Hesi nclex -rn comprehensive review exam 2025 latest questions and
answers with rationales|A+ graded|
The nurse identifies a potential for infec-
B - Careful handwashing technique is the
tion in a client with partial-thickness (sec-
single most effective intervention for the
ond-degree) and full-thickness (third-de-
prevention of contamination to all clients.
gree) burns. What intervention has the
Option A reverses the hypovolemia that
highest priority in decreasing the client's
initially accompanies burn trauma but is
risk of infection?
not related to decreasing the prolifera-
A. Administration of plasma expanders tion of infective organisms. Options C
B. Use of careful handwashing technique and D are recommended by various burn
centers as possible ways to reduce the
C. Application of a topical antibacterial
chance of infection. Option B is a proven
cream
technique to prevent infection.
D.Limiting visitors to the client with burns
A client becomes angry while waiting for
a supervised break to smoke a cigarette
outside and states, "I want to go outside
now and smoke. It takes forever to get D - The best nursing action is to re-
anything done here!" Which intervention view the schedule of outdoor breaks and
is best for the nurse to implement? provide concrete information about the
schedule. Option A is contraindicated if
A. Encourage the client to use a nicotine the client wants to continue smoking. Op-
patch. tion B is insufficient to encourage a trust-
B. Reassure the client that it is almost ing relationship with the client. Option C
time for another break. is preferential for this client only and is
C. Have the client leave the unit with inconsistent with unit rules.
another staff member.
D. Review the schedule of outdoor
breaks with the client.
The nurse is teaching a client how to
perform progressive muscle relaxation
D - The nurse should first evaluate
techniques to relieve insomnia. A week
whether the client has been adhering to
later the client reports that he is still un-
the original instructions. A verbal report
able to sleep, despite following the same
of the client's routine will provide more
routine every night. Which action should
specific information than the client's writ-
the nurse take first?
ten diary. The nurse can then determine
which changes need to be made. The
A. Instruct the client to add regular exer-
routine practiced by the client is clearly
cise as a daily routine.
B. Determine if the client has been keep-
, Hesi nclex -rn comprehensive review exam 2025 latest questions and
answers with rationales|A+ graded|
ing a sleep diary.
C. Encourage the client to continue the
unsuccessful, so encouragement alone
routine until sleep is achieved.
is insufficient.
D. Ask the client to describe the routine
he is currently following.
Based on the nursing diagnosis of risk for
infection, which intervention is best for
the nurse to implement when providing A - The best action to decrease the risk
care for an older incontinent client? of infection in vulnerable clients is hand-
washing. Option B is not necessary un-
A. Maintain standard precautions. less the client has an infection. Option C
B. Initiate contact isolation measures. increases the risk of infection. Option D
C. Insert an indwelling urinary catheter. does not reduce the risk of infection.
D. Instruct client in the use of adult dia-
pers.
A nurse stops at a motor vehicle collision
site to render aid until the emergency
personnel arrive and applies pressure to
a groin wound that is bleeding profusely.
C - The Good Samaritan Act protects
Later the client has to have the leg ampu-
health care professionals who practice
tated and sues the nurse for malpractice.
in good faith and provide reasonable
Which is the most likely outcome of this
care from malpractice claims, regardless
lawsuit?
of the client outcome. Although the Pa-
tient's Bill of Rights protects clients, this
A. The Patient's Bill of Rights protects
nurse is protected by the Good Samari-
clients from malicious intents, so the
tan Act. The state Board of Nursing has
nurse could lose the case.
no reason to revoke a registered nurse's
B. The lawsuit may be settled out of
license unless there was evidence that
court, but the nurse's license is likely to
actions taken in the emergency were not
be revoked.
done in good faith or that reasonable
C. There will be no judgment against
care was not provided. All four elements
the nurse, whose actions were protected
of malpractice were not shown.
under the Good Samaritan Act.
D.The client will win because the four
elements of negligence (duty, breach,
causation, and damages) can be proved.
