HESI LPN-ADN HESI ENTRANCE EXAM | MOBILITY EXAM-
QUESTIONS AND ANSWERS | VERIFIED AND WELL DETAILED
ANSWERS PLUS RATIONALES | GUARANTEED PASS | LATEST
EXAM UPDATE | EXAM PREP | STUDY GUIDE | PRACTICE
TEST| DOWNLOAD INSTANT PDF
1. A licensed practical nurse (LPN) is transitioning to an associate degree nursing (ADN)
program and reviewing client assignment principles. Which client situation should the
nurse identify as most appropriate to delegate to an unlicensed assistive personnel (UAP)?
A. Assessing a newly admitted client with a history of heart failure
B. Assisting a stable post-operative client with ambulation for the first time
C. Obtaining vital signs for a client who is two days post-cholecystectomy and clinically stable
D. Educating a client on the administration of subcutaneous insulin injections
ANSWER: C. Obtaining vital signs for a client who is two days post-cholecystectomy and
clinically stable
Rationale: The LPN-ADN transitioning nurse must understand delegation principles (EAT:
Evaluate, Assess, Teach cannot be delegated). Obtaining vital signs for a stable client falls
within the UAP's scope of practice. Initial assessments, initial ambulation post-surgery, and
client education require the critical thinking and clinical judgment of a licensed nurse.
2. A nurse is caring for a client receiving intravenous continuous heparin infusion. Which
laboratory test value requires immediate notification of the healthcare provider?
A. Prothrombin time (PT) of 12 seconds
B. Activated partial thromboplastin time (aPTT) of 110 seconds
C. International Normalized Ratio (INR) of 1.1
D. Platelet count of 250,000/mcL
ANSWER: B. Activated partial thromboplastin time (aPTT) of 110 seconds
Rationale: The therapeutic range for aPTT during continuous heparin therapy is typically 1.5
to 2.5 times the control value (approx. 60–80 seconds). An aPTT of 110 seconds indicates
excessive anticoagulation and places the client at high risk for hemorrhage, requiring
immediate protocol modification or notification. Options A and C measure warfarin
effectiveness. Option D is within normal limits.
3. A client with chronic kidney disease (CKD) presents with a serum potassium level of 6.4
mEq/L. Which electrocardiogram (ECG) change should the nurse anticipate finding?
A. Prominent U waves
,B. Tall, peaked T waves
C. ST-segment elevation in all leads
D. Prolonged QT interval
ANSWER: B. Tall, peaked T waves
Rationale: Hyperkalemia (potassium > 5.0 mEq/L) typically manifests on an ECG as tall,
peaked T waves, widened QRS complexes, and prolonged PR intervals. Prominent U waves are
associated with hypokalemia. Generalized ST elevation suggests acute pericarditis.
4. Which landmark is correct for administering an intramuscular injection using the
ventrogluteal site?
A. Two fingerbreadths below the acromion process
B. The mid-anterior thigh area
C. Placing the palm over the greater trochanter with the index finger pointed toward the anterior
superior iliac spine
D. Upper outer quadrant of the buttock near the posterior iliac crest
ANSWER: C. Placing the palm over the greater trochanter with the index finger pointed
toward the anterior superior iliac spine
Rationale: The ventrogluteal site is located by placing the heel of the hand over the greater
trochanter, pointing the index finger toward the anterior superior iliac spine, and spreading
the middle finger back toward the iliac crest. Option A describes the deltoid, Option B
describes the vastus lateralis, and Option D describes the dorsogluteal site, which is avoided
due to sciatic nerve risk.
5. A nurse administers an incorrect medication dose to a client. What is the nurse's priority
action immediately following the error?
A. Complete an incident/variance report
B. Assess the client's vital signs and physical condition
C. Notify the prescribing healthcare provider
D. Inform the nurse manager of the unit
ANSWER: B. Assess the client's vital signs and physical condition
Rationale: Client safety is always the primary nursing priority. Immediately upon discovering
a medication error, the nurse must assess the client for adverse reactions. Provider
notification and documentation on an incident report occur after the client's stability is
confirmed and immediate safety measures are taken.
