nightingale EXIT HESI
Comprehensive B Evolve Practice
Questions With Complete
Solutions
Course
HESI
1. A nurse is caring for a client who is 4 hours postoperative following abdominal surgery.
The client reports sudden shortness of breath and chest pain. Which action should the
nurse take FIRST?
A. Administer prescribed opioid medication
B. Apply oxygen and assess respiratory status
C. Encourage the client to ambulate
D. Notify the family of the complication
Correct Answer: B. Apply oxygen and assess respiratory status
Solution/Rationale:
Sudden dyspnea and chest pain after surgery may indicate a pulmonary embolism. The priority is
to support oxygenation and assess respiratory status using the ABCs (Airway, Breathing,
Circulation). The nurse should provide oxygen, assess vital signs, and notify the provider after
immediate stabilization.
2. A nurse is preparing to administer insulin to a client with diabetes mellitus. Which
finding requires the nurse to hold the medication and notify the provider?
A. Blood glucose level of 55 mg/dL
B. Blood glucose level of 180 mg/dL
C. Client reports increased thirst
D. Client ate breakfast 30 minutes ago
Correct Answer: A. Blood glucose level of 55 mg/dL
Solution/Rationale:
A glucose level of 55 mg/dL indicates hypoglycemia. Administering insulin could further lower
blood glucose and cause serious complications. The nurse should treat hypoglycemia according
to protocol and notify the provider if necessary.
,3. A nurse is caring for a client with heart failure. Which assessment finding requires
immediate intervention?
A. Weight gain of 2 kg (4.4 lb) in 2 days
B. Mild fatigue after activity
C. Heart rate of 82 beats/min
D. Blood pressure of 128/76 mmHg
Correct Answer: A. Weight gain of 2 kg (4.4 lb) in 2 days
Solution/Rationale:
Rapid weight gain indicates fluid retention and worsening heart failure. The nurse should assess
for edema, respiratory distress, and notify the healthcare provider.
4. A nurse is teaching a client who is prescribed warfarin. Which statement by the client
indicates understanding?
A. "I will avoid foods high in vitamin K."
B. "I can take aspirin whenever I have pain."
C. "I should stop the medication when I feel better."
D. "I do not need blood tests while taking this medication."
Correct Answer: A. "I will avoid foods high in vitamin K."
Solution/Rationale:
Vitamin K decreases the effectiveness of warfarin. Clients should maintain consistent vitamin K
intake and avoid sudden dietary changes. INR monitoring is required during therapy.
5. A nurse is caring for a client experiencing a seizure. Which action should the nurse take?
A. Insert a tongue blade into the client's mouth
B. Restrain the client's arms and legs
C. Protect the client from injury and maintain airway safety
D. Leave the client alone until the seizure stops
Correct Answer: C. Protect the client from injury and maintain airway safety
Solution/Rationale:
During a seizure, the priority is safety. The nurse should protect the client from injury, place
them in a safe position if possible, maintain airway, and monitor the duration of the seizure.
,6. A nurse is caring for a client receiving chemotherapy. Which laboratory value should the
nurse report immediately?
A. WBC count of 1,000/mm³
B. Hemoglobin of 12 g/dL
C. Platelet count of 250,000/mm³
D. Sodium level of 138 mEq/L
Correct Answer: A. WBC count of 1,000/mm³
Solution/Rationale:
A severely decreased white blood cell count indicates neutropenia and a high risk for infection.
The nurse should implement infection precautions and notify the provider.
7. A nurse is caring for a client who has a new prescription for morphine. Which
assessment finding requires immediate action?
A. Respiratory rate of 8 breaths/min
B. Pain rating of 7/10
C. Blood pressure of 130/80 mmHg
D. Drowsiness after administration
Correct Answer: A. Respiratory rate of 8 breaths/min
Solution/Rationale:
Morphine can cause respiratory depression. A respiratory rate below normal requires immediate
assessment and intervention, including possible administration of naloxone if prescribed.
