Naxlex HESI Review Questions & Answers
(2025) | Complete Exam Prep with Verified
Solutions
1 of 50
Term
The nurse is assessing an unresponsive client with no pulses. An image
of the client's EKG reading is included. After activating the emergency
response system and initiating CPR, what action should the nurse take
first?
A. Place a laryngeal mask airway (LMA).
B.Administer 1 mg epinephrine intravenously.
C. Administer 300 mg amiodarone
intravenously.
, D.Place defibrillator pads and defibrillate at
150 Joules.
Give this one a go later!
B
Rationale: When obtaining the blood pressure in the lower extremities, the popliteal pulse is the
site for auscultation when the blood pressure cuff is applied around the thigh.
The nurse should intervene with the UAP who has applied the cuff on the lower leg.
D
Rationale: The client’s symptoms of confusion, lethargy, and excessive thirst (polydipsia)
after receiving a large volume of intravenous fluids suggest a possible electrolyte
imbalance, particularly hyponatremia or hypernatremia.
Measure orthostatic vital signs: This assesses for volume depletion or postural hypotension but
does not address the likely cause of this client's symptoms, which are more consistent with
an electrolyte imbalance rather than hypovolemia.
D
Rationale: Pulseless VT is a "shockable" rhythm and defibrillation is the next step in the
cardiac arrest algorithm. The nurse has already activated the emergency response
system and started providing high quality CPR, so the next step is to defibrillate the
client to "restart" the heart and resume a normal cardiac rhythm.
D
Rationale: This is the correct instruction. The preferred injection site for LMWH is the lower
abdomen, avoiding the area around the umbilicus and scar tissue. This ensures effective
absorption and minimizes the risk of complications. The injection should be at least 2 inches
away from the umbilicus to avoid irritation or injury to surrounding tissues.
,
2 of 50
Term
The healthcare provider prescribes nasogastric tube (NGT) insertion for a
client with a postoperative ileus. During insertion, the client begins to gag.
Which action should the nurse take?
A. Use firm pressure to pass the tube through the glottis.
B.Have the client tilt head backward to open the passage.
C. Give the client a few sips of water to drink.
D.Remove the tube and attempt reinsertion.
Give this one a go later!
D
Rationale: Removing the tube and attempting reinsertion is the appropriate action if
the client begins to gag. It allows the nurse to reposition the tube and attempt
insertion more gently, ensuring the tube is correctly placed without causing undue
discomfort or harm.
, B
Rationale: In a proximal small bowel obstruction, the client often experiences vomiting and
loss of gastric contents, which are rich in electrolytes, especially potassium and hydrogen
ions. This leads to:
Hypokalemia: Due to excessive loss of potassium in vomit.
A
Rationale: If the suctioning is progressing without further compromise of oxygenation,
and the oxygen saturation is within an acceptable range, continuing the procedure is
reasonable. However, continued monitoring of oxygen saturation is important.
B
Rationale: Hyperkalemia directly affects the heart and can lead to dangerous
arrhythmias, such as ventricular fibrillation or asystole. Assessing the apical pulse and rhythm
is crucial to identify irregularities early.
3 of 50
Term
The nurse observes a UAP taking a client's blood pressure in the lower
extremity. Which observation of this procedure requires the nurse to
intervene with the UAP's approach?
A. The cuff wraps around the girth of the leg.
B. The UAP auscultates the popliteal pulse with the cuff on the lower leg
C. The client is placed in a prone position.
(2025) | Complete Exam Prep with Verified
Solutions
1 of 50
Term
The nurse is assessing an unresponsive client with no pulses. An image
of the client's EKG reading is included. After activating the emergency
response system and initiating CPR, what action should the nurse take
first?
A. Place a laryngeal mask airway (LMA).
B.Administer 1 mg epinephrine intravenously.
C. Administer 300 mg amiodarone
intravenously.
, D.Place defibrillator pads and defibrillate at
150 Joules.
Give this one a go later!
B
Rationale: When obtaining the blood pressure in the lower extremities, the popliteal pulse is the
site for auscultation when the blood pressure cuff is applied around the thigh.
The nurse should intervene with the UAP who has applied the cuff on the lower leg.
D
Rationale: The client’s symptoms of confusion, lethargy, and excessive thirst (polydipsia)
after receiving a large volume of intravenous fluids suggest a possible electrolyte
imbalance, particularly hyponatremia or hypernatremia.
Measure orthostatic vital signs: This assesses for volume depletion or postural hypotension but
does not address the likely cause of this client's symptoms, which are more consistent with
an electrolyte imbalance rather than hypovolemia.
D
Rationale: Pulseless VT is a "shockable" rhythm and defibrillation is the next step in the
cardiac arrest algorithm. The nurse has already activated the emergency response
system and started providing high quality CPR, so the next step is to defibrillate the
client to "restart" the heart and resume a normal cardiac rhythm.
D
Rationale: This is the correct instruction. The preferred injection site for LMWH is the lower
abdomen, avoiding the area around the umbilicus and scar tissue. This ensures effective
absorption and minimizes the risk of complications. The injection should be at least 2 inches
away from the umbilicus to avoid irritation or injury to surrounding tissues.
,
2 of 50
Term
The healthcare provider prescribes nasogastric tube (NGT) insertion for a
client with a postoperative ileus. During insertion, the client begins to gag.
Which action should the nurse take?
A. Use firm pressure to pass the tube through the glottis.
B.Have the client tilt head backward to open the passage.
C. Give the client a few sips of water to drink.
D.Remove the tube and attempt reinsertion.
Give this one a go later!
D
Rationale: Removing the tube and attempting reinsertion is the appropriate action if
the client begins to gag. It allows the nurse to reposition the tube and attempt
insertion more gently, ensuring the tube is correctly placed without causing undue
discomfort or harm.
, B
Rationale: In a proximal small bowel obstruction, the client often experiences vomiting and
loss of gastric contents, which are rich in electrolytes, especially potassium and hydrogen
ions. This leads to:
Hypokalemia: Due to excessive loss of potassium in vomit.
A
Rationale: If the suctioning is progressing without further compromise of oxygenation,
and the oxygen saturation is within an acceptable range, continuing the procedure is
reasonable. However, continued monitoring of oxygen saturation is important.
B
Rationale: Hyperkalemia directly affects the heart and can lead to dangerous
arrhythmias, such as ventricular fibrillation or asystole. Assessing the apical pulse and rhythm
is crucial to identify irregularities early.
3 of 50
Term
The nurse observes a UAP taking a client's blood pressure in the lower
extremity. Which observation of this procedure requires the nurse to
intervene with the UAP's approach?
A. The cuff wraps around the girth of the leg.
B. The UAP auscultates the popliteal pulse with the cuff on the lower leg
C. The client is placed in a prone position.
