HESI NCLEX Practice Questions
Six hours ago, a client of 72 returned from surgery. The client received hydromorphone 2 mg
IV 30 minutes ago for pain rating 8/10. The Family member requests her father be checked
immediately. With a respiration rate of 6, the patient is difficult to rouse when the nurse
enters the room. 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. Naloxone 0.4 mg intravenously 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 who requires a bed bath and has a stage 3 pressure ulcer. C. A patient
receiving an enteral feeding and consuming 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. The nurse should start with which prescribed intervention? A.
Increase the rate of O2 flow.
B. Get the results of the arterial blood gas. 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. Start access to a large-bore IV 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 mg/250 mL is equal to 2000 mg/mL. 5 mcg x 65 kg x 60 minutes equals 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. Dyspnea develops in the
patient. Which action should the nurse take first?
A. Call the HCP
B. Obtain a bedside pulse oximeter
C. Increase the bed's head height. D. Assess the clients vital signs - ANS-C. Raise the
head of the bed higher
For COPD you want an SpO2 >90%. Fowler's position can help to open up the chest wall
and aid in breathing. B and D are typically assessed simultaneously, so you can mark those
off. A client who has hyperparathyroidism is scheduled to receive a prescribed dose of oral
phosphate. The nurse notes that the client's serum calcium is 12.5 mg/dL. What action
should the nurse take?
A. Hold the phosphate and notify the HCP
B. Examine the client's serum level of parathyroid hormone. C. Give a PRN dose of IV
calcium per protocol
D. Administer the dose of oral phosphate - ANS-D. Administer the dose of oral phosphate
A normal calcium level is 5.5-10.5 mg/dL so this value is high. Because calcium and
phosphate react in opposite ways, reducing calcium necessitates adding more phosphate.
Giving the oral phosphate will be beneficial to lowering the serum calcium level.
A client who had a history of uterine fibroids underwent a cesarean section 12 hours earlier
and gave birth to twins who were healthy. At shift change, the nurse assesses the client and
notes shortness of breath, cool extremities, and oozing of blood from the incision site.
Based on the client's presentation, which nursing action has the highest priority?
A. Assess the client's temperature
B. Notify the healthcare provider
Six hours ago, a client of 72 returned from surgery. The client received hydromorphone 2 mg
IV 30 minutes ago for pain rating 8/10. The Family member requests her father be checked
immediately. With a respiration rate of 6, the patient is difficult to rouse when the nurse
enters the room. 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. Naloxone 0.4 mg intravenously 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 who requires a bed bath and has a stage 3 pressure ulcer. C. A patient
receiving an enteral feeding and consuming 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. The nurse should start with which prescribed intervention? A.
Increase the rate of O2 flow.
B. Get the results of the arterial blood gas. 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. Start access to a large-bore IV 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 mg/250 mL is equal to 2000 mg/mL. 5 mcg x 65 kg x 60 minutes equals 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. Dyspnea develops in the
patient. Which action should the nurse take first?
A. Call the HCP
B. Obtain a bedside pulse oximeter
C. Increase the bed's head height. D. Assess the clients vital signs - ANS-C. Raise the
head of the bed higher
For COPD you want an SpO2 >90%. Fowler's position can help to open up the chest wall
and aid in breathing. B and D are typically assessed simultaneously, so you can mark those
off. A client who has hyperparathyroidism is scheduled to receive a prescribed dose of oral
phosphate. The nurse notes that the client's serum calcium is 12.5 mg/dL. What action
should the nurse take?
A. Hold the phosphate and notify the HCP
B. Examine the client's serum level of parathyroid hormone. C. Give a PRN dose of IV
calcium per protocol
D. Administer the dose of oral phosphate - ANS-D. Administer the dose of oral phosphate
A normal calcium level is 5.5-10.5 mg/dL so this value is high. Because calcium and
phosphate react in opposite ways, reducing calcium necessitates adding more phosphate.
Giving the oral phosphate will be beneficial to lowering the serum calcium level.
A client who had a history of uterine fibroids underwent a cesarean section 12 hours earlier
and gave birth to twins who were healthy. At shift change, the nurse assesses the client and
notes shortness of breath, cool extremities, and oozing of blood from the incision site.
Based on the client's presentation, which nursing action has the highest priority?
A. Assess the client's temperature
B. Notify the healthcare provider
