answer: B
Rationale: Scrub-the-hub (disinfecting the access port) is a key CLABSI prevention
measure. Dressings are changed per protocol (not daily), and sterile gloves are
used.
11. A client is prescribed lithium. Which finding requires immediate follow-up?
A. Lithium level 0.8 mEq/L
B. Mild hand tremor
HESI / Elsevier | Nursing Test Bank |
Management of Care, Safety, Pharmacology,
Clinical Judgment | Q&A with Answers &
Rationales
1. A nurse is caring for four clients. Which client should the nurse assess first?
A. Client with COPD requesting a breathing treatment
B. Client 2 days post-op with sudden calf pain and shortness of breath
C. Client requesting pain medication for a headache
D. Client awaiting discharge instructions
Answer: B
Rationale: Sudden calf pain with SOB suggests DVT/PE — a life-threatening
emergency. ABCs and acute/unstable status take priority over comfort or routine
needs.
2. Which task is appropriate for the RN to delegate to a UAP?
A. Administering oral medications
B. Evaluating a client's response to pain medication
C. Obtaining vital signs on a stable client
D. Teaching a client about a new diet
Answer: C
Rationale: UAPs may perform routine, stable tasks like vital signs. Medication
administration, evaluation, and teaching require an RN (or LPN for some meds,
per state scope).
3. A client on heparin has a PTT of 95 seconds. Which action is priority?
A. Continue the infusion
B. Hold heparin and prepare protamine sulfate
C. Administer vitamin K
D. Increase the infusion rate
Answer: B
Rationale: Therapeutic PTT is roughly 1.5–2.5× control (~60–80 sec). 95 sec is
,supratherapeutic; hold and be ready to reverse with protamine sulfate. Vitamin K
reverses warfarin, not heparin.
4. Which client requires airborne precautions?
A. Influenza
B. MRSA
C. Active pulmonary tuberculosis
D. C. difficile
Answer: C
Rationale: TB requires airborne precautions (N95, negative-pressure room). Flu =
droplet; MRSA and C. diff = contact.
5. A nurse is teaching a client about warfarin. Which statement indicates correct
understanding?
A. "I should increase my vitamin K intake."
B. "I will use a soft toothbrush and electric razor."
C. "I can take aspirin for headaches."
D. "I will double my dose if I miss one."
Answer: B
Rationale: Bleeding precautions are essential. Vitamin K intake should be
consistent, not increased; aspirin increases bleeding risk; doses are never
doubled.
6. Which finding is the priority concern for a client receiving digoxin?
A. Heart rate of 58 bpm
B. Nausea and visual halos
C. Blood pressure 118/76
D. Mild ankle edema
Answer: B
Rationale: Nausea and visual disturbances (yellow/green halos) are signs of
digoxin toxicity. Hold and notify the provider; check the digoxin level.
7. A client with a new colostomy is being taught. Which statement shows need
for further teaching?
A. "I will empty the pouch when it is 1/3 full."
B. "I will use a skin barrier around the stoma."
C. "I should avoid all high-fiber foods forever."
, D. "I will clean the skin with warm water."
Answer: C
Rationale: Most foods can eventually be reintroduced; only gas/odor-producing
foods may need moderation. Avoidance "forever" is incorrect.
8. Which client is at greatest risk for falls?
A. Client on bed rest
B. Client taking furosemide and oxycodone
C. Client with a casted arm
D. Client 1 day post-appendectomy
Answer: B
Rationale: Diuretics (urinary urgency) plus opioids (sedation, dizziness) greatly
increase fall risk.
9. A nurse receives an order for potassium IV push. What should the nurse do?
A. Administer as ordered
B. Clarify the order — potassium is never given IV push
C. Dilute and give slowly
D. Give IM instead
Answer: B
Rationale: IV push potassium can cause fatal cardiac arrest. It must be diluted and
infused via pump at a controlled rate.
10. Which action best prevents central line–associated bloodstream infection
(CLABSI)?
A. Changing the dressing daily
B. Scrubbing the hub before accessing
C. Flushing with sterile water
D. Using clean gloves for dressing changes
Answer: B
Rationale: Scrub-the-hub (disinfecting the access port) is a key CLABSI prevention
measure. Dressings are changed per protocol (not daily), and sterile gloves are
used.
11. A client is prescribed lithium. Which finding requires immediate follow-up?
A. Lithium level 0.8 mEq/L
B. Mild hand tremor
