HESI NCLEX PN Review Rated A+ 2025

1) The nurse reinforces home care instructions to the parents of a child hospitalized with pertussis. The child is in the convalescent stage and is being prepared for discharge. Which statement by the parents indicates a need for further teaching? 1. "We need to encourage adequate fluid intake." 2. "Coughing spells may be triggered by dust or smoke." 3. "We need to maintain respiratory precautions and a quiet environment for at least 2 weeks." 4. "Good hand-washing techniques need to be instituted to prevent spreading the disease to others." 2) A client enters the emergency department confused, twitching, and having seizures. His family states he recently was placed on corticosteroids for arthritis and was feeling better and exercising daily. Upon assessment, he has flushed skin, dry mucous membranes, an elevated temperature, and poor skin turgor. His serum sodium level is 172 mEq/L. Which interventions would the health care provider likely prescribe? Select all that apply. 1. Monitor the vital signs. 2. Monitor intake and output. 3. Increase water intake orally. 4. Monitor the electrolyte levels. 5. Provide a sodium-reduced diet. 6. Administer sodium replacements. 3) The nurse is monitoring a client receiving glipizide (Glucotrol). Which outcome indicates an ineffective response from the medication? 1. A decrease in polyuria 2. A decrease in polyphagia 3. A fasting plasma glucose of 100 mg/dL 4. A glycosylated hemoglobin level of 12% 4) The nurse is reinforcing discharge instructions to a client receiving sulfisoxazole. Which should be included in the plan of care for instructions? 1. Maintain a high fluid intake. 2. Discontinue the medication when feeling better. 3. If the urine turns dark brown, call the health care provider immediately. 4. Decrease the dosage when symptoms are improving to prevent an allergic response. 5) Before administering an intermittent tube feeding through a nasogastric tube, the nurse checks for gastric residual volume. Which is the best rationale for checking gastric residual volume before administering the tube feeding? 1. Observe the digestion of formula. 2. Check fluid and electrolyte status. 3. Evaluate absorption of the last feeding. 4. Confirm proper nasogastric tube placement. 6) A postoperative client requests medication for flatulence (gas pains). Which medication from the following PRN list should the nurse administer to this client? 1. Ondansetron (Zofran) 2. Simethicone (Mylicon) 3. Acetaminophen (Tylenol) 4. Magnesium hydroxide (milk of magnesia, MOM) 7) A client is admitted to the hospital with a diagnosis of major depression. During the admission interview, the nurse determines that a major concern is the client's altered nutrition related to poor nutritional intake. Which nursing intervention related to altered nutrition should be the initial choice? 1. Weigh the client three times per week, before breakfast. 2. Explain to the client the importance of a good nutritional intake. 3. Report the nutritional concern to the psychiatrist and obtain a nutritional consult as soon as possible. 4. Offer the client several small, frequent meals daily, and schedule brief nursing interactions with the client during these times. 8) A client received 20 units of NPH insulin subcutaneously at 8:00 am. The nurse should check the client for a potential hypoglycemic reaction at which time? 1. 5:00 pm 2. 10:00 am 3. 11:00 am 4. 11:00 pm 9) An emergency department nurse is caring for an older client who may have been physically abused by her caregiver. In planning care for the client, the nurse makes a priority of: A) Notifying the police department B) Obtaining psychiatric help for the caregiver C) Contacting adult protective services to investigate the situation D) Telling the caregiver that he or she is not allowed to care for the client 10) A nurse responds to an external disaster in a large city involving an explosion at a shopping mall. Numerous victims require treatment. Which victim will the nurse attend to first? A) A victim with multiple bruises who is alert and oriented B) A victim who has sustained multiple lacerations with minor bleeding C) A victim who is alert and wandering around yelling that he cannot see D) A victim with a crush injury to the abdomen who has no pulse or blood pressure 11) A nurse on the day shift receives the client assignment for the day. Which assigned client will the nurse assess first? A) A client who has been fitted with a closed chest tube drainage system B) A client with a nasogastric tube who underwent bowel resection 2 days ago C) A client who was admitted during the night because of congestive heart failure D) A client on nothing-by-mouth (NPO) status who is scheduled for a barium enema at 10 a.m. 12) The nurse who works on the night shift enters the medication room and finds a coworker with a tourniquet wrapped around her upper arm. The coworker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse? 1. call security 2. call police 3. call the nursing supervisor 4. lock the coworker in the medication room until help is obtained 13) A hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer will be bringing the document to the hospital for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which is the most appropriate response to the client? 1. "I will sign as a witness to your signature" 2. "you will need to find a witness on your own" 3. "whoever is available at the time will sign as a witness for you" 4. "I will call the nursing supervisor to seek assistance regarding your request" 14) The nurse has made an error in documentation of dose administered of an opioid pain medication in the client's record. The nurse draws 1 mg from the vial and another RN witnesses wasting of the remaining 1 mg. When scanning the medication, the nurse entered into the MAR that 2 mg of hydromorphone was administered instead of the actual dose administered, which was 1 mg. The nurse should take which actions to correct the MAR? Select all that apply: 1. complete and file an occurrence report 2. right-click on the entry and modify it to reflect the correct information 3. document the correct information and end with the nurse's signature and title 4. obtain a cosignature from the RN who witnessed the waste of the remaining 1 mg 5. document in a nurse's note in the client's record detailing the corrected information. 15) Which identifies accurate nursing documentation notations? Select all that apply: 1. The client slept through the night 2. Abdominal wound dressing is dry and intact without drainage 3. The client seemed angry when awakened for vital sign measurement 4. The client appears to become anxious when it is time for respiratory treatments 5. The client's left lower medial leg wound is 3cm in length without redness, drainage, or edema 16) A nursing instructor delivers a lecture to nursing students regarding the issue of client's rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of this client right? 1. performing a procedure without consent 2. threatening to give a client medication 3. telling the client that he or she cannot leave the hospital 4. observing care provided to the client without the client's permission 17) Nursing staff members are sitting in the lounge taking their morning break. An unlicensed assistive personnel (UAP) tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. Which legal tort has the UAP violated? 1. Libel 2. Slander 3. Assault 4. Negligence 18) An older woman is brought to the ED for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he gets home from work. Which is the most appropriate nursing response? 1. "Oh, really? I will discuss this situation with your son" 2. "Lets talk about ways you can manage your time to prevent this from happening" 3. "Do you have any friends who could help you out until you resolve these issues with your son?" 4. "As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay" 19) The nurse calls the primary hc provider regarding a new medication prescription, because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the primary hc provider, and the medication is due to be administered. Which action should the nurse take? 1. contact the nursing supervisor 2. administer the dose prescribed 3. hold the medication until the primary hc provider can be contacted 4. administer the recommended does until the primary hc provider can be located