HESI NCLEX Practice Questions
A 72-year-old client returned from surgery 6 hours ago. The client received hydromorphone 2
mg IV 30 minutes ago for pain rating 8/10. The Family member requests her father be checked
immediately. On arrival to the room, the nurse finds the client difficult to arouse, with a
respiration rate of 6. Which is the priority nursing action?
A. Elevate the head of the bed.
B. Administer naloxone 0.4 mg IV
C. Assess breath sounds.
D. Check vital signs and pulse oximetry - ANS-B. Administer naloxone 0.4 mg IV
The patient had too much opioids and needs to have naloxone immediately. Taking time for
assessments can lead to more problems.
\A charge nurse is making assignments for five clients. The nursing team has an RN, a PN, and
two UAPs. Which client(s) are appropriate to assign to the RN? (Select all that apply)
A. A client from the previous shift with unstable angina.
B. A client with a stage 3 pressure ulcer who needs a bed bath.
C. A client with an enteral feeding absorbing at 30 mL/h
D. A cardiotomy client who is day 2 postoperative and who has chest tubes.
E. A client with quadriplegia for whom urinary catheterization is prescribed. - ANS-A. A client
from the previous shift with unstable angina.
D. A cardiotomy client who is day 2 postoperative and who has chest tubes.
A involves pain medications that only RNs can give and D involves complicated equipment. B
can be given to the UAP. C and E can be given to the PN because of the feeding tube
equipment and the need for catheterization.
\A client has not had a bowel movement in 2 days and reports this information to the nurse.
Which intervention should the nurse implement first?
A. Instruct the caregiver to offer a glass of warm prune juice at mealtimes.
B. Notify the HCP and request a prescription for a stool softener
C. Assess the client's medical record to determine his normal bowel pattern.
D. Instruct the caregiver to increase the client's fluids to five 8 ounce glasses per day. - ANS-C.
Assess the client's medical record to determine his normal bowel pattern.
Bowel movements vary per person. Some people go multiple times a day and others go a few
times a week. The answer is an assessment, not an intervention.
\A client in shock develops a mean arterial pressure (MAP) of 60 mm Hg and a heart rate of 110
beats per minute. Which prescribed intervention should the nurse implement first?
, A. Increase the rate of O2 flow.
B. Obtain arterial blood gas results.
C. Insert and indwelling urinary catheter.
D. Increase the rate of IV fluids. - ANS-D. Increase the rate of IV fluids.
MAP of 60 is low and requires more organ perfusion. Thus, increasing IV fluids should help to
raise the pressure.
\A client is admitted with a 2-day history of cough, fever, and fatigue. The medical history is
positive for type 1 diabetes and recent upper respiratory infection (URI). Vita signs are heart rate
109 beats per minute, blood pressure 102/58 mm Hg, respiratory rate 24 breaths/min,
temperature 104 F (40 C) , and SpO2 92% on 2 L oxygen via nasal cannula. Which prescription
has the highest priority in this client's care?
A. Initiate large-bore IV access
B. Draw two sets of blood cultures
C. Administer the ordered IV antibiotics
D. Draw serum lactate and glucose levels - ANS-B. Draw two sets of blood cultures
The cultures are needed in order for the antibiotics to be administered for the infection. The
diabetes part is a distractor for the infection.
\A client is receiving an infusion of dobutamine hydrochloride. The order reads: Infuse
dobutamine IV at 5 mcg/kg/min. 500 mg in 250 mL D5W. The client weighs 65 kg. Calculate the
flow rate in mL/hr.
_________ mL/hr - ANS-9.75
500 mg x 1000 mg = 500000 mcg
500000 mcg/ 250 mL = 2000 mcg/mL
5 mcg x 65 kg x 60 min = 95000 mcg/hr
95000 mcg/hr / 2000 mcg/mL = 9.75 mL/hr
\A client recovering from ARDS is awake and alert but has residual fatigue and generalized
weakness. The client's current vital signs are heart rate 83 beats per minute, blood pressure
104/64 mm Hg, respiratory rate 25 breaths/min, SpO2 is 92% on 2 L/min oxygen via nasal
cannula. Which vital sign finding should the unlicensed assistive personnel (UAP) immediately
report to the nurse?
A. Heart rate of 83 beats per minute
B. Blood pressure of 104/64 mm Hg
C. Respiratory rate of 25 breaths/minute
D. SpO2 92% of 2 L/min O2 via nasal cannula - ANS-
\A client who has chronic obstructive pulmonary disease (COPD) is resting in a semi-Fowler's
position with oxygen at 2 L/min per nasal cannula. The client develops dyspnea. Which action
should the nurse take first?
