Week 3 BSN 225 EAQ HESI Practice Test Assessment
Performance Review - Questions and Correct Answers with
Rationales/ BSN 225 HESI Practice Questions and Correct
Detailed Answers
This Week 3 EAQ HESI Practice Test assesses BSN students' clinical judgment, prioritization, and application of
nursing knowledge across the major HESI specialty exam domains. It integrates the NCSBN Clinical Judgment
Measurement Model with current 2025-2026 guidelines to prepare students for the rigor of the HESI exit and
NCLEX-RN. Emphasis is placed on analysis, evaluation, and synthesis of complex patient scenarios rather than
simple recall. It contains 50 multiple-choice questions, each with four distractors and a fully worked rationale
that explains why the keyed answer is correct. Questions are organized into clearly labelled sections that mirror
the major content areas of the course. Targeted learning outcomes include: Apply the NCSBN Clinical Judgment
Measurement Model to prioritize and manage care for patients with complex, multi-system health alterations.;
Analyze the pharmacological and pathophysiological rationale for nursing interventions, including safe
medication administration and monitoring for adverse effects.; Synthesize principles of safety, infection control,
and health promotion to design and evaluate care for diverse populations across the lifespan.. Every item has
been reviewed for clinical accuracy, current guidelines, and clarity so that students can study with confidence and
self-correct as they work through the bank. Use it as a high-yield review immediately before the exam, or as a
structured practice tool during the unit - the rationales double as concise teaching notes. The recommended
writing time is 2 hours, with a passing score of 75% (HESI Conversion Score 850 recommended for progression).
Section 1: General (Questions 1-50)
1 Which assessment finding requires immediate intervention for a patient receiving
intravenous heparin?
A) Platelet count of 110,000/mm³ with new bruising
B) Activated partial thromboplastin time (aPTT) of 60 seconds
C) Hemoglobin of 12.5 g/dL and hematocrit of 38%
D) Blood glucose of 140 mg/dL
Answer: A
Rationale: A falling platelet count with new bruising suggests heparin-induced
thrombocytopenia (HIT), a life-threatening immune reaction requiring immediate
heparin discontinuation. A therapeutic aPTT (60-80 sec) and normal
hemoglobin/glucose do not indicate immediate danger.
2 A patient with acute pancreatitis is prescribed enteral nutrition. Which
intervention is most appropriate before initiation?
A) Verify nasogastric tube placement by auscultating an air bolus.
B) Confirm tolerance by assessing for abdominal pain and distension.
C) Place the patient in high Fowler's position for feeding.
D) Check gastric residual volume every 4 hours.
,Answer: B
Rationale: Before initiating enteral nutrition in acute pancreatitis, assessing
abdominal pain, distension, and bowel sounds ensures tolerance and prevents
exacerbation. Auscultating an air bolus is unreliable for tube placement; high
Fowler's is not required for jejunal feeding; checking residual is not standard for
small bowel feeding.
3 Which laboratory result is most concerning for a patient taking spironolactone and
lisinopril?
A) Potassium 5.8 mEq/L
B) Sodium 134 mEq/L
C) Creatinine 1.1 mg/dL
D) Blood urea nitrogen 18 mg/dL
Answer: A
Rationale: Spironolactone (potassium-sparing diuretic) and lisinopril (ACE inhibitor)
both increase potassium; a level of 5.8 mEq/L indicates hyperkalemia, risking fatal
dysrhythmias. The other values are within normal or near-normal limits and not
immediately life-threatening.
4 A postpartum patient reports unilateral calf pain and swelling. Which action
should the nurse take first?
A) Apply warm compresses to the affected leg.
B) Massage the calf to relieve discomfort.
C) Perform a Doppler ultrasound immediately.
D) Administer prescribed anticoagulant therapy.
Answer: C
Rationale: Unilateral calf pain and swelling suggest deep vein thrombosis (DVT);
Doppler ultrasound is the priority diagnostic to confirm the diagnosis. Massaging or
applying heat could dislodge a thrombus, and anticoagulation should follow
confirmation, not precede it.
5 A child with sickle cell disease is admitted with vaso-occlusive crisis. Which
intervention is the priority?