8. A nurse is preparing discharge teaching for a client after a myocardial infarction. Which
instruction is appropriate?
A. Resume strenuous exercise immediately
B. Follow a heart-healthy diet and gradually increase activity
C. Stop taking medications when symptoms improve
D. Avoid all physical activity permanently
Correct Answer: B. Follow a heart-healthy diet and gradually increase activity
Solution/Rationale:
Post-MI care focuses on preventing recurrence through medication adherence, lifestyle
modification, dietary changes, smoking cessation, and gradual activity progression.
, 9. A nurse is caring for a client with pneumonia. Which finding indicates improvement?
A. Oxygen saturation increases from 89% to 96%
B. Respiratory rate increases from 20 to 36/min
C. Temperature increases to 39°C (102.2°F)
D. Increased production of thick sputum
Correct Answer: A. Oxygen saturation increases from 89% to 96%
Solution/Rationale:
Improved oxygen saturation indicates better respiratory function. Increased respiratory rate,
fever, and worsening sputum may indicate deterioration.
10. A nurse is caring for a client who expresses suicidal thoughts. Which action is the
priority?
A. Ask the client directly about a suicide plan
B. Leave the client alone to provide privacy
C. Tell the client that suicide is wrong
D. Change the subject to reduce anxiety
Correct Answer: A. Ask the client directly about a suicide plan
Solution/Rationale:
Clients expressing suicidal thoughts require immediate safety assessment. Asking directly about
intent, plan, and means does not increase suicide risk and helps determine necessary
interventions.
11. A nurse is caring for a client with chronic obstructive pulmonary disease (COPD).
Which intervention should the nurse include?
A. Encourage rapid deep breathing
B. Teach pursed-lip breathing techniques
C. Place the client in a flat supine position
D. Restrict all physical activity
Correct Answer: B. Teach pursed-lip breathing techniques
Solution/Rationale:
Pursed-lip breathing helps clients with COPD improve oxygenation by prolonging exhalation,
reducing air trapping, and improving ventilation.
Comprehensive B Evolve Practice
Questions With Complete
Solutions
Course
HESI
1. A nurse is caring for a client who is 4 hours postoperative following abdominal surgery.
The client reports sudden shortness of breath and chest pain. Which action should the
nurse take FIRST?
A. Administer prescribed opioid medication
B. Apply oxygen and assess respiratory status
C. Encourage the client to ambulate
D. Notify the family of the complication
Correct Answer: B. Apply oxygen and assess respiratory status
Solution/Rationale:
Sudden dyspnea and chest pain after surgery may indicate a pulmonary embolism. The priority is
to support oxygenation and assess respiratory status using the ABCs (Airway, Breathing,
Circulation). The nurse should provide oxygen, assess vital signs, and notify the provider after
immediate stabilization.
2. A nurse is preparing to administer insulin to a client with diabetes mellitus. Which
finding requires the nurse to hold the medication and notify the provider?
A. Blood glucose level of 55 mg/dL
B. Blood glucose level of 180 mg/dL
C. Client reports increased thirst
D. Client ate breakfast 30 minutes ago
Correct Answer: A. Blood glucose level of 55 mg/dL
Solution/Rationale:
A glucose level of 55 mg/dL indicates hypoglycemia. Administering insulin could further lower
blood glucose and cause serious complications. The nurse should treat hypoglycemia according
to protocol and notify the provider if necessary.
,3. A nurse is caring for a client with heart failure. Which assessment finding requires
immediate intervention?
A. Weight gain of 2 kg (4.4 lb) in 2 days
B. Mild fatigue after activity
C. Heart rate of 82 beats/min
D. Blood pressure of 128/76 mmHg
Correct Answer: A. Weight gain of 2 kg (4.4 lb) in 2 days
Solution/Rationale:
Rapid weight gain indicates fluid retention and worsening heart failure. The nurse should assess
for edema, respiratory distress, and notify the healthcare provider.
4. A nurse is teaching a client who is prescribed warfarin. Which statement by the client
indicates understanding?