Ten minutes after signing an operative B - This statement may indicate that
permit for a fractured hip, an older client the client is confused. Informed consent
, Hesi nclex -rn comprehensive review exam 2025 latest questions and
answers with rationales|A+ graded|
states, "The aliens will be coming to get
must be provided by a mentally compe-
me soon!" and falls asleep. Which action
tent individual, so the nurse should fur-
should the nurse implement next?
ther assess the client's neurologic sta-
tus to be sure that the client under-
A. Make the client comfortable and allow
stands and can legally provide consent
the client to sleep.
for surgery. Option A does not provide
B. Assess the client's neurologic status.
sufficient follow-up. If the nurse deter-
C. Notify the surgeon about the com-
mines that the client is confused, the
ment.
surgeon must be notified and permission
D. Ask the client's family to co-sign the
obtained from the next of kin.
operative permit.
When taking a client's blood pressure,
the nurse is unable to distinguish the
point at which the first sound was heard.
Which is the best action for the nurse to
take? C - Deflating the cuff for 30 to 60 seconds
allows blood flow to return to the extrem-
A. Deflate the cuff completely and imme- ity so that an accurate reading can be
diately reattempt the reading. obtained on that extremity a second time.
B. Reinflate the cuff completely and Option A could result in a falsely high
leave it inflated for 90 to 110 seconds reading. Option B reduces circulation,
before taking the second reading. causes pain, and could alter the reading.
C. Deflate the cuff to zero and wait 30 Option D is not an accurate method of
to 60 seconds before reattempting the assessing blood pressure.
reading.
D. Document the exact level visualized
on the sphygmomanometer where the
first fluctuation was seen.
D - The client's recognition of a "new"
The nurse is administering the 0900
pill requires further assessment to veri-
medications to a client who was admitted
fy that the medication is correct, if it is
during the night. Which client statement
a new prescription or a different man-
indicates that the nurse should further
ufacturer, or if the client needs further
assess the medication order?
instruction. The time difference may not
A. "At home I take my pills at 8:00 am." be as significant in terms of its effect,
but this should be explained. Although
B. "It costs a lot of money to buy all of
comments about cost should be consid-
these pills."
ered when developing a discharge plan,
answers with rationales|A+ graded|
The nurse identifies a potential for infec-
B - Careful handwashing technique is the
tion in a client with partial-thickness (sec-
single most effective intervention for the
ond-degree) and full-thickness (third-de-
prevention of contamination to all clients.
gree) burns. What intervention has the
Option A reverses the hypovolemia that
highest priority in decreasing the client's
initially accompanies burn trauma but is
risk of infection?
not related to decreasing the prolifera-
A. Administration of plasma expanders tion of infective organisms. Options C
B. Use of careful handwashing technique and D are recommended by various burn
centers as possible ways to reduce the
C. Application of a topical antibacterial
chance of infection. Option B is a proven
cream
technique to prevent infection.
D.Limiting visitors to the client with burns
A client becomes angry while waiting for
a supervised break to smoke a cigarette
outside and states, "I want to go outside
now and smoke. It takes forever to get D - The best nursing action is to re-
anything done here!" Which intervention view the schedule of outdoor breaks and
is best for the nurse to implement? provide concrete information about the
schedule. Option A is contraindicated if
A. Encourage the client to use a nicotine the client wants to continue smoking. Op-
patch. tion B is insufficient to encourage a trust-
B. Reassure the client that it is almost ing relationship with the client. Option C
time for another break. is preferential for this client only and is
C. Have the client leave the unit with inconsistent with unit rules.
another staff member.
D. Review the schedule of outdoor
breaks with the client.
The nurse is teaching a client how to
perform progressive muscle relaxation
D - The nurse should first evaluate
techniques to relieve insomnia. A week
whether the client has been adhering to
later the client reports that he is still un-
the original instructions. A verbal report
able to sleep, despite following the same
of the client's routine will provide more
routine every night. Which action should
specific information than the client's writ-
the nurse take first?
ten diary. The nurse can then determine
which changes need to be made. The
A. Instruct the client to add regular exer-
routine practiced by the client is clearly
cise as a daily routine.
