HESI EXIT PRACTICE EXAM -
COMPREHENSIVE NURSING REVIEW
QUESTIONS AND CORRECT DETAILED
ANSWERS
1. A client with a history of heart failure is prescribed digoxin. Which assessment finding
should the nurse prioritize before administration?
A. Blood pressure 110/70 mmHg
B. Serum potassium level of 4.5 mEq/L
C. Respiratory rate of 18 breaths per minute
D. Apical pulse of 52 beats per minute
Answer: D
Conceptual Explanation: Digoxin is a cardiac glycoside that slows the heart rate. It should
be withheld if the apical pulse is less than 60 bpm in an adult to avoid toxicity and
bradycardia.
2. A nurse is caring for a client with a chest tube. The nurse notes continuous bubbling in the
water seal chamber. What is the appropriate interpretation?
A. The lung has fully expanded.
B. The suction is set too high.
,C. There is an air leak in the system.
D. This is a normal finding during expiration.
Answer: C
Conceptual Explanation: Continuous bubbling in the water seal chamber indicates an air
leak in the drainage system or the pleural space. Intermittent bubbling is normal during
coughing or expiration.
3. A client is admitted with a suspected diagnosis of Addisonian crisis. Which laboratory result
should the nurse expect?
A. Hyperglycemia and hypernatremia
B. Hypokalemia and hypocalcemia
C. Hyponatremia and hyperkalemia
D. Metabolic alkalosis
Answer: C
Conceptual Explanation: Addisonian crisis involves an acute insufficiency of adrenal
hormones, leading to sodium loss (hyponatremia) and potassium retention
(hyperkalemia).
4. Which action should the nurse take first for a client exhibiting signs of autonomic
dysreflexia?
A. Raise the head of the bed to a high-Fowler’s position.
, B. Check the client for bladder distension.
C. Administer an antihypertensive medication.
D. Notify the healthcare provider immediately.
Answer: A
Conceptual Explanation: The priority action is to sit the client up to utilize orthostatic
pressure to lower the dangerously high blood pressure associated with autonomic
dysreflexia.
5. A client is receiving a blood transfusion and develops chills, fever, and lower back pain.
Which is the nurse’s first action?
A. Slow the infusion rate.
B. Stop the transfusion immediately.
C. Administer diphenhydramine.
D. Notify the blood bank.
Answer: B
Conceptual Explanation: These symptoms suggest a hemolytic reaction. The transfusion
must be stopped immediately to prevent further infusion of incompatible blood.
6. A nurse is teaching a client about the use of a spacer with a metered-dose inhaler (MDI).
What is the primary benefit of the spacer?
A. It makes the inhaler easier to hold.
COMPREHENSIVE NURSING REVIEW
QUESTIONS AND CORRECT DETAILED
ANSWERS
1. A client with a history of heart failure is prescribed digoxin. Which assessment finding
should the nurse prioritize before administration?
A. Blood pressure 110/70 mmHg
B. Serum potassium level of 4.5 mEq/L
C. Respiratory rate of 18 breaths per minute
D. Apical pulse of 52 beats per minute
Answer: D
Conceptual Explanation: Digoxin is a cardiac glycoside that slows the heart rate. It should
be withheld if the apical pulse is less than 60 bpm in an adult to avoid toxicity and
bradycardia.
2. A nurse is caring for a client with a chest tube. The nurse notes continuous bubbling in the
water seal chamber. What is the appropriate interpretation?
A. The lung has fully expanded.
B. The suction is set too high.
,C. There is an air leak in the system.
D. This is a normal finding during expiration.
Answer: C
Conceptual Explanation: Continuous bubbling in the water seal chamber indicates an air
leak in the drainage system or the pleural space. Intermittent bubbling is normal during
coughing or expiration.
3. A client is admitted with a suspected diagnosis of Addisonian crisis. Which laboratory result
should the nurse expect?
A. Hyperglycemia and hypernatremia
B. Hypokalemia and hypocalcemia
C. Hyponatremia and hyperkalemia
D. Metabolic alkalosis
Answer: C
Conceptual Explanation: Addisonian crisis involves an acute insufficiency of adrenal
hormones, leading to sodium loss (hyponatremia) and potassium retention
(hyperkalemia).
4. Which action should the nurse take first for a client exhibiting signs of autonomic
dysreflexia?
A. Raise the head of the bed to a high-Fowler’s position.
, B. Check the client for bladder distension.
C. Administer an antihypertensive medication.
D. Notify the healthcare provider immediately.
Answer: A
Conceptual Explanation: The priority action is to sit the client up to utilize orthostatic
pressure to lower the dangerously high blood pressure associated with autonomic
dysreflexia.
5. A client is receiving a blood transfusion and develops chills, fever, and lower back pain.
Which is the nurse’s first action?
A. Slow the infusion rate.
B. Stop the transfusion immediately.
C. Administer diphenhydramine.
D. Notify the blood bank.
Answer: B
Conceptual Explanation: These symptoms suggest a hemolytic reaction. The transfusion
must be stopped immediately to prevent further infusion of incompatible blood.
6. A nurse is teaching a client about the use of a spacer with a metered-dose inhaler (MDI).
What is the primary benefit of the spacer?
A. It makes the inhaler easier to hold.
