HESI RN NCLEX PREP CLINICAL JUDGMENT
TEST Exit exam Questions with 100% Correct
Answers Latest Versions 2025 Graded A+
The nurse is assessing a client who returns to the unit after a
thoracentesis in the procedure room. Which finding should the
nurse report to the healthcare provider immediately?
A. Diminished breath sounds over the trocar insertion site
B. Equal bilateral chest expansion
C. Scattered crackles unchanged from baseline
D. Respiratory rate of 22 breaths/minute - ANSWER-A.
Diminished breath sounds over the trocar insertion site
An adult client is admitted to the emergency department after
falling from a ladder. While waiting to have a computed
tomography (CT) scan, the client requests something for a
severe headache. When the nurse offers a prescribed dose of
acetaminophen, the client asks for something stronger. Which
intervention should the nurse implement?
A. Assess client's pupils for their reaction to light
B. Request that the CT scan be done immediately
C. Review client's history for use of illicit drugs
D. Explain the reason for using only non-narcotics - ANSWER-
D. Explain the reason for using only non-narcotics
,When caring for a client with a traumatic brain injury (TBI) who
had a craniotomy for increased intracranial pressure (ICP), the
nurse assesses the client using the Glasgow coma scale (GCS)
every 2 hours. For the past 8 hours the client's GCS score has
been 14. What does this GCS finding indicate about this client?
A. Rehabilitative prognosis is an expected full recovery
B. Risk for irreversible cerebral damage related to increased ICP
C. Insertion of an ICP monitoring device is necessary
D. Neurologically stable without indications of an increased ICP
- ANSWER-D. Neurologically stable without indications of an
increased ICP
A client with cirrhosis of the liver is admitted with
complications related to end stage liver disease. Which
interventions should the nurse implement?
A. Report serum albumin and globulin levels
B. Provide diet low in phosphorus
C. Note signs of swelling and edema
D. Monitor abdominal girth
E. Increase oral fluid intake to 1,500 mL daily - ANSWER-A.
Report serum albumin and globulin levels
C. Note signs of swelling and edema
, D. Monitor abdominal girth
The nurse is caring for a seated client who is experiencing a
tonic-clonic seizure. What actions should the nurse implement?
A. Insert a bite block
B. Restrain the client
C. Loosen restrictive clothing9
D. Note the duration of the seizure
E. Ease the client to the floor - ANSWER-C. Loosen restrictive
clothing
D. Note the duration of the seizure
E. Ease the client to the floor
The nurse caring for a child with mononucleosis can expect the
child to exhibit which symptoms?
A. Positive Epstein-Barr, and malaise
B. Ear pain and fever
C. Elevated WBC and sedimentation rate
D. Increased BUN and serum creatinine - ANSWER-B. Ear pain
and fever
The public health nurse receives funding to initiate a primary
, prevention program in the community. Which program best fits
the nurse's proposal?
A. Regional relocation center for earthquake victims
B. Vitamin supplements for high-risk pregnant women
C. Lead screening for children in low-income housing
D. Case management and screening for clients with HIV -
ANSWER-B. Vitamin supplements for high-risk pregnant
women
A client arrives for an annual physical exam and complains of
having calf pain. The client's health history reveals peripheral
arterial disease. Which question should the nurse ask the client
about expected findings related to chronic arterial symptoms?
A. Were your legs ever suddenly swollen, red, warm, and
painful?
B. Does the calf pain occur when walking short distances?
C. Did you receive treatment for weeping ulcers on lower legs?
D. Have you experienced ankle edema and varicose veins? -
ANSWER-B. Does the calf pain occur when walking short
distances?
A client is admitted with the diagnosis of Wernicke's syndrome.
Which assessment finding should the nurse use in planning the
client's care?
TEST Exit exam Questions with 100% Correct
Answers Latest Versions 2025 Graded A+
The nurse is assessing a client who returns to the unit after a
thoracentesis in the procedure room. Which finding should the
nurse report to the healthcare provider immediately?
A. Diminished breath sounds over the trocar insertion site
B. Equal bilateral chest expansion
C. Scattered crackles unchanged from baseline
D. Respiratory rate of 22 breaths/minute - ANSWER-A.
Diminished breath sounds over the trocar insertion site
An adult client is admitted to the emergency department after
falling from a ladder. While waiting to have a computed
tomography (CT) scan, the client requests something for a
severe headache. When the nurse offers a prescribed dose of
acetaminophen, the client asks for something stronger. Which
intervention should the nurse implement?
A. Assess client's pupils for their reaction to light
B. Request that the CT scan be done immediately
C. Review client's history for use of illicit drugs
D. Explain the reason for using only non-narcotics - ANSWER-
D. Explain the reason for using only non-narcotics
,When caring for a client with a traumatic brain injury (TBI) who
had a craniotomy for increased intracranial pressure (ICP), the
nurse assesses the client using the Glasgow coma scale (GCS)
every 2 hours. For the past 8 hours the client's GCS score has
been 14. What does this GCS finding indicate about this client?
A. Rehabilitative prognosis is an expected full recovery
B. Risk for irreversible cerebral damage related to increased ICP
C. Insertion of an ICP monitoring device is necessary
D. Neurologically stable without indications of an increased ICP
- ANSWER-D. Neurologically stable without indications of an
increased ICP
A client with cirrhosis of the liver is admitted with
complications related to end stage liver disease. Which
interventions should the nurse implement?
A. Report serum albumin and globulin levels
B. Provide diet low in phosphorus
C. Note signs of swelling and edema
D. Monitor abdominal girth
E. Increase oral fluid intake to 1,500 mL daily - ANSWER-A.
Report serum albumin and globulin levels
C. Note signs of swelling and edema
, D. Monitor abdominal girth
The nurse is caring for a seated client who is experiencing a
tonic-clonic seizure. What actions should the nurse implement?
A. Insert a bite block
B. Restrain the client
C. Loosen restrictive clothing9
D. Note the duration of the seizure
E. Ease the client to the floor - ANSWER-C. Loosen restrictive
clothing
D. Note the duration of the seizure
E. Ease the client to the floor
The nurse caring for a child with mononucleosis can expect the
child to exhibit which symptoms?
A. Positive Epstein-Barr, and malaise
B. Ear pain and fever
C. Elevated WBC and sedimentation rate
D. Increased BUN and serum creatinine - ANSWER-B. Ear pain
and fever
The public health nurse receives funding to initiate a primary
, prevention program in the community. Which program best fits
the nurse's proposal?
A. Regional relocation center for earthquake victims
B. Vitamin supplements for high-risk pregnant women
C. Lead screening for children in low-income housing
D. Case management and screening for clients with HIV -
ANSWER-B. Vitamin supplements for high-risk pregnant
women
A client arrives for an annual physical exam and complains of
having calf pain. The client's health history reveals peripheral
arterial disease. Which question should the nurse ask the client
about expected findings related to chronic arterial symptoms?
A. Were your legs ever suddenly swollen, red, warm, and
painful?
B. Does the calf pain occur when walking short distances?
C. Did you receive treatment for weeping ulcers on lower legs?
D. Have you experienced ankle edema and varicose veins? -
ANSWER-B. Does the calf pain occur when walking short
distances?
A client is admitted with the diagnosis of Wernicke's syndrome.
Which assessment finding should the nurse use in planning the
client's care?
