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 prescribed digoxin 0.25 mg PO daily.
Which serum potassium level reported by the laboratory warrants immediate
intervention by the nurse?
A. 3.8 mEq/L
B. 4.0 mEq/L
C. 3.2 mEq/L
D. 4.5 mEq/L
Correct Answer: C
Rationale: Hypokalemia (serum potassium < 3.5 mEq/L) significantly increases the risk
of digoxin toxicity by enhancing myocardial sensitivity to the drug. The level of 3.2
mEq/L is below the normal range (3.5–5.0 mEq/L) and therefore requires immediate
notification of the provider and prompt replacement. Options A, B, and D are within or
very close to normal range and do not pose an acute threat of toxicity.
2. The nurse is caring for a 6-hour-old newborn who has yet to pass meconium. The
infant is breast-feeding well, temperature stable, and has voided once. Which
action is most appropriate?
A. Notify the neonatologist immediately
,B. Document the finding and continue to monitor
C. Perform a rectal stimulation with a thermometer
D. Insert a urinary catheter to assess for obstruction
Correct Answer: B
Rationale: A delay in passage of meconium for up to 24 hours is within normal limits for
a term newborn, particularly if feeding and voiding are adequate and no abdominal
distension is present. Documentation and ongoing assessment are sufficient at this
time. Immediate notification (A) is unnecessary without additional signs of distress.
Rectal stimulation (C) and catheter insertion (D) are invasive and unwarranted.
3. A client with schizophrenia tells the nurse, “The FBI planted a microchip in my
molar.” This statement is an example of:
A. Loose association
B. Delusion of persecution
C. Delusion of reference
D. Hallucination
Correct Answer: B
Rationale: A fixed false belief of being monitored or harmed by a powerful entity (FBI) is
a persecutory delusion. Loose association (A) refers to disorganized speech, not
content. Delusion of reference (C) involves believing neutral stimuli are directed at
oneself. Hallucination (D) is a false sensory perception, not a belief.
, 4. During morning rounds the nurse notes that a postoperative cholecystectomy
client’s T-tube drainage has decreased from 500 mL to 50 mL over 24 hours. The
client reports mild right upper-quadrant discomfort. What is the priority nursing
action?
A. Irrigate the T-tube with 30 mL sterile saline
B. Advance the T-tube 2 cm and re-tape
C. Notify the surgeon promptly
D. Encourage early ambulation to stimulate flow
Correct Answer: C
Rationale: A sudden drop in bile output accompanied by discomfort may indicate T-tube
occlusion or dislodgement, placing the client at risk for bile peritonitis. The surgeon
must be notified immediately for evaluation. Irrigation (A) is performed only under
physician order and with strict sterile technique. Advancing the tube (B) is outside
nursing scope. Ambulation (D) will not resolve mechanical obstruction.
5. A 4-year-old with acute lymphoblastic leukemia is receiving methotrexate
intrathecally. Which intervention best reduces the risk of chemical arachnoiditis?
A. Administer dexamethasone 6 mg IV prior to methotrexate
B. Hydrate the child with 2 L/m²/day IV fluids
C. Apply ice to the lumbar puncture site for 10 minutes
D. Keep the child flat for 4 hours after injection
Correct Answer: A
, Rationale: Prophylactic IV dexamethasone decreases inflammatory cytokine release
within the subarachnoid space, lowering the incidence of arachnoiditis. Aggressive
hydration (B) is used for high-dose systemic methotrexate to prevent nephrotoxicity, not
arachnoiditis. Ice (C) and flat positioning (D) do not influence meningeal inflammation.
6. The charge nurse is making assignments on a medical floor. Which client is most
appropriate for a new graduate nurse to care for independently?
A. A stable client 2 days post-MI awaiting stress test
B. A newly admitted client with sepsis on a norepinephrine drip
C. A client with newly diagnosed type 1 diabetes requiring discharge teaching
D. A client with acute asthma exacerbation on continuous albuterol
Correct Answer: A
Rationale: A stable post-MI client without active complications provides an opportunity
for the new nurse to practice telemetry monitoring and reinforcing teaching while having
predictable outcomes. The other clients require advanced assessment skills, titration of
vasoactive drips (B), extensive education (C), or frequent respiratory evaluations (D) that
exceed independent new-graduate scope.
7. A client in labor at 39 weeks receives an intrathecal dose of fentanyl and
bupivacaine. Within 5 minutes the nurse notes fetal bradycardia to 90
beats/minute for 90 seconds. The first action is to:
A. Administer IV terbutaline
B. Turn the client to the left lateral position
C. Apply fetal scalp electrode
EXAM | Complete Questions & Verified Answers |
Latest Update | Already Graded A
1. A client with a history of heart failure is prescribed digoxin 0.25 mg PO daily.
Which serum potassium level reported by the laboratory warrants immediate
intervention by the nurse?
