HESI Comprehensive Nursing Exam | ACTUAL
EXAM | Complete Questions & Verified Answers |
Latest Update | Already Graded A
1. A postoperative client receiving morphine reports nausea and is found to be
mildly hypotensive. Which action should the nurse take first?
A. Administer an antiemetic as prescribed
B. Decrease the morphine infusion rate
C. Assess the client’s respiratory rate and depth
D. Obtain a stat 12-lead ECG
Correct Answer: C
Rationale: Morphine can cause respiratory depression, hypotension, and nausea. The
priority nursing action is to assess the respiratory status first (ABCs). If respiratory
depression is present, naloxone may be required. Antiemetics and rate changes are
secondary to ensuring adequate ventilation.
2. A client with heart failure is prescribed digoxin 0.25 mg PO daily. Which finding
best indicates therapeutic effectiveness?
A. Heart rate 68 beats/min
B. Serum digoxin level 1.8 ng/mL
C. Decreased bilateral crackles
,D. Potassium level 3.2 mEq/L
Correct Answer: C
Rationale: The goal of digoxin therapy is improved cardiac output and decreased
congestion; decreased crackles reflect reduced pulmonary edema. A HR of 68 is
acceptable but not specific. Serum level is within range but does not prove clinical
effect. Hypokalemia increases digoxin toxicity risk.
3. The nurse is caring for a client with a chest tube that becomes dislodged from
the drainage system. What is the immediate priority?
A. Clamp the chest tube with a hemostat
B. Submerge the tube 2 cm under sterile water
C. Apply an occlusive sterile dressing taped on three sides
D. Reconnect the tube to a new drainage system
Correct Answer: C
Rationale: An occlusive dressing taped on three sides creates a one-way valve
preventing air entry while allowing escape, reducing risk of tension pneumothorax.
Clamping can trap air and cause tension pneumothorax. Submersion is not feasible at
bedside. Reconnection is done after immediate air leak is controlled.
4. A 6-hour-old newborn has a heel-stick glucose of 38 mg/dL. Which nursing action
is most appropriate?
A. Encourage early breastfeeding
B. Prepare for IV dextrose 10% bolus
,C. Notify neonatologist stat
D. Obtain a serum glucose confirmatory specimen
Correct Answer: A
Rationale: Normal term newborns may have transient glucose 30–45 mg/dL in first 12
hours. Initial management is early feeding to stabilize glucose. IV bolus is reserved for
symptomatic or <25 mg/dL. Confirmatory specimen is drawn only if screening value is
questionable after feeding attempt.
5. A client with bipolar disorder is pacing, clenching fists, and shouting after being
told TV time is over. Which intervention is best?
A. Offer extra TV time to prevent escalation
B. Administer PRN haloperidol immediately
C. Provide a quiet area with punching pillow
D. Place in seclusion without delay
Correct Answer: C
Rationale: De-escalation techniques (verbal, environmental, physical outlets) are
first-line. Offering extra time reinforces maladaptive behavior. PRN medication is used if
de-escalation fails and client is imminently aggressive. Seclusion is last resort for
imminent danger.
6. The nurse delegates to an experienced UAP the task of obtaining vital signs on a
stable post-appendectomy client. Which evaluation is required?
A. Compare UAP’s findings with previous set within 30 minutes
, B. Re-take vitals on any abnormal finding reported
C. Ask UAP to document findings in the EMR
D. Confirm UAP understood delegation instructions
Correct Answer: B
Rationale: The nurse retains accountability for interpretation of data; must reassess any
abnormal vital signs. Comparing within 30 minutes is unnecessary if stable.
Documentation is UAP responsibility but not evaluation. Confirming understanding
occurs at time of delegation, not evaluation.
7. A client receiving total parenteral nutrition (TPN) through a central line develops
sudden dyspnea, tachycardia, and chest pain. What should the nurse suspect?
A. Hyperglycemia
B. Air embolism
C. Catheter-related bloodstream infection
D. Fluid overload
Correct Answer: B
Rationale: Sudden respiratory distress and chest pain after central line manipulation
strongly suggest air embolism. Immediate actions include clamping catheter, placing
client in left lateral Trendelenburg. Hyperglycemia and infection have gradual onset; fluid
overload presents with crackles, JVD, not acute chest pain.
