HESI Mental Health RN
2026/2027 Questions and
Answers from V1-V2 & V3
ALREADY GRADED A+ |
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A nurse is preparing to administer an enteral feeding through a
nasogastric tube. Which of the following actions should the nurse take
first?
a. Check the gastric residual volume
b. Verify tube placement by aspirating gastric contents and checking pH
c. Flush the tube with 30 mL of sterile water
d. Elevate the head of the bed to 45 degrees
✔️ Correct Answer: B
Rationale: Verification of nasogastric tube placement is the priority
action prior to administering any enteral feeding to prevent accidental
administration into the pulmonary system. The most reliable method at
the bedside is aspiration of gastric contents with pH testing, with gastric
pH typically being between 1 and 4. While checking residual volume
(Option A) is important for assessing gastric emptying and tolerance, it
should occur after placement verification. Flushing the tube (Option C)
and elevating the head of the bed (Option D) are appropriate
interventions but are secondary to confirming correct tube positioning.
Auscultation of air insufflation is no longer recommended as a sole
method for placement verification due to unreliability.
,A nurse is assessing a client who has a history of heart failure and is
receiving digoxin therapy. Which of the following findings should
indicate to the nurse that the client is experiencing digoxin toxicity?
a. Heart rate of 72 beats per minute and regular
b. Serum potassium level of 3.2 mEq/L
c. Blood pressure of 118/76 mm Hg
d. Respiratory rate of 18 breaths per minute
✔️ Correct Answer: B
Rationale: Hypokalemia, defined as a serum potassium level below 3.5
mEq/L, significantly increases the risk of digoxin toxicity because digoxin
competes with potassium for binding sites on the sodium-potassium
ATPase pump in cardiac muscle cells. When potassium levels are low,
digoxin binds more readily, leading to increased cardiac sensitivity and
potential toxicity. Classic manifestations of digoxin toxicity include
gastrointestinal symptoms such as nausea and vomiting, visual
disturbances including yellow-green halos, and cardiac dysrhythmias.
Option A represents a normal heart rate and does not indicate toxicity.
Option C is a normal blood pressure finding. Option D is a normal
respiratory rate. The nurse should monitor potassium levels closely and
report values below normal range to the healthcare provider.
A nurse is caring for a client who has a prescription for 0.9% sodium
chloride 1,000 mL to infuse over 8 hours. The drop factor of the manual
IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to
deliver how many gtt/min? (Round the answer to the nearest whole
number.)
a. 31 gtt/min
b. 125 gtt/min
, c. 15 gtt/min
d. 8 gtt/min
✔️ Correct Answer: A
Rationale: To calculate the IV flow rate in drops per minute, the nurse
must use the formula: (Total volume in mL ÷ Total time in minutes) ×
Drop factor = Flow rate in gtt/min. First, convert the total infusion time
to minutes: 8 hours × 60 minutes/hour = 480 minutes. Next, divide the
total volume by the total time in minutes: 1,000 mL ÷ 480 minutes =
2.083 mL/min. Finally, multiply by the drop factor: 2.083 mL/min × 15
gtt/mL = 31.25 gtt/min, which rounds to 31 gtt/min. Option B (125
gtt/min) would result in infusion over approximately 2 hours, which is
too rapid. Option C (15 gtt/min) would result in infusion over
approximately 16.7 hours, which is too slow. Option D (8 gtt/min) would
result in infusion over approximately 31 hours, which is significantly
delayed. Accurate calculation of IV flow rates is essential to ensure safe
medication and fluid administration.
