HESI-style practice questions with correct
answers and brief rationales (mixed
topics: med-surg, pharm, maternity, peds,
psych, leadership)2025_2026
1. A client with chronic heart failure reports gaining 4 kg (8.8 lb) in 3 days
and increasing shortness of breath. Which action should the nurse take
first?
A. Restrict fluids to 1 L/day.
✅
B. Obtain orthostatic vital signs.
C. Auscultate lung sounds and assess respiratory status.
D. Administer prescribed potassium supplement.
Rationale: Rapid weight gain and dyspnea suggest fluid overload/pulmonary edema; assessing
respiratory status (lung sounds, work of breathing, O₂ sat) is priority to determine urgent
interventions.
2. A patient is prescribed lisinopril for hypertension. Which adverse effect
should the nurse teach the patient to report immediately?
A. Dry cough.
✅
B. Dizziness on standing.
C. Swelling of face or lips.
D. Mild fatigue.
Rationale: Angioedema (facial or lip swelling) is a rare but life-threatening adverse effect of
ACE inhibitors that requires immediate attention.
3. A laboring client at 39 weeks has contractions every 2 minutes, fetal
heart rate (FHR) 170/min with moderate variability. What is the nurse’s best
interpretation?
, ✅
A. Early fetal tachycardia — continue routine monitoring.
B. Fetal tachycardia; evaluate maternal temperature and possible infection.
C. Normal reactive tracing — encourage ambulation.
D. Variable decelerations — prepare for operative delivery.
Rationale: FHR 170 is tachycardia; moderate variability is reassuring but maternal
fever/infection or fetal issues should be assessed as causes.
4. A client with type 1 diabetes has weakness, tremors, diaphoresis, and
confusion 30 minutes after insulin. Which is the best immediate action?
✅
A. Give 4 oz fruit juice or 15 g fast-acting carb.
B. Give subcutaneous glucagon.
C. Give a bolus of IV regular insulin.
D. Give complex carbohydrate and protein snack.
Rationale: Symptoms indicate hypoglycemia — give 15 g quick-acting carbohydrate (juice,
glucose gel) immediately; if unable to swallow or unconscious, use glucagon/IV dextrose.
5. A client taking warfarin has INR 4.2 and no bleeding. Which action
should nurse expect?
✅
A. Administer vitamin K IV immediately.
B. Hold warfarin and notify provider; consider vitamin K per protocol.
C. Continue warfarin and recheck in one week.
D. Give fresh frozen plasma now.
Rationale: INR >4.0 without bleeding often requires holding warfarin and contacting provider;
vitamin K may be ordered depending on risk—FFP is for significant bleeding or very high INR.
6. Post-op patient on PCA morphine: respiratory rate 8/min, somnolent, O₂
sat 89%. What is priority nursing action?
A. Give naloxone and call rapid response. ✅
B. Decrease PCA basal rate and continue monitoring.
C. Encourage deep breathing and coughing.
D. Apply oxygen at 2 L/min by nasal cannula.
answers and brief rationales (mixed
topics: med-surg, pharm, maternity, peds,
psych, leadership)2025_2026
1. A client with chronic heart failure reports gaining 4 kg (8.8 lb) in 3 days
and increasing shortness of breath. Which action should the nurse take
first?
A. Restrict fluids to 1 L/day.
✅
B. Obtain orthostatic vital signs.
C. Auscultate lung sounds and assess respiratory status.
D. Administer prescribed potassium supplement.
Rationale: Rapid weight gain and dyspnea suggest fluid overload/pulmonary edema; assessing
respiratory status (lung sounds, work of breathing, O₂ sat) is priority to determine urgent
interventions.
2. A patient is prescribed lisinopril for hypertension. Which adverse effect
should the nurse teach the patient to report immediately?
A. Dry cough.
✅
B. Dizziness on standing.
C. Swelling of face or lips.
D. Mild fatigue.
Rationale: Angioedema (facial or lip swelling) is a rare but life-threatening adverse effect of
ACE inhibitors that requires immediate attention.
3. A laboring client at 39 weeks has contractions every 2 minutes, fetal
heart rate (FHR) 170/min with moderate variability. What is the nurse’s best
interpretation?
, ✅
A. Early fetal tachycardia — continue routine monitoring.
B. Fetal tachycardia; evaluate maternal temperature and possible infection.
C. Normal reactive tracing — encourage ambulation.
D. Variable decelerations — prepare for operative delivery.
Rationale: FHR 170 is tachycardia; moderate variability is reassuring but maternal
fever/infection or fetal issues should be assessed as causes.
4. A client with type 1 diabetes has weakness, tremors, diaphoresis, and
confusion 30 minutes after insulin. Which is the best immediate action?
✅
A. Give 4 oz fruit juice or 15 g fast-acting carb.
B. Give subcutaneous glucagon.
C. Give a bolus of IV regular insulin.
D. Give complex carbohydrate and protein snack.
Rationale: Symptoms indicate hypoglycemia — give 15 g quick-acting carbohydrate (juice,
glucose gel) immediately; if unable to swallow or unconscious, use glucagon/IV dextrose.
5. A client taking warfarin has INR 4.2 and no bleeding. Which action
should nurse expect?
✅
A. Administer vitamin K IV immediately.
B. Hold warfarin and notify provider; consider vitamin K per protocol.
C. Continue warfarin and recheck in one week.
D. Give fresh frozen plasma now.
Rationale: INR >4.0 without bleeding often requires holding warfarin and contacting provider;
vitamin K may be ordered depending on risk—FFP is for significant bleeding or very high INR.
6. Post-op patient on PCA morphine: respiratory rate 8/min, somnolent, O₂
sat 89%. What is priority nursing action?
A. Give naloxone and call rapid response. ✅
B. Decrease PCA basal rate and continue monitoring.
C. Encourage deep breathing and coughing.
D. Apply oxygen at 2 L/min by nasal cannula.