6. A client presents with shortness of breath, bilateral crackles on auscultation, and a blood
pressure of 168/94 mmHg. Which position should the nurse place the client in to promote
optimal respiratory function?
,A. Supine with legs elevated
B. High-Fowler's position
C. Left lateral Sims' position
D. Trendelenburg position
ANSWER: B. High-Fowler's position
Rationale: High-Fowler's position (sitting upright at 60–90 degrees) decreases venous return
to the heart, reduces preload, and allows maximum chest expansion, alleviating dyspnea
associated with fluid overload or heart failure. The other options increase venous return or
restrict pulmonary expansion.
7. An adult client who is non-verbal exhibits grimacing, guarding of the abdomen, and
tachycardia. Which pain assessment scale should the nurse utilize?
A. Visual Analog Scale (VAS)
B. Numeric Rating Scale (NRS)
C. Critical-Care Pain Observation Tool (CPOT) or FLACC scale
D. Wong-Baker FACES Rating Scale
ANSWER: C. Critical-Care Pain Observation Tool (CPOT) or FLACC scale
Rationale: Behavioral assessment tools like CPOT or FLACC are validated for non-verbal or
critically ill adult clients who cannot self-report pain. VAS, NRS, and Wong-Baker rely on
self-reporting capabilities.
8. Which dietary choice demonstrates client understanding of a low-sodium diet prescribed
for hypertension management?
A. Canned tomato soup with whole wheat crackers
B. Grilled chicken breast with fresh steamed broccoli and brown rice
C. Processed turkey breast sandwich with pickles
D. Canned tuna salad on rye bread
ANSWER: B. Grilled chicken breast with fresh steamed broccoli and brown rice
Rationale: Fresh meats, fresh vegetables, and whole grains naturally contain low sodium
levels. Canned soups, processed lunch meats, pickles, and canned seafood contain significant
hidden sodium added during processing.
9. A nurse is preparing to insert an indwelling urinary catheter for a female client. What is
the first step after opening the sterile catheter kit using sterile technique?
A. Lubricate the catheter tip
B. Don sterile gloves
C. Cleanse the meatus with antiseptic solution
, D. Inflate the balloon to test integrity
ANSWER: B. Don sterile gloves
Rationale: Maintaining strict aseptic technique requires the nurse to don sterile gloves before
handling sterile components inside the kit, such as the lubricant, antiseptic solution, or
catheter. Cleaning the meatus and manipulating equipment occurs after sterile gloves are
applied.
10. A client with type 1 diabetes mellitus presents with diaphoresis, tremors, and a
capillary blood glucose reading of 54 mg/dL. The client is conscious and oriented. Which
action should the nurse perform first?
A. Administer 1 mg of glucagon intramuscularly
B. Provide 15 to 20 grams of fast-acting simple carbohydrates orally
C. Administer 50 mL of 50% Dextrose intravenously
D. Recheck the blood glucose level in 30 minutes
ANSWER: B. Provide 15 to 20 grams of fast-acting simple carbohydrates orally
Rationale: According to the Rule of 15 for hypoglycemia management, an awake, conscious
client who can swallow should immediately receive 15–20g of simple oral carbohydrates (e.g.,
4 oz fruit juice). Parenteral glucose (IV D50 or IM Glucagon) is reserved for unconscious or
uncooperative clients unable to swallow safely.
11. A nurse receives a order for a client to receive a unit of packed red blood cells (PRBCs).
What is the maximum time allowed for the infusion of one unit of PRBCs from the time it
leaves the blood bank?
A. 2 hours
B. 4 hours
C. 6 hours
D. 8 hours
ANSWER: B. 4 hours
Rationale: Blood products must be completely infused within 4 hours of removal from the
blood bank refrigerator to prevent bacterial growth and cellular destruction at room
temperature.
12. A client is admitted with deep vein thrombosis (DVT) of the left lower extremity. Which
intervention is contraindicated in the plan of care?