A) Administer intravenous opioids for pain.
B) Initiate oxygen therapy at 2 L/min.
C) Encourage vigorous oral hydration.
D) Apply cold compresses to painful joints.
Answer: A
, Rationale: Pain management with IV opioids is the priority for vaso-occlusive crisis,
as severe pain is the hallmark. Oxygen is used only if hypoxic; hydration should be
cautious to avoid fluid overload; cold compresses can worsen sickling.
6 Which statement by a patient prescribed lithium indicates a need for further
teaching?
A) I will maintain a consistent sodium intake.
B) I will take the medication with food to avoid nausea.
C) I will stop the medication if I experience fine hand tremors.
D) I will drink 2 to 3 liters of fluid daily.
Answer: C
Rationale: Fine hand tremors are a common, expected side effect of lithium and do
not warrant stopping the medication; abrupt discontinuation can cause relapse.
Consistent sodium and fluid intake help maintain therapeutic lithium levels, and
taking with food reduces GI upset.
7 A community health nurse is planning a program to reduce obesity. Which
strategy best applies the ecological model?
A) Provide free gym memberships to individuals.
B) Offer nutrition education classes at a local clinic.
C) Implement a farmers' market incentive program with zoning changes.
D) Distribute pamphlets on healthy eating in schools.
Answer: C
Rationale: The ecological model targets multiple levels of influence; combining a
farmers' market incentive (community) with zoning changes (policy) addresses
environmental and systemic factors. Individual-level strategies (A, B, D) are less
effective for population-wide change.
8 During a shift, a nurse must delegate tasks. Which task is appropriate to delegate
to unlicensed assistive personnel (UAP)?
A) Administering oral pain medication to a stable patient.
B) Reinforcing teaching about a new medication.
C) Measuring and recording intake and output.
D) Assessing a patient's response to a blood transfusion.
Answer: C
Rationale: Measuring and recording intake and output is a routine, non-invasive task
within UAP scope. Medication administration, teaching, and assessment require a
licensed nurse's clinical judgment and are not delegable to UAP.
Performance Review - Questions and Correct Answers with
Rationales/ BSN 225 HESI Practice Questions and Correct
Detailed Answers
This Week 3 EAQ HESI Practice Test assesses BSN students' clinical judgment, prioritization, and application of
nursing knowledge across the major HESI specialty exam domains. It integrates the NCSBN Clinical Judgment
Measurement Model with current 2025-2026 guidelines to prepare students for the rigor of the HESI exit and
NCLEX-RN. Emphasis is placed on analysis, evaluation, and synthesis of complex patient scenarios rather than
simple recall. It contains 50 multiple-choice questions, each with four distractors and a fully worked rationale
that explains why the keyed answer is correct. Questions are organized into clearly labelled sections that mirror
the major content areas of the course. Targeted learning outcomes include: Apply the NCSBN Clinical Judgment
Measurement Model to prioritize and manage care for patients with complex, multi-system health alterations.;
Analyze the pharmacological and pathophysiological rationale for nursing interventions, including safe
medication administration and monitoring for adverse effects.; Synthesize principles of safety, infection control,
and health promotion to design and evaluate care for diverse populations across the lifespan.. Every item has
been reviewed for clinical accuracy, current guidelines, and clarity so that students can study with confidence and
self-correct as they work through the bank. Use it as a high-yield review immediately before the exam, or as a
structured practice tool during the unit - the rationales double as concise teaching notes. The recommended
writing time is 2 hours, with a passing score of 75% (HESI Conversion Score 850 recommended for progression).
Section 1: General (Questions 1-50)
1 Which assessment finding requires immediate intervention for a patient receiving
intravenous heparin?
A) Platelet count of 110,000/mm³ with new bruising
B) Activated partial thromboplastin time (aPTT) of 60 seconds
C) Hemoglobin of 12.5 g/dL and hematocrit of 38%
D) Blood glucose of 140 mg/dL
Answer: A
Rationale: A falling platelet count with new bruising suggests heparin-induced
thrombocytopenia (HIT), a life-threatening immune reaction requiring immediate
heparin discontinuation. A therapeutic aPTT (60-80 sec) and normal
hemoglobin/glucose do not indicate immediate danger.
