HESI with Rationales
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 the medication?` - ANS C.
Hypertension.
The nurse has completed the diet teaching of a male client who is being discharged following treatment
of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the
client indicates that the teaching was effective? ` - ANS B. A tunafish sandwich with chips and ice cream.
The nurse discontinues a continuous IV heparin infusion for a male client on strict bed rest, and is now
preparing to administer the client's first dose of in enoxaparin (Lovenox). Prior to giving this
subcutaneous injection, which assessment finding requires additional intervention by the nurse?` - ANS
C. The client states that his right calf is aching, and wants pain medication.
While the nurse is providing morning care for a client with chronic obstructive pulmonary disease
(COPD), the client becomes very dyspneic and starts to panic. What action should the nurse implement
first? ` - ANS Answer
D. Assist the client to an upright position.
Rationale
A female client's estranged husband arrives at the hospital and demands that his wife have no other
visitors. The client becomes angry and insists that the estranged husband be barred from visiting her.
Which intervention should the nurse implement?` - ANS Answer
B. Request a multidisciplinary care conference to discuss husband's demands.
Rationale
,The nurse working in a critical care unit is assigned the care of two clients, one with pneumonia who is
being mechanically ventilated and the other who had a thoracotomy yesterday and is complaining of
incisional pain. What should the nurse to first? ` - ANS Answer
A. Assess the level of consciousness and vital signs for both clients.
Rationale
A woman at 24 weeks gestation who has fever, bodyaches, and has been coughing for the last 5 days is
sent to the hospital with admission prescriptions for H1N1 influenza. Which prescription has the highest
priority?` - ANS Answer
C. Assign private room.
Rationale
A client who received partial thickness (second degree) burns over the anterior surfaces of both arms,
legs, and chest in a burning vehicle collision receives a prescription for daily dressing changes and
therapeutic baths. The nurse determines that a hoist is required to move the immobile client from a
stretcher into the therapeutic bath. Which intervention should the nurse implement first?` - ANS
Answer
B. Explain the procedure to the client.
Rationale
A client develops urticaria on the trunk and neck shortly after a secondary infusion of piperacillin is
initiated. In what order should the nurse implement these interventions? (Arrange the actions in order
of priority, with the highest priority first and least priority last or at the bottom.)` - ANS Answer
1. Stop the infusion.
2. Assess vital signs.
3. Contact the healthcare provider.
,4. Document reaction to the drug.
5. Initiate adverse event report.
Rationale
The nurse is conducting intake interviews of children at a city clinic. Which child is most susceptible to
contracting lead poisoning? ` - ANS Answer
D. A 2-year-old who plays on aging outdoor playground equipment.
Rationale
While changing a client's postoperative dressing, the nurse observes a red and swollen wound with a
moderate amount of yellow and green drainage and a foul odor. Given there is a positive methicillin-
resistant Staphylococcus aureus (MRSA), which is the most important action for the nurse to take?` -
ANS Answer
C. Administer prescribed antibiotics.
Rationale
An older male adult resident of a long-term care facility is hospitalized for a cardiac catheterization that
occurred yesterday. Since the procedure was conducted, the client has become increasingly disoriented.
The night shift nurse reports that he attempted to remove the sandbag from his femoral artery multiple
times during the night. What actions should the nurse take? (Select all that apply.)` - ANS Answer
B. Notify the healthcare provider of the client's change in mental status.
C. Include q2 hour reorientation in the client's plan of care.
Rationale
, In determining the one minute Apgar score of a male infant, the nurse assesses a heart rate of 120 beats
per minute and 44 respirations per minute. He has flaccid muscle tone with slight flexion and slight
resistance to straightening. He has a loud cry with stimulation, and his color is acrocyanotic. What is the
correct Apgar score for this infant? ` - ANS Answer
B. 8.
Rationale
A client who had a right total knee replacement two days ago is progressed to a soft diet. Which food
selections should the nurse recommend to this client? (Select all that apply.)` - ANS Answer
A. Pasta with a cream sauce.
B. Pancakes with syrup.
C. Scrambled eggs and potatoes.
D. Steamed rice and cooked squash.
Rationale
While administering a continuous insulin infusion to a client with diabetic ketoacidosis, it is essential for
the nurse to monitor which serum lab value?` - ANS Answer
D. Potassium.
Rationale
While caring for a client with a cervical spine injury, which assessment finding should the nurse report to
the healthcare provider immediately?` - ANS Answer
B. Respiratory rate 6 breaths/minute.
Rationale
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 the medication?` - ANS C.
