Foundations of Nursing HESI Exam 1 Practice Exam (LATEST EDITION) |
Complete Questions & Verified Answers | 100% Correct | Grade A – Herzing
University LPN
1. A nurse is assessing a client's vital signs. Which of the following findings should the nurse report
immediately to the provider?
A) Blood pressure 118/76 mmHg
B) Heart rate 88 beats/min
C) Respiratory rate 8 breaths/min
D) Temperature 98.6°F (37°C)
Answer: C
Rationale:
A respiratory rate of 8 breaths/min is below the normal adult range of 12-20 breaths/min and indicates
respiratory depression, which requires immediate intervention. Blood pressure 118/76 (A), heart rate 88
(B), and temperature 98.6°F (D) are within normal limits.
2. A nurse is preparing to administer medication to a client. Which of the following is the priority
action before administration?
A) Check the medication against the MAR
B) Verify the client's identity using two identifiers
C) Assess the client for allergies
D) Document the medication administration
Answer: B
Rationale:
Verifying the client's identity using two identifiers is the priority to ensure the right patient receives the
medication. Checking against the MAR (A) and assessing allergies (C) are important but come after verifying
identity. Documentation (D) occurs after administration.
3. A client is admitted with dehydration. Which of the following findings should the nurse expect?
A) Bounding pulse
B) Hypertension
C) Poor skin turgor
,D) Peripheral edema
Answer: C
Rationale:
Poor skin turgor is a classic sign of dehydration due to loss of interstitial fluid. Bounding pulse (A),
hypertension (B), and peripheral edema (D) are signs of fluid volume excess.
4. A nurse is caring for a client with a new colostomy. Which stoma appearance indicates a need for
further assessment?
A) Red and moist
B) Pale and dry
C) Pink and raised
D) Slight edema
Answer: B
Rationale:
A healthy stoma is red and moist. Pale and dry (B) indicates poor perfusion and requires immediate
assessment. Pink (C) and slight edema (D) are normal postoperative findings.
5. A nurse is teaching a client about a low-sodium diet. Which food should the client avoid?
A) Fresh chicken
B) Canned soup
C) Brown rice
D) Broccoli
Answer: B
Rationale:
Canned soup is high in sodium due to processing. Fresh chicken (A), brown rice (C), and broccoli (D) are low
in sodium.
6. A client is receiving heparin therapy. Which laboratory value should the nurse monitor?
A) PT/INR
B) aPTT
C) Platelet count
D) Hemoglobin
Answer: B
2
,Rationale:
aPTT monitors heparin therapy. PT/INR (A) monitors warfarin. Platelets (C) monitor for heparin-induced
thrombocytopenia. Hemoglobin (D) monitors bleeding.
7. A nurse is assessing a client with heart failure. Which finding indicates fluid volume excess?
A) Decreased urine output
B) Weight loss
C) Crackles in the lungs
D) Poor skin turgor
Answer: C
Rationale:
Crackles indicate pulmonary congestion from fluid overload. Decreased urine output (A) may occur but is
not specific. Weight loss (B) and poor skin turgor (D) indicate fluid deficit.
8. A client with COPD is receiving oxygen. What is the target SpO2 range?
A) 85-90%
B) 88-92%
C) 94-98%
D) 100%
Answer: B
Rationale:
Target SpO2 for COPD is 88-92% to avoid oxygen-induced hypercapnia. Lower (A) is hypoxic. Higher (C, D)
may suppress respiratory drive.
9. A nurse is teaching a client about warfarin. Which instruction is correct?
A) Avoid green leafy vegetables
B) Maintain consistent intake of green leafy vegetables
C) Take aspirin for headaches
D) Stop taking if feeling better
Answer: B
Rationale:
Consistent vitamin K intake is essential for stable INR. Avoiding all greens (A) is unnecessary. Aspirin (C)
increases bleeding risk. Stopping (D) is dangerous.
3
, 10. A client is admitted with diabetic ketoacidosis (DKA). Which finding should the nurse expect?
A) Blood glucose 180 mg/dL
B) pH 7.50
C) Kussmaul respirations
D) Bradycardia
Answer: C
Rationale:
DKA causes Kussmaul respirations to blow off CO2. Blood glucose is usually >250 mg/dL (A). pH is <7.35 (B).
Tachycardia (D) occurs.
11. A nurse is caring for a client with a new tracheostomy. Which action is priority?
A) Suctioning every 2 hours
B) Maintaining a patent airway
C) Changing the dressing daily
D) Providing a speaking valve
Answer: B
Rationale:
Airway patency is the priority. Suctioning (A) is as needed. Dressing (C) is as needed. Speaking valve (D) is
later.
12. A client with a chest tube has continuous bubbling in the water seal chamber. What does this
indicate?
A) Normal finding
B) Air leak
C) Tube obstruction
D) Resolution of pneumothorax
Answer: B
Rationale:
Continuous bubbling indicates an air leak. Intermittent bubbling is normal with coughing. Obstruction (C)
would stop bubbling. Resolution (D) would show no bubbling.
