HESI LPN-TO-ADN EXAM 200 ACTUAL
QUESTIONS AND CORRECT ANSWERS WITH
RATIONALE LATEST 2026/2027 ALREADY
GRADED A+
1. A nurse is preparing to ambulate a client who had cardiac surgery 48 hours
ago. What action should the nurse take to ensure the client best tolerates the
activity?
A) Provide the client with a walker
B) Remove the telemetry equipment
C) Encourage the client to cough and deep breathe
D) Premedicate the client with an analgesic before ambulating
Answer D: ) Premedicate the client with an analgesic before ambulating
Rationale: Managing postoperative pain allows the client to exert more effort
during ambulation and prevents complications like atelectasis. Pain can limit
mobility and increase the risk of falls.
2. A client is wearing a continuous cardiac monitor, which begins to alarm.
The nurse observes ventricular fibrillation on the monitor. What is the
priority nursing action?
A) Call a code and initiate CPR
B) Administer amiodarone IV
C) Check the client's pulse
,D) Defibrillate the client
Answer A: ) Call a code and initiate CPR
Rationale: Ventricular fibrillation is a life-threatening arrhythmia requiring
immediate CPR and defibrillation. The priority is to call for help and begin chest
compressions.
3. Which nursing intervention is most effective in preventing pressure
injuries in an immobile client?
A) Massage bony prominences
B) Reposition the client every 2 hours
C) Use a donut-shaped cushion
D) Apply moisturizer to intact skin
Answer B: ) Reposition the client every 2 hours
Rationale: Frequent repositioning relieves pressure on vulnerable areas. Massage
is not recommended for bony prominences, and donut cushions can increase
pressure.
4. A client with a nasogastric tube to low intermittent suction reports feeling
nauseated. What is the first action the nurse should take?
A) Notify the healthcare provider
B) Check the tube for kinks or obstructions
C) Administer an antiemetic as prescribed
D) Irrigate the tube with 30 mL of normal saline
,Answer B: ) Check the tube for kinks or obstructions
Rationale: The most common cause of nausea in a client with an NG tube is tube
displacement or blockage. Assessing the equipment is the first step in
troubleshooting.
5. Which action should the nurse take to prevent pacemaker dislodgement
following a right subclavian insertion?
A) Instruct the client to avoid raising the right arm above shoulder level for 4-6
weeks
B) Place the client in a supine position
C) Apply a sling to the right arm
D) Restrict all movement of the right arm
Answer A: ) Instruct the client to avoid raising the right arm above shoulder
level for 4-6 weeks
Rationale: Limiting arm movement prevents dislodgement of the newly placed
pacemaker leads.
6. A nurse is caring for a client with a chest tube. The nurse notes that
bubbling in the water-seal chamber has stopped. What is the most
appropriate action?
A) Assess the chest tube system for kinks or obstruction
B) Clamp the chest tube immediately
C) Increase the suction pressure
, D) Notify the healthcare provider
Answer A: ) Assess the chest tube system for kinks or obstruction
Rationale: Cessation of bubbling may indicate that the lung has re-expanded OR
that the tube is obstructed. The first step is to assess the system for kinks,
dependent loops, or disconnection.
7. A client is admitted with a suspected bowel obstruction. Which assessment
finding should the nurse report to the healthcare provider immediately?
A) Hypoactive bowel sounds
B) A rigid, board-like abdomen
C) Cramping abdominal pain
D) Nausea and vomiting
Answer B: ) A rigid, board-like abdomen
Rationale: A rigid, board-like abdomen is a classic sign of peritonitis, which is a
medical emergency indicating potential perforation.
8. Which instruction should the nurse give to a client with a new colostomy
regarding pouch care?
