HESI Comprehensive Nursing Exam | ACTUAL
EXAM | Complete Questions & Verified Answers |
Latest Update | Already Graded A
1. A client with a history of heart failure is prescribed furosemide 40 mg IV every
morning. Which laboratory finding requires immediate intervention by the nurse?
A. Serum sodium 138 mEq/L
B. Serum potassium 3.0 mEq/L
C. Serum chloride 100 mEq/L
D. Serum glucose 110 mg/dL
Correct Answer: B
Rationale: Furosemide is a loop diuretic that causes potassium wasting. A serum
potassium of 3.0 mEq/L indicates moderate hypokalemia, which can precipitate
life-threatening ventricular dysrhythmias in a client with heart failure who is also on
digoxin. Sodium 138 mEq/L is normal (135–145 mEq/L), chloride 100 mEq/L is normal
(98–106 mEq/L), and glucose 110 mg/dL is within acceptable fasting range.
2. The nurse is caring for a client who had a cesarean birth 36 hours ago and
suddenly reports acute shortness of breath. Which action should the nurse take
first?
A. Obtain a 12-lead ECG
B. Measure oxygen saturation with pulse oximetry
C. Auscultate lung sounds bilaterally
,D. Encourage deep breathing and coughing
Correct Answer: B
Rationale: Sudden postpartum dyspnea is potentially life-threatening (pulmonary
embolism, amniotic-fluid embolism, or fluid overload). The first step is to quickly assess
oxygenation so that immediate supplemental oxygen can be initiated if SpO₂ is < 94%.
ECG, auscultation, and coughing are important but come after the immediate
oxygenation assessment.
3. A 6-year-old with asthma is receiving albuterol via small-volume nebulizer. Which
adverse effect should the nurse report immediately?
A. Fine tremor of hands
B. Heart rate 118 beats/min
C. Excitability and giggling
D. Blood pressure 88/50 mm Hg
Correct Answer: B
Rationale: Albuterol is a β₂-adrenergic agonist that can cause tachycardia. A heart rate
of 118 beats/min exceeds the expected pediatric upper limit (≈ 70–100 beats/min at
rest) and may herald toxicity. Fine tremor and excitability are common, mild, transient
side effects. The BP is low-normal for age and not immediately concerning.
4. A client with bipolar disorder is started on lithium carbonate 300 mg PO BID.
Which instruction is most important for the nurse to provide?
A. “Take the medication on an empty stomach to improve absorption.”
B. “Maintain your usual caffeine intake to prevent headaches.”
,C. “Drink 2–3 L of water daily and avoid NSAIDs.”
D. “Expect therapeutic effects within 48 hours.”
Correct Answer: C
Rationale: Lithium is nephrotoxic and easily affected by dehydration or NSAID-induced
decreased renal blood flow, leading to toxicity. Clients must maintain adequate
hydration and avoid NSAIDs. Lithium should be taken with food to reduce GI upset,
therapeutic onset takes 5–7 days, and caffeine increases lithium excretion.
5. The nurse is delegating morning hygiene to an unlicensed assistive personnel
(UAP) for a client with Clostridioides difficile infection. Which instruction is
essential?
A. “Wear an N95 respirator while in the room.”
B. “Use soap and water for hand hygiene, not alcohol gel.”
C. “Place the client in a private negative-pressure room.”
D. “Apply a gown only if you anticipate spraying fluids.”
Correct Answer: B
Rationale: C. difficile spores are resistant to alcohol; physical removal with soap and
water is required. Contact precautions (gown and gloves) are needed for all entries, but
an N95 and negative pressure are unnecessary because the organism is not airborne.
6. A client is receiving morphine sulfate 10 mg IV q4h for postoperative pain. Which
finding best indicates to the nurse that the goal of pain management is met?
A. Client reports pain 2/10 within 30 minutes
B. Client sleeps for 4 hours after injection
, C. Respiratory rate 10 breaths/min
D. Client turns, coughs, and deep breathes easily
Correct Answer: D
Rationale: Effective pain control is evidenced by the client’s ability to perform pulmonary
hygiene and participate in recovery activities without guarding. A pain score of 2/10 is
desirable but is subjective; sleep may indicate oversedation; respiratory rate 10 is too
low and signals opioid-induced respiratory depression.
7. A newborn of a diabetic mother is jittery and has a serum glucose of 32 mg/dL.
Which nursing action has highest priority?
A. Begin IV dextrose 10% bolus per protocol
B. Obtain a bedside hematocrit
C. Encourage early breastfeeding
D. Wrap the infant in warm blankets
Correct Answer: A
Rationale: Glucose < 40 mg/dL in a newborn requires immediate IV dextrose to prevent
neurologic injury. While breastfeeding and thermoregulation are important, the
hypoglycemia must first be corrected with a bolus of 10% dextrose followed by
continuous infusion per protocol.
8. The nurse notes that a postpartum client’s fundus is boggy and deviated to the
right. Which action should the nurse perform first?