A 72-year-old client returned from surgery 6 hours ago. The client received hydromorphone 2
mg IV 30 minutes ago for pain rating 8/10. The Family member requests her father be checked
immediately. On arrival to the room, the nurse finds the client difficult to arouse, with a
respiration rate of 6. Which is the priority nursing action?
A. Elevate the head of the bed.
B. Administer naloxone 0.4 mg IV
C. Assess breath sounds.
D. Check vital signs and pulse oximetry - ANS-B. Administer naloxone 0.4 mg IV
The patient had too much opioids and needs to have naloxone immediately. Taking time for
assessments can lead to more problems.
\A charge nurse is making assignments for five clients. The nursing team has an RN, a PN, and
two UAPs. Which client(s) are appropriate to assign to the RN? (Select all that apply)
A. A client from the previous shift with unstable angina.
B. A client with a stage 3 pressure ulcer who needs a bed bath.
C. A client with an enteral feeding absorbing at 30 mL/h
D. A cardiotomy client who is day 2 postoperative and who has chest tubes.
E. A client with quadriplegia for whom urinary catheterization is prescribed. - ANS-A. A client
from the previous shift with unstable angina.
D. A cardiotomy client who is day 2 postoperative and who has chest tubes.
A involves pain medications that only RNs can give and D involves complicated equipment. B
can be given to the UAP. C and E can be given to the PN because of the feeding tube
equipment and the need for catheterization.
\A client has not had a bowel movement in 2 days and reports this information to the nurse.
Which intervention should the nurse implement first?
A. Instruct the caregiver to offer a glass of warm prune juice at mealtimes.
B. Notify the HCP and request a prescription for a stool softener
C. Assess the client's medical record to determine his normal bowel pattern.
D. Instruct the caregiver to increase the client's fluids to five 8 ounce glasses per day. - ANS-C.
Assess the client's medical record to determine his normal bowel pattern.
Bowel movements vary per person. Some people go multiple times a day and others go a few
times a week. The answer is an assessment, not an intervention.
\A client in shock develops a mean arterial pressure (MAP) of 60 mm Hg and a heart rate of 110
beats per minute. Which prescribed intervention should the nurse implement first?
, A. Increase the rate of O2 flow.
B. Obtain arterial blood gas results.
C. Insert and indwelling urinary catheter.
D. Increase the rate of IV fluids. - ANS-D. Increase the rate of IV fluids.
MAP of 60 is low and requires more organ perfusion. Thus, increasing IV fluids should help to
raise the pressure.
\A client is admitted with a 2-day history of cough, fever, and fatigue. The medical history is
positive for type 1 diabetes and recent upper respiratory infection (URI). Vita signs are heart rate
109 beats per minute, blood pressure 102/58 mm Hg, respiratory rate 24 breaths/min,
temperature 104 F (40 C) , and SpO2 92% on 2 L oxygen via nasal cannula. Which prescription
has the highest priority in this client's care?
A. Initiate large-bore IV access
B. Draw two sets of blood cultures
C. Administer the ordered IV antibiotics
D. Draw serum lactate and glucose levels - ANS-B. Draw two sets of blood cultures
The cultures are needed in order for the antibiotics to be administered for the infection. The
diabetes part is a distractor for the infection.
\A client is receiving an infusion of dobutamine hydrochloride. The order reads: Infuse
dobutamine IV at 5 mcg/kg/min. 500 mg in 250 mL D5W. The client weighs 65 kg. Calculate the
flow rate in mL/hr.
_________ mL/hr - ANS-9.75
500 mg x 1000 mg = 500000 mcg
500000 mcg/ 250 mL = 2000 mcg/mL
5 mcg x 65 kg x 60 min = 95000 mcg/hr
95000 mcg/hr / 2000 mcg/mL = 9.75 mL/hr
\A client recovering from ARDS is awake and alert but has residual fatigue and generalized
weakness. The client's current vital signs are heart rate 83 beats per minute, blood pressure
104/64 mm Hg, respiratory rate 25 breaths/min, SpO2 is 92% on 2 L/min oxygen via nasal
cannula. Which vital sign finding should the unlicensed assistive personnel (UAP) immediately
report to the nurse?
A. Heart rate of 83 beats per minute
B. Blood pressure of 104/64 mm Hg
C. Respiratory rate of 25 breaths/minute
D. SpO2 92% of 2 L/min O2 via nasal cannula - ANS-
\A client who has chronic obstructive pulmonary disease (COPD) is resting in a semi-Fowler's
position with oxygen at 2 L/min per nasal cannula. The client develops dyspnea. Which action
should the nurse take first?