A. 3.8 mEq/L
B. 4.0 mEq/L
C. 3.2 mEq/L
D. 4.5 mEq/L
Correct Answer: C
Rationale: Hypokalemia (serum potassium < 3.5 mEq/L) significantly increases the risk
of digoxin toxicity by enhancing myocardial sensitivity to the drug. The level of 3.2
mEq/L is below the normal range (3.5–5.0 mEq/L) and therefore requires immediate
notification of the provider and prompt replacement. Options A, B, and D are within or
very close to normal range and do not pose an acute threat of toxicity.
2. The nurse is caring for a 6-hour-old newborn who has yet to pass meconium. The
infant is breast-feeding well, temperature stable, and has voided once. Which
action is most appropriate?
A. Notify the neonatologist immediately
,B. Document the finding and continue to monitor
C. Perform a rectal stimulation with a thermometer
D. Insert a urinary catheter to assess for obstruction
Correct Answer: B
Rationale: A delay in passage of meconium for up to 24 hours is within normal limits for
a term newborn, particularly if feeding and voiding are adequate and no abdominal
distension is present. Documentation and ongoing assessment are sufficient at this
time. Immediate notification (A) is unnecessary without additional signs of distress.
Rectal stimulation (C) and catheter insertion (D) are invasive and unwarranted.
3. A client with schizophrenia tells the nurse, “The FBI planted a microchip in my
molar.” This statement is an example of:
A. Loose association
B. Delusion of persecution
C. Delusion of reference
D. Hallucination
Correct Answer: B
Rationale: A fixed false belief of being monitored or harmed by a powerful entity (FBI) is
a persecutory delusion. Loose association (A) refers to disorganized speech, not
content. Delusion of reference (C) involves believing neutral stimuli are directed at
oneself. Hallucination (D) is a false sensory perception, not a belief.
, 4. During morning rounds the nurse notes that a postoperative cholecystectomy
client’s T-tube drainage has decreased from 500 mL to 50 mL over 24 hours. The
client reports mild right upper-quadrant discomfort. What is the priority nursing
action?
A. Irrigate the T-tube with 30 mL sterile saline
B. Advance the T-tube 2 cm and re-tape
C. Notify the surgeon promptly
D. Encourage early ambulation to stimulate flow
Correct Answer: C
Rationale: A sudden drop in bile output accompanied by discomfort may indicate T-tube
occlusion or dislodgement, placing the client at risk for bile peritonitis. The surgeon
must be notified immediately for evaluation. Irrigation (A) is performed only under
physician order and with strict sterile technique. Advancing the tube (B) is outside
nursing scope. Ambulation (D) will not resolve mechanical obstruction.
5. A 4-year-old with acute lymphoblastic leukemia is receiving methotrexate
intrathecally. Which intervention best reduces the risk of chemical arachnoiditis?
A. Administer dexamethasone 6 mg IV prior to methotrexate
B. Hydrate the child with 2 L/m²/day IV fluids
C. Apply ice to the lumbar puncture site for 10 minutes
D. Keep the child flat for 4 hours after injection
Correct Answer: A
, Rationale: Prophylactic IV dexamethasone decreases inflammatory cytokine release
within the subarachnoid space, lowering the incidence of arachnoiditis. Aggressive
hydration (B) is used for high-dose systemic methotrexate to prevent nephrotoxicity, not
arachnoiditis. Ice (C) and flat positioning (D) do not influence meningeal inflammation.
6. The charge nurse is making assignments on a medical floor. Which client is most
appropriate for a new graduate nurse to care for independently?
A. A stable client 2 days post-MI awaiting stress test
B. A newly admitted client with sepsis on a norepinephrine drip
C. A client with newly diagnosed type 1 diabetes requiring discharge teaching
D. A client with acute asthma exacerbation on continuous albuterol
Correct Answer: A
Rationale: A stable post-MI client without active complications provides an opportunity
for the new nurse to practice telemetry monitoring and reinforcing teaching while having
predictable outcomes. The other clients require advanced assessment skills, titration of
vasoactive drips (B), extensive education (C), or frequent respiratory evaluations (D) that
exceed independent new-graduate scope.
7. A client in labor at 39 weeks receives an intrathecal dose of fentanyl and
bupivacaine. Within 5 minutes the nurse notes fetal bradycardia to 90
beats/minute for 90 seconds. The first action is to:
A. Administer IV terbutaline
B. Turn the client to the left lateral position
C. Apply fetal scalp electrode
