HESI Comprehensive Nursing Exam | ACTUAL
EXAM | Complete Questions & Verified Answers |
Latest Update | Already Graded A
1. A client with a history of heart failure is admitted with worsening dyspnea and
bilateral ankle edema. Which assessment finding requires immediate nursing
intervention?
A. Oxygen saturation 92% on room air
B. Weight gain of 1 kg (2.2 lb) since yesterday
C. Urine output 25 mL/hr for the past 4 hours
D. Respiratory rate 24 breaths/min
Correct Answer: C
Rationale: Oliguria (≤30 mL/hr) signals inadequate renal perfusion from declining
cardiac output and can rapidly progress to acute kidney injury; therefore immediate
intervention such as diuretic adjustment or fluid management is required. Option A
(SpO₂ 92%) is mild hypoxemia that can be managed with supplemental oxygen. Option
B (1 kg weight gain) is significant but not as immediately life-threatening as oliguria.
Option D (RR 24) is tachypneic but expected in acute decompensated heart failure.
2. The nurse is preparing to administer enoxaparin 40 mg subcutaneous to a
postoperative client. Which action is essential?
A. Expel the air bubble from the prefilled syringe before injection
,B. Pinch the skin and inject at a 90-degree angle into the abdomen
C. Massage the site after injection to enhance absorption
D. Aspirate prior to injection to avoid intravascular placement
Correct Answer: B
Rationale: Low-molecular-weight heparins are given subcutaneously via deep abdominal
fold injection at 90° without aspiration or massage to minimize bruising. The prefilled
syringe contains an intentional air lock that should NOT be expelled (A) because it
clears the needle track and reduces hematoma risk. Massaging (C) and aspirating (D)
are contraindicated.
3. A client on telemetry suddenly develops coarse ventricular fibrillation. What is the
nurse’s first action?
A. Administer amiodarone 300 mg IV push
B. Defibrillate at 200 J immediately
C. Check carotid pulse for up to 10 seconds
D. Establish IV access in the antecubital vein
Correct Answer: B
Rationale: V-fib is a shockable rhythm; immediate defibrillation is the priority within <2
minutes to improve survival. Pulse check (C) delays definitive treatment. Amiodarone
(A) is given after initial shocks and CPR. IV access (D) can be established concurrently
but does not precede defibrillation.
4. A 6-hour-old newborn has not passed meconium. The nurse should first:
,A. Notify the neonatologist immediately
B. Document and continue routine monitoring
C. Gently stimulate the rectum with a thermometer
D. Offer 10 mL sterile water to promote peristalsis
Correct Answer: B
Rationale: Term infants may pass meconium up to 24 hours after birth; 6 hours is within
normal limits. Immediate notification (A) is premature. Rectal stimulation (C) risks
mucosal trauma. Offering water (D) is contraindicated in exclusively breast/formula-fed
newborns.
5. A school-age child with asthma is taught to use a peak-flow meter. Which
statement indicates correct understanding?
A. “I should stop my daily inhaled steroid if my reading is in the green zone.”
B. “I will record my highest reading each afternoon after recess.”
C. “I will measure my peak flow every morning before taking my medications.”
D. “A yellow-zone reading means I need to go to the emergency room.”
Correct Answer: C
Correct: Consistent morning pre-medication readings establish a personal-best
baseline. Green-zone readings do NOT justify stopping controller meds (A). Highest
reading (B) is irrelevant; personal-best is used. Yellow zone indicates caution and
provider-directed plan changes, not ER visit (D).
, 6. A client with major depressive disorder is started on sertraline. Which instruction
is most important for the client?
A. Expect full therapeutic effect within 3 days
B. Avoid grapefruit juice while taking this drug
C. Report any sudden elevation in mood
D. Take the dose at bedtime to prevent daytime drowsiness
Correct Answer: C
Rationale: SSRI therapy can precipitate mania/hypomania; clients must report abrupt
mood elevation. Therapeutic lag is 2–4 weeks (A). Grapefruit (B) is not a significant
interaction for sertraline. Sedation is uncommon; if it occurs, bedtime dosing is
acceptable but not universally required (D).
7. The charge nurse observes a new graduate documenting “lidocaine 2 g IV push”
for a ventricular dysrhythmia. What action should the charge nurse take first?
A. Complete an incident report after the shift
B. Immediately verify the amount administered with the graduate
C. Ask the pharmacist to double-check the syringe
D. Re-educate the graduate on antiarrhythmic dosing
Correct Answer: B
Rationale: 2 g is ten times the maximum IV dose; immediate verification prevents
further harm. Incident report (A) and education (D) follow client stabilization.