A nurse is performing a sterile wound dressing change for a client who
has a surgical incision. Which of the following actions by the nurse
requires intervention?
a. Opening the sterile package away from the body
b. Applying sterile gloves after opening the sterile field
c. Placing sterile items within the 1-inch border of the sterile field
d. Using sterile forceps to handle sterile supplies
✔️ Correct Answer: C
Rationale: The 1-inch border around the periphery of a sterile field is
considered contaminated because it may have come into contact with
unsterile surfaces during setup or handling. Sterile items must be placed
2026/2027 Questions and
Answers from V1-V2 & V3
ALREADY GRADED A+ |
LATEST VERSIONS
GUARANTEED PASS (JUST
RELEASED WITH
RATIONALE)
Test
, Banks and Actual Exams
Latest
A nurse is preparing to administer an enteral feeding through a
nasogastric tube. Which of the following actions should the nurse take
first?
a. Check the gastric residual volume
b. Verify tube placement by aspirating gastric contents and checking pH
c. Flush the tube with 30 mL of sterile water
d. Elevate the head of the bed to 45 degrees
✔️ Correct Answer: B
Rationale: Verification of nasogastric tube placement is the priority
action prior to administering any enteral feeding to prevent accidental
administration into the pulmonary system. The most reliable method at
the bedside is aspiration of gastric contents with pH testing, with gastric
pH typically being between 1 and 4. While checking residual volume
(Option A) is important for assessing gastric emptying and tolerance, it
should occur after placement verification. Flushing the tube (Option C)
and elevating the head of the bed (Option D) are appropriate
interventions but are secondary to confirming correct tube positioning.
Auscultation of air insufflation is no longer recommended as a sole
method for placement verification due to unreliability.
,A nurse is assessing a client who has a history of heart failure and is
receiving digoxin therapy. Which of the following findings should
indicate to the nurse that the client is experiencing digoxin toxicity?
a. Heart rate of 72 beats per minute and regular
b. Serum potassium level of 3.2 mEq/L
c. Blood pressure of 118/76 mm Hg
d. Respiratory rate of 18 breaths per minute
✔️ Correct Answer: B
Rationale: Hypokalemia, defined as a serum potassium level below 3.5
mEq/L, significantly increases the risk of digoxin toxicity because digoxin
competes with potassium for binding sites on the sodium-potassium
ATPase pump in cardiac muscle cells. When potassium levels are low,
digoxin binds more readily, leading to increased cardiac sensitivity and
potential toxicity. Classic manifestations of digoxin toxicity include
gastrointestinal symptoms such as nausea and vomiting, visual
disturbances including yellow-green halos, and cardiac dysrhythmias.
Option A represents a normal heart rate and does not indicate toxicity.
Option C is a normal blood pressure finding. Option D is a normal
respiratory rate. The nurse should monitor potassium levels closely and
report values below normal range to the healthcare provider.
A nurse is caring for a client who has a prescription for 0.9% sodium
chloride 1,000 mL to infuse over 8 hours. The drop factor of the manual
IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to
deliver how many gtt/min? (Round the answer to the nearest whole
number.)
a. 31 gtt/min
b. 125 gtt/min
, c. 15 gtt/min
d. 8 gtt/min
✔️ Correct Answer: A
Rationale: To calculate the IV flow rate in drops per minute, the nurse
must use the formula: (Total volume in mL ÷ Total time in minutes) ×
Drop factor = Flow rate in gtt/min. First, convert the total infusion time
to minutes: 8 hours × 60 minutes/hour = 480 minutes. Next, divide the
total volume by the total time in minutes: 1,000 mL ÷ 480 minutes =
2.083 mL/min. Finally, multiply by the drop factor: 2.083 mL/min × 15
gtt/mL = 31.25 gtt/min, which rounds to 31 gtt/min. Option B (125
gtt/min) would result in infusion over approximately 2 hours, which is
too rapid. Option C (15 gtt/min) would result in infusion over
approximately 16.7 hours, which is too slow. Option D (8 gtt/min) would
result in infusion over approximately 31 hours, which is significantly
delayed. Accurate calculation of IV flow rates is essential to ensure safe
medication and fluid administration.
A nurse is performing a sterile wound dressing change for a client who
has a surgical incision. Which of the following actions by the nurse
requires intervention?
a. Opening the sterile package away from the body
b. Applying sterile gloves after opening the sterile field
c. Placing sterile items within the 1-inch border of the sterile field
d. Using sterile forceps to handle sterile supplies
✔️ Correct Answer: C
Rationale: The 1-inch border around the periphery of a sterile field is
considered contaminated because it may have come into contact with
unsterile surfaces during setup or handling. Sterile items must be placed