EXAM | Complete Questions & Verified Answers |
Latest Update | Already Graded A
1. A postoperative client receiving morphine reports nausea and is found to be
mildly hypotensive. Which action should the nurse take first?
A. Administer an antiemetic as prescribed
B. Decrease the morphine infusion rate
C. Assess the client’s respiratory rate and depth
D. Obtain a stat 12-lead ECG
Correct Answer: C
Rationale: Morphine can cause respiratory depression, hypotension, and nausea. The
priority nursing action is to assess the respiratory status first (ABCs). If respiratory
depression is present, naloxone may be required. Antiemetics and rate changes are
secondary to ensuring adequate ventilation.
2. A client with heart failure is prescribed digoxin 0.25 mg PO daily. Which finding
best indicates therapeutic effectiveness?
A. Heart rate 68 beats/min
B. Serum digoxin level 1.8 ng/mL
C. Decreased bilateral crackles
,D. Potassium level 3.2 mEq/L
Correct Answer: C
Rationale: The goal of digoxin therapy is improved cardiac output and decreased
congestion; decreased crackles reflect reduced pulmonary edema. A HR of 68 is
acceptable but not specific. Serum level is within range but does not prove clinical
effect. Hypokalemia increases digoxin toxicity risk.
3. The nurse is caring for a client with a chest tube that becomes dislodged from
the drainage system. What is the immediate priority?
A. Clamp the chest tube with a hemostat
B. Submerge the tube 2 cm under sterile water
C. Apply an occlusive sterile dressing taped on three sides
D. Reconnect the tube to a new drainage system
Correct Answer: C
Rationale: An occlusive dressing taped on three sides creates a one-way valve
preventing air entry while allowing escape, reducing risk of tension pneumothorax.
Clamping can trap air and cause tension pneumothorax. Submersion is not feasible at
bedside. Reconnection is done after immediate air leak is controlled.
4. A 6-hour-old newborn has a heel-stick glucose of 38 mg/dL. Which nursing action
is most appropriate?
A. Encourage early breastfeeding
B. Prepare for IV dextrose 10% bolus
,C. Notify neonatologist stat
D. Obtain a serum glucose confirmatory specimen
Correct Answer: A
Rationale: Normal term newborns may have transient glucose 30–45 mg/dL in first 12
hours. Initial management is early feeding to stabilize glucose. IV bolus is reserved for
symptomatic or <25 mg/dL. Confirmatory specimen is drawn only if screening value is
questionable after feeding attempt.
5. A client with bipolar disorder is pacing, clenching fists, and shouting after being
told TV time is over. Which intervention is best?
A. Offer extra TV time to prevent escalation
B. Administer PRN haloperidol immediately
C. Provide a quiet area with punching pillow
D. Place in seclusion without delay
Correct Answer: C
Rationale: De-escalation techniques (verbal, environmental, physical outlets) are
first-line. Offering extra time reinforces maladaptive behavior. PRN medication is used if
de-escalation fails and client is imminently aggressive. Seclusion is last resort for
imminent danger.
6. The nurse delegates to an experienced UAP the task of obtaining vital signs on a
stable post-appendectomy client. Which evaluation is required?
A. Compare UAP’s findings with previous set within 30 minutes
, B. Re-take vitals on any abnormal finding reported
C. Ask UAP to document findings in the EMR
D. Confirm UAP understood delegation instructions
Correct Answer: B
Rationale: The nurse retains accountability for interpretation of data; must reassess any
abnormal vital signs. Comparing within 30 minutes is unnecessary if stable.
Documentation is UAP responsibility but not evaluation. Confirming understanding
occurs at time of delegation, not evaluation.
7. A client receiving total parenteral nutrition (TPN) through a central line develops
sudden dyspnea, tachycardia, and chest pain. What should the nurse suspect?
A. Hyperglycemia
B. Air embolism
C. Catheter-related bloodstream infection
D. Fluid overload
Correct Answer: B
Rationale: Sudden respiratory distress and chest pain after central line manipulation
strongly suggest air embolism. Immediate actions include clamping catheter, placing
client in left lateral Trendelenburg. Hyperglycemia and infection have gradual onset; fluid
overload presents with crackles, JVD, not acute chest pain.