A) Empty the pouch when it is one-third to one-half full
B) Change the pouch every day
C) Apply alcohol to the peristomal skin
D) Use baby powder to keep the skin dry
Answer A: ) Empty the pouch when it is one-third to one-half full
QUESTIONS AND CORRECT ANSWERS WITH
RATIONALE LATEST 2026/2027 ALREADY
GRADED A+
1. A nurse is preparing to ambulate a client who had cardiac surgery 48 hours
ago. What action should the nurse take to ensure the client best tolerates the
activity?
A) Provide the client with a walker
B) Remove the telemetry equipment
C) Encourage the client to cough and deep breathe
D) Premedicate the client with an analgesic before ambulating
Answer D: ) Premedicate the client with an analgesic before ambulating
Rationale: Managing postoperative pain allows the client to exert more effort
during ambulation and prevents complications like atelectasis. Pain can limit
mobility and increase the risk of falls.
2. A client is wearing a continuous cardiac monitor, which begins to alarm.
The nurse observes ventricular fibrillation on the monitor. What is the
priority nursing action?
A) Call a code and initiate CPR
B) Administer amiodarone IV
C) Check the client's pulse
,D) Defibrillate the client
Answer A: ) Call a code and initiate CPR
Rationale: Ventricular fibrillation is a life-threatening arrhythmia requiring
immediate CPR and defibrillation. The priority is to call for help and begin chest
compressions.
3. Which nursing intervention is most effective in preventing pressure
injuries in an immobile client?
A) Massage bony prominences
B) Reposition the client every 2 hours
C) Use a donut-shaped cushion
D) Apply moisturizer to intact skin
Answer B: ) Reposition the client every 2 hours
Rationale: Frequent repositioning relieves pressure on vulnerable areas. Massage
is not recommended for bony prominences, and donut cushions can increase
pressure.
4. A client with a nasogastric tube to low intermittent suction reports feeling
nauseated. What is the first action the nurse should take?
A) Notify the healthcare provider
B) Check the tube for kinks or obstructions
C) Administer an antiemetic as prescribed
D) Irrigate the tube with 30 mL of normal saline
,Answer B: ) Check the tube for kinks or obstructions
Rationale: The most common cause of nausea in a client with an NG tube is tube
displacement or blockage. Assessing the equipment is the first step in
troubleshooting.
5. Which action should the nurse take to prevent pacemaker dislodgement
following a right subclavian insertion?
A) Instruct the client to avoid raising the right arm above shoulder level for 4-6
weeks
B) Place the client in a supine position
C) Apply a sling to the right arm
D) Restrict all movement of the right arm
Answer A: ) Instruct the client to avoid raising the right arm above shoulder
level for 4-6 weeks
Rationale: Limiting arm movement prevents dislodgement of the newly placed
pacemaker leads.
6. A nurse is caring for a client with a chest tube. The nurse notes that
bubbling in the water-seal chamber has stopped. What is the most
appropriate action?
A) Assess the chest tube system for kinks or obstruction
B) Clamp the chest tube immediately
C) Increase the suction pressure
, D) Notify the healthcare provider
Answer A: ) Assess the chest tube system for kinks or obstruction
Rationale: Cessation of bubbling may indicate that the lung has re-expanded OR
that the tube is obstructed. The first step is to assess the system for kinks,
dependent loops, or disconnection.
7. A client is admitted with a suspected bowel obstruction. Which assessment
finding should the nurse report to the healthcare provider immediately?
A) Hypoactive bowel sounds
B) A rigid, board-like abdomen
C) Cramping abdominal pain
D) Nausea and vomiting
Answer B: ) A rigid, board-like abdomen
Rationale: A rigid, board-like abdomen is a classic sign of peritonitis, which is a
medical emergency indicating potential perforation.
8. Which instruction should the nurse give to a client with a new colostomy
regarding pouch care?
A) Empty the pouch when it is one-third to one-half full
B) Change the pouch every day
C) Apply alcohol to the peristomal skin
D) Use baby powder to keep the skin dry
Answer A: ) Empty the pouch when it is one-third to one-half full
