Page 1 of 248
HESI NCLEX PRACTICE EXAM 2025 NEWEST ACTUAL
EXAM COMPLETE 50 QUESTIONS AND DETAILED
VERIFIED ANSWERS (100% CORRECT ANSWERS) WITH
RATIONALES/ALREADY GRADED A+
A 2-month-old infant is admitted with respiratory syncytial virus
and bronchiolitis. Which of the following interventions should the
nurse anticipate? Select all that apply.
1.Administer antipyretics
2.Initiate IV fluids
3.Keep the head of the bed flat
4.Maintain isolation precautions
5.Suction as needed ......ANSWER........Respiratory syncytial virus
(RSV) is a common cause of respiratory tract infection and
bronchiolitis in infants and children, occurring primarily during
the winter. It affects the ciliated cells of the respiratory tract,
,Page 2 of 248
causing bronchiolar swelling and excessive mucus production.
RSV in infants causes rhinorrhea, fever, cough, lethargy,
irritability, and poor feeding. Severe RSV infection also causes
tachypnea, dyspnea, and poor air exchange. Interventions are
supportive, including:
Administering antipyretics to reduce fever and provide comfort
(Option 1).
Initiating IV fluids to correct dehydration due to fever,
tachypnea, or poor oral intake (Option 2).
Maintaining contact isolation; droplet precautions are added if
within 3 ft (0.91 m) of the client, depending on the facility policy
(Option 4).
Providing supplemental oxygen and suctioning to support
oxygen exchange and clear the airway (Option 5).
,Page 3 of 248
(Option 3) The nurse should elevate the head of the bed to
improve diaphragmatic expansion and promote secretion
clearance.
Palivizumab, a monoclonal antibody, is administered
intramuscularly once monthly during the winter and spring to
prevent RSV in children at high risk for contracting the infection
(eg, prematurity, chronic lung disease).
Educational objective:Respiratory syncytial virus is a common
cause of respiratory tract infection and bronchiolitis in infants
and children. Nursing management includes respiratory support
(ie, supplemental oxygen, elevation of the head of the bed,
airway suctioning) and administration of antipyretics and IV
fluids. Contact isolation and droplet precautions are required.
, Page 4 of 248
A client arrives in the emergency department with right-sided
paralysis and slurred speech. The nurse understands that the
client cannot receive thrombolytic therapy due to which reason?
1. Client had gallbladder surgery 2 months ago (11%)
2.Client has experienced loss of the gag reflex (2%)
3.Client has platelet count of 130,000/mm3 [130 × 109/L]
(27%)
4.Client has symptoms that started 12 hours earlier (58%)
......ANSWER........Thrombolytic therapy (tissue plasminogen
activator [tPA]) is used to dissolve blood clots and restore
perfusion in clients with ischemic stroke. The nurse assesses for
contraindications to tPA due to the risk of hemorrhage.
tPA must be administered within a 3- to 4.5-hour window from
onset of symptoms for full effectiveness (Option 4).
(Option 1) Recent major surgery (within the past 14 days) is a
contraindication as tPA dissolves all clots in the body and may
HESI NCLEX PRACTICE EXAM 2025 NEWEST ACTUAL
EXAM COMPLETE 50 QUESTIONS AND DETAILED
VERIFIED ANSWERS (100% CORRECT ANSWERS) WITH
RATIONALES/ALREADY GRADED A+
A 2-month-old infant is admitted with respiratory syncytial virus
and bronchiolitis. Which of the following interventions should the
nurse anticipate? Select all that apply.
1.Administer antipyretics
2.Initiate IV fluids
3.Keep the head of the bed flat
4.Maintain isolation precautions
5.Suction as needed ......ANSWER........Respiratory syncytial virus
(RSV) is a common cause of respiratory tract infection and
bronchiolitis in infants and children, occurring primarily during
the winter. It affects the ciliated cells of the respiratory tract,
,Page 2 of 248
causing bronchiolar swelling and excessive mucus production.
RSV in infants causes rhinorrhea, fever, cough, lethargy,
irritability, and poor feeding. Severe RSV infection also causes
tachypnea, dyspnea, and poor air exchange. Interventions are
supportive, including:
Administering antipyretics to reduce fever and provide comfort
(Option 1).
Initiating IV fluids to correct dehydration due to fever,
tachypnea, or poor oral intake (Option 2).
Maintaining contact isolation; droplet precautions are added if
within 3 ft (0.91 m) of the client, depending on the facility policy
(Option 4).
Providing supplemental oxygen and suctioning to support
oxygen exchange and clear the airway (Option 5).
,Page 3 of 248
(Option 3) The nurse should elevate the head of the bed to
improve diaphragmatic expansion and promote secretion
clearance.
Palivizumab, a monoclonal antibody, is administered
intramuscularly once monthly during the winter and spring to
prevent RSV in children at high risk for contracting the infection
(eg, prematurity, chronic lung disease).
Educational objective:Respiratory syncytial virus is a common
cause of respiratory tract infection and bronchiolitis in infants
and children. Nursing management includes respiratory support
(ie, supplemental oxygen, elevation of the head of the bed,
airway suctioning) and administration of antipyretics and IV
fluids. Contact isolation and droplet precautions are required.
, Page 4 of 248
A client arrives in the emergency department with right-sided
paralysis and slurred speech. The nurse understands that the
client cannot receive thrombolytic therapy due to which reason?
1. Client had gallbladder surgery 2 months ago (11%)
2.Client has experienced loss of the gag reflex (2%)
3.Client has platelet count of 130,000/mm3 [130 × 109/L]
(27%)
4.Client has symptoms that started 12 hours earlier (58%)
......ANSWER........Thrombolytic therapy (tissue plasminogen
activator [tPA]) is used to dissolve blood clots and restore
perfusion in clients with ischemic stroke. The nurse assesses for
contraindications to tPA due to the risk of hemorrhage.
tPA must be administered within a 3- to 4.5-hour window from
onset of symptoms for full effectiveness (Option 4).
(Option 1) Recent major surgery (within the past 14 days) is a
contraindication as tPA dissolves all clots in the body and may