2 A patient with acute pancreatitis is prescribed enteral nutrition. Which
intervention is most appropriate before initiation?
A) Verify nasogastric tube placement by auscultating an air bolus.
B) Confirm tolerance by assessing for abdominal pain and distension.
C) Place the patient in high Fowler's position for feeding.
D) Check gastric residual volume every 4 hours.
,Answer: B
Rationale: Before initiating enteral nutrition in acute pancreatitis, assessing
abdominal pain, distension, and bowel sounds ensures tolerance and prevents
exacerbation. Auscultating an air bolus is unreliable for tube placement; high
Fowler's is not required for jejunal feeding; checking residual is not standard for
small bowel feeding.
3 Which laboratory result is most concerning for a patient taking spironolactone and
lisinopril?
A) Potassium 5.8 mEq/L
B) Sodium 134 mEq/L
C) Creatinine 1.1 mg/dL
D) Blood urea nitrogen 18 mg/dL
Answer: A
Rationale: Spironolactone (potassium-sparing diuretic) and lisinopril (ACE inhibitor)
both increase potassium; a level of 5.8 mEq/L indicates hyperkalemia, risking fatal
dysrhythmias. The other values are within normal or near-normal limits and not
immediately life-threatening.
4 A postpartum patient reports unilateral calf pain and swelling. Which action
should the nurse take first?
A) Apply warm compresses to the affected leg.
B) Massage the calf to relieve discomfort.
C) Perform a Doppler ultrasound immediately.
D) Administer prescribed anticoagulant therapy.
Answer: C
Rationale: Unilateral calf pain and swelling suggest deep vein thrombosis (DVT);
Doppler ultrasound is the priority diagnostic to confirm the diagnosis. Massaging or
applying heat could dislodge a thrombus, and anticoagulation should follow
confirmation, not precede it.
5 A child with sickle cell disease is admitted with vaso-occlusive crisis. Which
intervention is the priority?
A) Administer intravenous opioids for pain.
B) Initiate oxygen therapy at 2 L/min.
C) Encourage vigorous oral hydration.
D) Apply cold compresses to painful joints.
Answer: A
, Rationale: Pain management with IV opioids is the priority for vaso-occlusive crisis,
as severe pain is the hallmark. Oxygen is used only if hypoxic; hydration should be
cautious to avoid fluid overload; cold compresses can worsen sickling.
6 Which statement by a patient prescribed lithium indicates a need for further
teaching?
A) I will maintain a consistent sodium intake.
B) I will take the medication with food to avoid nausea.
C) I will stop the medication if I experience fine hand tremors.
D) I will drink 2 to 3 liters of fluid daily.
Answer: C
Rationale: Fine hand tremors are a common, expected side effect of lithium and do
not warrant stopping the medication; abrupt discontinuation can cause relapse.
Consistent sodium and fluid intake help maintain therapeutic lithium levels, and
taking with food reduces GI upset.
7 A community health nurse is planning a program to reduce obesity. Which
strategy best applies the ecological model?
A) Provide free gym memberships to individuals.
B) Offer nutrition education classes at a local clinic.
C) Implement a farmers' market incentive program with zoning changes.
D) Distribute pamphlets on healthy eating in schools.
Answer: C
Rationale: The ecological model targets multiple levels of influence; combining a
farmers' market incentive (community) with zoning changes (policy) addresses
environmental and systemic factors. Individual-level strategies (A, B, D) are less
effective for population-wide change.
8 During a shift, a nurse must delegate tasks. Which task is appropriate to delegate
to unlicensed assistive personnel (UAP)?
A) Administering oral pain medication to a stable patient.
B) Reinforcing teaching about a new medication.
C) Measuring and recording intake and output.
D) Assessing a patient's response to a blood transfusion.
Answer: C
Rationale: Measuring and recording intake and output is a routine, non-invasive task
within UAP scope. Medication administration, teaching, and assessment require a
licensed nurse's clinical judgment and are not delegable to UAP.