Hypertension.
The nurse has completed the diet teaching of a male client who is being discharged following treatment
of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the
client indicates that the teaching was effective? ` - ANS B. A tunafish sandwich with chips and ice cream.
The nurse discontinues a continuous IV heparin infusion for a male client on strict bed rest, and is now
preparing to administer the client's first dose of in enoxaparin (Lovenox). Prior to giving this
subcutaneous injection, which assessment finding requires additional intervention by the nurse?` - ANS
C. The client states that his right calf is aching, and wants pain medication.
While the nurse is providing morning care for a client with chronic obstructive pulmonary disease
(COPD), the client becomes very dyspneic and starts to panic. What action should the nurse implement
first? ` - ANS Answer
D. Assist the client to an upright position.
Rationale
A female client's estranged husband arrives at the hospital and demands that his wife have no other
visitors. The client becomes angry and insists that the estranged husband be barred from visiting her.
Which intervention should the nurse implement?` - ANS Answer
B. Request a multidisciplinary care conference to discuss husband's demands.
Rationale
,The nurse working in a critical care unit is assigned the care of two clients, one with pneumonia who is
being mechanically ventilated and the other who had a thoracotomy yesterday and is complaining of
incisional pain. What should the nurse to first? ` - ANS Answer
A. Assess the level of consciousness and vital signs for both clients.
Rationale
A woman at 24 weeks gestation who has fever, bodyaches, and has been coughing for the last 5 days is
sent to the hospital with admission prescriptions for H1N1 influenza. Which prescription has the highest
priority?` - ANS Answer
C. Assign private room.
Rationale
A client who received partial thickness (second degree) burns over the anterior surfaces of both arms,
legs, and chest in a burning vehicle collision receives a prescription for daily dressing changes and
therapeutic baths. The nurse determines that a hoist is required to move the immobile client from a
stretcher into the therapeutic bath. Which intervention should the nurse implement first?` - ANS
Answer
B. Explain the procedure to the client.
Rationale
A client develops urticaria on the trunk and neck shortly after a secondary infusion of piperacillin is
initiated. In what order should the nurse implement these interventions? (Arrange the actions in order
of priority, with the highest priority first and least priority last or at the bottom.)` - ANS Answer
1. Stop the infusion.
2. Assess vital signs.
3. Contact the healthcare provider.
,4. Document reaction to the drug.
5. Initiate adverse event report.
Rationale
The nurse is conducting intake interviews of children at a city clinic. Which child is most susceptible to
contracting lead poisoning? ` - ANS Answer
D. A 2-year-old who plays on aging outdoor playground equipment.
Rationale
While changing a client's postoperative dressing, the nurse observes a red and swollen wound with a
moderate amount of yellow and green drainage and a foul odor. Given there is a positive methicillin-
resistant Staphylococcus aureus (MRSA), which is the most important action for the nurse to take?` -
ANS Answer
C. Administer prescribed antibiotics.
Rationale
An older male adult resident of a long-term care facility is hospitalized for a cardiac catheterization that
occurred yesterday. Since the procedure was conducted, the client has become increasingly disoriented.
The night shift nurse reports that he attempted to remove the sandbag from his femoral artery multiple
times during the night. What actions should the nurse take? (Select all that apply.)` - ANS Answer
B. Notify the healthcare provider of the client's change in mental status.
C. Include q2 hour reorientation in the client's plan of care.
Rationale
, In determining the one minute Apgar score of a male infant, the nurse assesses a heart rate of 120 beats
per minute and 44 respirations per minute. He has flaccid muscle tone with slight flexion and slight
resistance to straightening. He has a loud cry with stimulation, and his color is acrocyanotic. What is the
correct Apgar score for this infant? ` - ANS Answer
B. 8.
Rationale
A client who had a right total knee replacement two days ago is progressed to a soft diet. Which food
selections should the nurse recommend to this client? (Select all that apply.)` - ANS Answer
A. Pasta with a cream sauce.
B. Pancakes with syrup.
C. Scrambled eggs and potatoes.
D. Steamed rice and cooked squash.
Rationale
While administering a continuous insulin infusion to a client with diabetic ketoacidosis, it is essential for
the nurse to monitor which serum lab value?` - ANS Answer
D. Potassium.
Rationale
While caring for a client with a cervical spine injury, which assessment finding should the nurse report to
the healthcare provider immediately?` - ANS Answer
B. Respiratory rate 6 breaths/minute.
Rationale