A. Massage the fundus until firm
B. Assist the client to empty her bladder
EXAM | Complete Questions & Verified Answers |
Latest Update | Already Graded A
1. A client with a history of heart failure is prescribed furosemide 40 mg IV every
morning. Which laboratory finding requires immediate intervention by the nurse?
A. Serum sodium 138 mEq/L
B. Serum potassium 3.0 mEq/L
C. Serum chloride 100 mEq/L
D. Serum glucose 110 mg/dL
Correct Answer: B
Rationale: Furosemide is a loop diuretic that causes potassium wasting. A serum
potassium of 3.0 mEq/L indicates moderate hypokalemia, which can precipitate
life-threatening ventricular dysrhythmias in a client with heart failure who is also on
digoxin. Sodium 138 mEq/L is normal (135–145 mEq/L), chloride 100 mEq/L is normal
(98–106 mEq/L), and glucose 110 mg/dL is within acceptable fasting range.
2. The nurse is caring for a client who had a cesarean birth 36 hours ago and
suddenly reports acute shortness of breath. Which action should the nurse take
first?
A. Obtain a 12-lead ECG
B. Measure oxygen saturation with pulse oximetry
C. Auscultate lung sounds bilaterally
,D. Encourage deep breathing and coughing
Correct Answer: B
Rationale: Sudden postpartum dyspnea is potentially life-threatening (pulmonary
embolism, amniotic-fluid embolism, or fluid overload). The first step is to quickly assess
oxygenation so that immediate supplemental oxygen can be initiated if SpO₂ is < 94%.
ECG, auscultation, and coughing are important but come after the immediate
oxygenation assessment.
3. A 6-year-old with asthma is receiving albuterol via small-volume nebulizer. Which
adverse effect should the nurse report immediately?
A. Fine tremor of hands
B. Heart rate 118 beats/min
C. Excitability and giggling
D. Blood pressure 88/50 mm Hg
Correct Answer: B
Rationale: Albuterol is a β₂-adrenergic agonist that can cause tachycardia. A heart rate
of 118 beats/min exceeds the expected pediatric upper limit (≈ 70–100 beats/min at
rest) and may herald toxicity. Fine tremor and excitability are common, mild, transient
side effects. The BP is low-normal for age and not immediately concerning.
4. A client with bipolar disorder is started on lithium carbonate 300 mg PO BID.
Which instruction is most important for the nurse to provide?
A. “Take the medication on an empty stomach to improve absorption.”
B. “Maintain your usual caffeine intake to prevent headaches.”
,C. “Drink 2–3 L of water daily and avoid NSAIDs.”
D. “Expect therapeutic effects within 48 hours.”
Correct Answer: C
Rationale: Lithium is nephrotoxic and easily affected by dehydration or NSAID-induced
decreased renal blood flow, leading to toxicity. Clients must maintain adequate
hydration and avoid NSAIDs. Lithium should be taken with food to reduce GI upset,
therapeutic onset takes 5–7 days, and caffeine increases lithium excretion.
5. The nurse is delegating morning hygiene to an unlicensed assistive personnel
(UAP) for a client with Clostridioides difficile infection. Which instruction is
essential?
A. “Wear an N95 respirator while in the room.”
B. “Use soap and water for hand hygiene, not alcohol gel.”
C. “Place the client in a private negative-pressure room.”
D. “Apply a gown only if you anticipate spraying fluids.”
Correct Answer: B
Rationale: C. difficile spores are resistant to alcohol; physical removal with soap and
water is required. Contact precautions (gown and gloves) are needed for all entries, but
an N95 and negative pressure are unnecessary because the organism is not airborne.
6. A client is receiving morphine sulfate 10 mg IV q4h for postoperative pain. Which
finding best indicates to the nurse that the goal of pain management is met?
A. Client reports pain 2/10 within 30 minutes
B. Client sleeps for 4 hours after injection
, C. Respiratory rate 10 breaths/min
D. Client turns, coughs, and deep breathes easily
Correct Answer: D
Rationale: Effective pain control is evidenced by the client’s ability to perform pulmonary
hygiene and participate in recovery activities without guarding. A pain score of 2/10 is
desirable but is subjective; sleep may indicate oversedation; respiratory rate 10 is too
low and signals opioid-induced respiratory depression.
7. A newborn of a diabetic mother is jittery and has a serum glucose of 32 mg/dL.
Which nursing action has highest priority?
A. Begin IV dextrose 10% bolus per protocol
B. Obtain a bedside hematocrit
C. Encourage early breastfeeding
D. Wrap the infant in warm blankets
Correct Answer: A
Rationale: Glucose < 40 mg/dL in a newborn requires immediate IV dextrose to prevent
neurologic injury. While breastfeeding and thermoregulation are important, the
hypoglycemia must first be corrected with a bolus of 10% dextrose followed by
continuous infusion per protocol.
8. The nurse notes that a postpartum client’s fundus is boggy and deviated to the
right. Which action should the nurse perform first?
A. Massage the fundus until firm
B. Assist the client to empty her bladder