A. Elevating the affected limb above heart level
B. Massaging the affected calf to relieve localized cramping
C. Administering prescribed low-molecular-weight heparin
QUESTIONS AND ANSWERS | VERIFIED AND WELL DETAILED
ANSWERS PLUS RATIONALES | GUARANTEED PASS | LATEST
EXAM UPDATE | EXAM PREP | STUDY GUIDE | PRACTICE
TEST| DOWNLOAD INSTANT PDF
1. A licensed practical nurse (LPN) is transitioning to an associate degree nursing (ADN)
program and reviewing client assignment principles. Which client situation should the
nurse identify as most appropriate to delegate to an unlicensed assistive personnel (UAP)?
A. Assessing a newly admitted client with a history of heart failure
B. Assisting a stable post-operative client with ambulation for the first time
C. Obtaining vital signs for a client who is two days post-cholecystectomy and clinically stable
D. Educating a client on the administration of subcutaneous insulin injections
ANSWER: C. Obtaining vital signs for a client who is two days post-cholecystectomy and
clinically stable
Rationale: The LPN-ADN transitioning nurse must understand delegation principles (EAT:
Evaluate, Assess, Teach cannot be delegated). Obtaining vital signs for a stable client falls
within the UAP's scope of practice. Initial assessments, initial ambulation post-surgery, and
client education require the critical thinking and clinical judgment of a licensed nurse.
2. A nurse is caring for a client receiving intravenous continuous heparin infusion. Which
laboratory test value requires immediate notification of the healthcare provider?
A. Prothrombin time (PT) of 12 seconds
B. Activated partial thromboplastin time (aPTT) of 110 seconds
C. International Normalized Ratio (INR) of 1.1
D. Platelet count of 250,000/mcL
ANSWER: B. Activated partial thromboplastin time (aPTT) of 110 seconds
Rationale: The therapeutic range for aPTT during continuous heparin therapy is typically 1.5
to 2.5 times the control value (approx. 60–80 seconds). An aPTT of 110 seconds indicates
excessive anticoagulation and places the client at high risk for hemorrhage, requiring
immediate protocol modification or notification. Options A and C measure warfarin
effectiveness. Option D is within normal limits.
3. A client with chronic kidney disease (CKD) presents with a serum potassium level of 6.4
mEq/L. Which electrocardiogram (ECG) change should the nurse anticipate finding?
A. Prominent U waves
,B. Tall, peaked T waves
C. ST-segment elevation in all leads
D. Prolonged QT interval
ANSWER: B. Tall, peaked T waves
Rationale: Hyperkalemia (potassium > 5.0 mEq/L) typically manifests on an ECG as tall,
peaked T waves, widened QRS complexes, and prolonged PR intervals. Prominent U waves are
associated with hypokalemia. Generalized ST elevation suggests acute pericarditis.
4. Which landmark is correct for administering an intramuscular injection using the
ventrogluteal site?
A. Two fingerbreadths below the acromion process
B. The mid-anterior thigh area
C. Placing the palm over the greater trochanter with the index finger pointed toward the anterior
superior iliac spine
D. Upper outer quadrant of the buttock near the posterior iliac crest
ANSWER: C. Placing the palm over the greater trochanter with the index finger pointed
toward the anterior superior iliac spine
Rationale: The ventrogluteal site is located by placing the heel of the hand over the greater
trochanter, pointing the index finger toward the anterior superior iliac spine, and spreading
the middle finger back toward the iliac crest. Option A describes the deltoid, Option B
describes the vastus lateralis, and Option D describes the dorsogluteal site, which is avoided
due to sciatic nerve risk.
5. A nurse administers an incorrect medication dose to a client. What is the nurse's priority
action immediately following the error?
A. Complete an incident/variance report
B. Assess the client's vital signs and physical condition
C. Notify the prescribing healthcare provider
D. Inform the nurse manager of the unit
ANSWER: B. Assess the client's vital signs and physical condition
Rationale: Client safety is always the primary nursing priority. Immediately upon discovering
a medication error, the nurse must assess the client for adverse reactions. Provider
notification and documentation on an incident report occur after the client's stability is
confirmed and immediate safety measures are taken.