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Complete Questions & Verified Answers | 100% Correct | Grade A – Herzing
University LPN
1. A nurse is assessing a client's vital signs. Which of the following findings should the nurse report
immediately to the provider?
A) Blood pressure 118/76 mmHg
B) Heart rate 88 beats/min
C) Respiratory rate 8 breaths/min
D) Temperature 98.6°F (37°C)
Answer: C
Rationale:
A respiratory rate of 8 breaths/min is below the normal adult range of 12-20 breaths/min and indicates
respiratory depression, which requires immediate intervention. Blood pressure 118/76 (A), heart rate 88
(B), and temperature 98.6°F (D) are within normal limits.
2. A nurse is preparing to administer medication to a client. Which of the following is the priority
action before administration?
A) Check the medication against the MAR
B) Verify the client's identity using two identifiers
C) Assess the client for allergies
D) Document the medication administration
Answer: B
Rationale:
Verifying the client's identity using two identifiers is the priority to ensure the right patient receives the
medication. Checking against the MAR (A) and assessing allergies (C) are important but come after verifying
identity. Documentation (D) occurs after administration.
3. A client is admitted with dehydration. Which of the following findings should the nurse expect?
A) Bounding pulse
B) Hypertension
C) Poor skin turgor
,D) Peripheral edema
Answer: C
Rationale:
Poor skin turgor is a classic sign of dehydration due to loss of interstitial fluid. Bounding pulse (A),
hypertension (B), and peripheral edema (D) are signs of fluid volume excess.
4. A nurse is caring for a client with a new colostomy. Which stoma appearance indicates a need for
further assessment?
A) Red and moist
B) Pale and dry
C) Pink and raised
D) Slight edema
Answer: B
Rationale:
A healthy stoma is red and moist. Pale and dry (B) indicates poor perfusion and requires immediate
assessment. Pink (C) and slight edema (D) are normal postoperative findings.
5. A nurse is teaching a client about a low-sodium diet. Which food should the client avoid?
A) Fresh chicken
B) Canned soup
C) Brown rice
D) Broccoli
Answer: B
Rationale:
Canned soup is high in sodium due to processing. Fresh chicken (A), brown rice (C), and broccoli (D) are low
in sodium.
6. A client is receiving heparin therapy. Which laboratory value should the nurse monitor?
A) PT/INR
B) aPTT
C) Platelet count
D) Hemoglobin
Answer: B
2
,Rationale:
aPTT monitors heparin therapy. PT/INR (A) monitors warfarin. Platelets (C) monitor for heparin-induced
thrombocytopenia. Hemoglobin (D) monitors bleeding.
7. A nurse is assessing a client with heart failure. Which finding indicates fluid volume excess?
A) Decreased urine output
B) Weight loss
C) Crackles in the lungs
D) Poor skin turgor
Answer: C
Rationale:
Crackles indicate pulmonary congestion from fluid overload. Decreased urine output (A) may occur but is
not specific. Weight loss (B) and poor skin turgor (D) indicate fluid deficit.
8. A client with COPD is receiving oxygen. What is the target SpO2 range?
A) 85-90%
B) 88-92%
C) 94-98%
D) 100%
Answer: B
Rationale:
Target SpO2 for COPD is 88-92% to avoid oxygen-induced hypercapnia. Lower (A) is hypoxic. Higher (C, D)
may suppress respiratory drive.
9. A nurse is teaching a client about warfarin. Which instruction is correct?
A) Avoid green leafy vegetables
B) Maintain consistent intake of green leafy vegetables
C) Take aspirin for headaches
D) Stop taking if feeling better
Answer: B
Rationale:
Consistent vitamin K intake is essential for stable INR. Avoiding all greens (A) is unnecessary. Aspirin (C)
increases bleeding risk. Stopping (D) is dangerous.
3
, 10. A client is admitted with diabetic ketoacidosis (DKA). Which finding should the nurse expect?
A) Blood glucose 180 mg/dL
B) pH 7.50
C) Kussmaul respirations
D) Bradycardia
Answer: C
Rationale:
DKA causes Kussmaul respirations to blow off CO2. Blood glucose is usually >250 mg/dL (A). pH is <7.35 (B).
Tachycardia (D) occurs.
11. A nurse is caring for a client with a new tracheostomy. Which action is priority?
A) Suctioning every 2 hours
B) Maintaining a patent airway
C) Changing the dressing daily
D) Providing a speaking valve
Answer: B
Rationale:
Airway patency is the priority. Suctioning (A) is as needed. Dressing (C) is as needed. Speaking valve (D) is
later.
12. A client with a chest tube has continuous bubbling in the water seal chamber. What does this
indicate?
A) Normal finding
B) Air leak
C) Tube obstruction
D) Resolution of pneumothorax
Answer: B
Rationale:
Continuous bubbling indicates an air leak. Intermittent bubbling is normal with coughing. Obstruction (C)
would stop bubbling. Resolution (D) would show no bubbling.
4