Pharmacist (C) is secondary to direct nurse verification.
EXAM | Complete Questions & Verified Answers |
Latest Update | Already Graded A
1. A client with a history of heart failure is admitted with worsening dyspnea and
bilateral ankle edema. Which assessment finding requires immediate nursing
intervention?
A. Oxygen saturation 92% on room air
B. Weight gain of 1 kg (2.2 lb) since yesterday
C. Urine output 25 mL/hr for the past 4 hours
D. Respiratory rate 24 breaths/min
Correct Answer: C
Rationale: Oliguria (≤30 mL/hr) signals inadequate renal perfusion from declining
cardiac output and can rapidly progress to acute kidney injury; therefore immediate
intervention such as diuretic adjustment or fluid management is required. Option A
(SpO₂ 92%) is mild hypoxemia that can be managed with supplemental oxygen. Option
B (1 kg weight gain) is significant but not as immediately life-threatening as oliguria.
Option D (RR 24) is tachypneic but expected in acute decompensated heart failure.
2. The nurse is preparing to administer enoxaparin 40 mg subcutaneous to a
postoperative client. Which action is essential?
A. Expel the air bubble from the prefilled syringe before injection
,B. Pinch the skin and inject at a 90-degree angle into the abdomen
C. Massage the site after injection to enhance absorption
D. Aspirate prior to injection to avoid intravascular placement
Correct Answer: B
Rationale: Low-molecular-weight heparins are given subcutaneously via deep abdominal
fold injection at 90° without aspiration or massage to minimize bruising. The prefilled
syringe contains an intentional air lock that should NOT be expelled (A) because it
clears the needle track and reduces hematoma risk. Massaging (C) and aspirating (D)
are contraindicated.
3. A client on telemetry suddenly develops coarse ventricular fibrillation. What is the
nurse’s first action?
A. Administer amiodarone 300 mg IV push
B. Defibrillate at 200 J immediately
C. Check carotid pulse for up to 10 seconds
D. Establish IV access in the antecubital vein
Correct Answer: B
Rationale: V-fib is a shockable rhythm; immediate defibrillation is the priority within <2
minutes to improve survival. Pulse check (C) delays definitive treatment. Amiodarone
(A) is given after initial shocks and CPR. IV access (D) can be established concurrently
but does not precede defibrillation.
4. A 6-hour-old newborn has not passed meconium. The nurse should first:
,A. Notify the neonatologist immediately
B. Document and continue routine monitoring
C. Gently stimulate the rectum with a thermometer
D. Offer 10 mL sterile water to promote peristalsis
Correct Answer: B
Rationale: Term infants may pass meconium up to 24 hours after birth; 6 hours is within
normal limits. Immediate notification (A) is premature. Rectal stimulation (C) risks
mucosal trauma. Offering water (D) is contraindicated in exclusively breast/formula-fed
newborns.
5. A school-age child with asthma is taught to use a peak-flow meter. Which
statement indicates correct understanding?
A. “I should stop my daily inhaled steroid if my reading is in the green zone.”
B. “I will record my highest reading each afternoon after recess.”
C. “I will measure my peak flow every morning before taking my medications.”
D. “A yellow-zone reading means I need to go to the emergency room.”
Correct Answer: C
Correct: Consistent morning pre-medication readings establish a personal-best
baseline. Green-zone readings do NOT justify stopping controller meds (A). Highest
reading (B) is irrelevant; personal-best is used. Yellow zone indicates caution and
provider-directed plan changes, not ER visit (D).
, 6. A client with major depressive disorder is started on sertraline. Which instruction
is most important for the client?
A. Expect full therapeutic effect within 3 days
B. Avoid grapefruit juice while taking this drug
C. Report any sudden elevation in mood
D. Take the dose at bedtime to prevent daytime drowsiness
Correct Answer: C
Rationale: SSRI therapy can precipitate mania/hypomania; clients must report abrupt
mood elevation. Therapeutic lag is 2–4 weeks (A). Grapefruit (B) is not a significant
interaction for sertraline. Sedation is uncommon; if it occurs, bedtime dosing is
acceptable but not universally required (D).
7. The charge nurse observes a new graduate documenting “lidocaine 2 g IV push”
for a ventricular dysrhythmia. What action should the charge nurse take first?
A. Complete an incident report after the shift
B. Immediately verify the amount administered with the graduate
C. Ask the pharmacist to double-check the syringe
D. Re-educate the graduate on antiarrhythmic dosing
Correct Answer: B
Rationale: 2 g is ten times the maximum IV dose; immediate verification prevents
further harm. Incident report (A) and education (D) follow client stabilization.
Pharmacist (C) is secondary to direct nurse verification.