B. Determine if the client has been keep-
, Hesi nclex -rn comprehensive review exam 2025 latest questions and
answers with rationales|A+ graded|
ing a sleep diary.
C. Encourage the client to continue the
unsuccessful, so encouragement alone
routine until sleep is achieved.
is insufficient.
D. Ask the client to describe the routine
he is currently following.
Based on the nursing diagnosis of risk for
infection, which intervention is best for
the nurse to implement when providing A - The best action to decrease the risk
care for an older incontinent client? of infection in vulnerable clients is hand-
washing. Option B is not necessary un-
A. Maintain standard precautions. less the client has an infection. Option C
B. Initiate contact isolation measures. increases the risk of infection. Option D
C. Insert an indwelling urinary catheter. does not reduce the risk of infection.
D. Instruct client in the use of adult dia-
pers.
A nurse stops at a motor vehicle collision
site to render aid until the emergency
personnel arrive and applies pressure to
a groin wound that is bleeding profusely.
C - The Good Samaritan Act protects
Later the client has to have the leg ampu-
health care professionals who practice
tated and sues the nurse for malpractice.
in good faith and provide reasonable
Which is the most likely outcome of this
care from malpractice claims, regardless
lawsuit?
of the client outcome. Although the Pa-
tient's Bill of Rights protects clients, this
A. The Patient's Bill of Rights protects
nurse is protected by the Good Samari-
clients from malicious intents, so the
tan Act. The state Board of Nursing has
nurse could lose the case.
no reason to revoke a registered nurse's
B. The lawsuit may be settled out of
license unless there was evidence that
court, but the nurse's license is likely to
actions taken in the emergency were not
be revoked.
done in good faith or that reasonable
C. There will be no judgment against
care was not provided. All four elements
the nurse, whose actions were protected
of malpractice were not shown.
under the Good Samaritan Act.
D.The client will win because the four
elements of negligence (duty, breach,
causation, and damages) can be proved.
Ten minutes after signing an operative B - This statement may indicate that
permit for a fractured hip, an older client the client is confused. Informed consent
, Hesi nclex -rn comprehensive review exam 2025 latest questions and
answers with rationales|A+ graded|
states, "The aliens will be coming to get
must be provided by a mentally compe-
me soon!" and falls asleep. Which action
tent individual, so the nurse should fur-
should the nurse implement next?
ther assess the client's neurologic sta-
tus to be sure that the client under-
A. Make the client comfortable and allow
stands and can legally provide consent
the client to sleep.
for surgery. Option A does not provide
B. Assess the client's neurologic status.
sufficient follow-up. If the nurse deter-
C. Notify the surgeon about the com-
mines that the client is confused, the
ment.
surgeon must be notified and permission
D. Ask the client's family to co-sign the
obtained from the next of kin.
operative permit.
When taking a client's blood pressure,
the nurse is unable to distinguish the
point at which the first sound was heard.
Which is the best action for the nurse to
take? C - Deflating the cuff for 30 to 60 seconds
allows blood flow to return to the extrem-
A. Deflate the cuff completely and imme- ity so that an accurate reading can be
diately reattempt the reading. obtained on that extremity a second time.
B. Reinflate the cuff completely and Option A could result in a falsely high
leave it inflated for 90 to 110 seconds reading. Option B reduces circulation,
before taking the second reading. causes pain, and could alter the reading.
C. Deflate the cuff to zero and wait 30 Option D is not an accurate method of
to 60 seconds before reattempting the assessing blood pressure.
reading.
D. Document the exact level visualized
on the sphygmomanometer where the
first fluctuation was seen.
D - The client's recognition of a "new"
The nurse is administering the 0900
pill requires further assessment to veri-
medications to a client who was admitted
fy that the medication is correct, if it is
during the night. Which client statement
a new prescription or a different man-
indicates that the nurse should further
ufacturer, or if the client needs further
assess the medication order?
instruction. The time difference may not
A. "At home I take my pills at 8:00 am." be as significant in terms of its effect,
but this should be explained. Although
B. "It costs a lot of money to buy all of
comments about cost should be consid-
these pills."
ered when developing a discharge plan,