6. A client presents with shortness of breath, bilateral crackles on auscultation, and a blood
pressure of 168/94 mmHg. Which position should the nurse place the client in to promote
optimal respiratory function?
,A. Supine with legs elevated
B. High-Fowler's position
C. Left lateral Sims' position
D. Trendelenburg position
ANSWER: B. High-Fowler's position
Rationale: High-Fowler's position (sitting upright at 60–90 degrees) decreases venous return
to the heart, reduces preload, and allows maximum chest expansion, alleviating dyspnea
associated with fluid overload or heart failure. The other options increase venous return or
restrict pulmonary expansion.
7. An adult client who is non-verbal exhibits grimacing, guarding of the abdomen, and
tachycardia. Which pain assessment scale should the nurse utilize?
A. Visual Analog Scale (VAS)
B. Numeric Rating Scale (NRS)
C. Critical-Care Pain Observation Tool (CPOT) or FLACC scale
D. Wong-Baker FACES Rating Scale
ANSWER: C. Critical-Care Pain Observation Tool (CPOT) or FLACC scale
Rationale: Behavioral assessment tools like CPOT or FLACC are validated for non-verbal or
critically ill adult clients who cannot self-report pain. VAS, NRS, and Wong-Baker rely on
self-reporting capabilities.
8. Which dietary choice demonstrates client understanding of a low-sodium diet prescribed
for hypertension management?
A. Canned tomato soup with whole wheat crackers
B. Grilled chicken breast with fresh steamed broccoli and brown rice
C. Processed turkey breast sandwich with pickles
D. Canned tuna salad on rye bread
ANSWER: B. Grilled chicken breast with fresh steamed broccoli and brown rice
Rationale: Fresh meats, fresh vegetables, and whole grains naturally contain low sodium
levels. Canned soups, processed lunch meats, pickles, and canned seafood contain significant
hidden sodium added during processing.
9. A nurse is preparing to insert an indwelling urinary catheter for a female client. What is
the first step after opening the sterile catheter kit using sterile technique?
A. Lubricate the catheter tip
B. Don sterile gloves
C. Cleanse the meatus with antiseptic solution
, D. Inflate the balloon to test integrity
ANSWER: B. Don sterile gloves
Rationale: Maintaining strict aseptic technique requires the nurse to don sterile gloves before
handling sterile components inside the kit, such as the lubricant, antiseptic solution, or
catheter. Cleaning the meatus and manipulating equipment occurs after sterile gloves are
applied.
10. A client with type 1 diabetes mellitus presents with diaphoresis, tremors, and a
capillary blood glucose reading of 54 mg/dL. The client is conscious and oriented. Which
action should the nurse perform first?
A. Administer 1 mg of glucagon intramuscularly
B. Provide 15 to 20 grams of fast-acting simple carbohydrates orally
C. Administer 50 mL of 50% Dextrose intravenously
D. Recheck the blood glucose level in 30 minutes
ANSWER: B. Provide 15 to 20 grams of fast-acting simple carbohydrates orally
Rationale: According to the Rule of 15 for hypoglycemia management, an awake, conscious
client who can swallow should immediately receive 15–20g of simple oral carbohydrates (e.g.,
4 oz fruit juice). Parenteral glucose (IV D50 or IM Glucagon) is reserved for unconscious or
uncooperative clients unable to swallow safely.
11. A nurse receives a order for a client to receive a unit of packed red blood cells (PRBCs).
What is the maximum time allowed for the infusion of one unit of PRBCs from the time it
leaves the blood bank?
A. 2 hours
B. 4 hours
C. 6 hours
D. 8 hours
ANSWER: B. 4 hours
Rationale: Blood products must be completely infused within 4 hours of removal from the
blood bank refrigerator to prevent bacterial growth and cellular destruction at room
temperature.
12. A client is admitted with deep vein thrombosis (DVT) of the left lower extremity. Which
intervention is contraindicated in the plan of care?
A. Elevating the affected limb above heart level
B. Massaging the affected calf to relieve localized cramping
C. Administering prescribed low-molecular-weight heparin