A. "I will avoid foods high in vitamin K."
B. "I can take aspirin whenever I have pain."
C. "I should stop the medication when I feel better."
D. "I do not need blood tests while taking this medication."
Correct Answer: A. "I will avoid foods high in vitamin K."
Solution/Rationale:
Vitamin K decreases the effectiveness of warfarin. Clients should maintain consistent vitamin K
intake and avoid sudden dietary changes. INR monitoring is required during therapy.
5. A nurse is caring for a client experiencing a seizure. Which action should the nurse take?
A. Insert a tongue blade into the client's mouth
B. Restrain the client's arms and legs
C. Protect the client from injury and maintain airway safety
D. Leave the client alone until the seizure stops
Correct Answer: C. Protect the client from injury and maintain airway safety
Solution/Rationale:
During a seizure, the priority is safety. The nurse should protect the client from injury, place
them in a safe position if possible, maintain airway, and monitor the duration of the seizure.
,6. A nurse is caring for a client receiving chemotherapy. Which laboratory value should the
nurse report immediately?
A. WBC count of 1,000/mm³
B. Hemoglobin of 12 g/dL
C. Platelet count of 250,000/mm³
D. Sodium level of 138 mEq/L
Correct Answer: A. WBC count of 1,000/mm³
Solution/Rationale:
A severely decreased white blood cell count indicates neutropenia and a high risk for infection.
The nurse should implement infection precautions and notify the provider.
7. A nurse is caring for a client who has a new prescription for morphine. Which
assessment finding requires immediate action?
A. Respiratory rate of 8 breaths/min
B. Pain rating of 7/10
C. Blood pressure of 130/80 mmHg
D. Drowsiness after administration
Correct Answer: A. Respiratory rate of 8 breaths/min
Solution/Rationale:
Morphine can cause respiratory depression. A respiratory rate below normal requires immediate
assessment and intervention, including possible administration of naloxone if prescribed.
8. A nurse is preparing discharge teaching for a client after a myocardial infarction. Which
instruction is appropriate?
A. Resume strenuous exercise immediately
B. Follow a heart-healthy diet and gradually increase activity
C. Stop taking medications when symptoms improve
D. Avoid all physical activity permanently
Correct Answer: B. Follow a heart-healthy diet and gradually increase activity
Solution/Rationale:
Post-MI care focuses on preventing recurrence through medication adherence, lifestyle
modification, dietary changes, smoking cessation, and gradual activity progression.
, 9. A nurse is caring for a client with pneumonia. Which finding indicates improvement?
A. Oxygen saturation increases from 89% to 96%
B. Respiratory rate increases from 20 to 36/min
C. Temperature increases to 39°C (102.2°F)
D. Increased production of thick sputum
Correct Answer: A. Oxygen saturation increases from 89% to 96%
Solution/Rationale:
Improved oxygen saturation indicates better respiratory function. Increased respiratory rate,
fever, and worsening sputum may indicate deterioration.
10. A nurse is caring for a client who expresses suicidal thoughts. Which action is the
priority?
A. Ask the client directly about a suicide plan
B. Leave the client alone to provide privacy
C. Tell the client that suicide is wrong
D. Change the subject to reduce anxiety
Correct Answer: A. Ask the client directly about a suicide plan
Solution/Rationale:
Clients expressing suicidal thoughts require immediate safety assessment. Asking directly about
intent, plan, and means does not increase suicide risk and helps determine necessary
interventions.
11. A nurse is caring for a client with chronic obstructive pulmonary disease (COPD).
Which intervention should the nurse include?
A. Encourage rapid deep breathing
B. Teach pursed-lip breathing techniques
C. Place the client in a flat supine position
D. Restrict all physical activity
Correct Answer: B. Teach pursed-lip breathing techniques
Solution/Rationale:
Pursed-lip breathing helps clients with COPD improve oxygenation by prolonging exhalation,
reducing air trapping, and improving ventilation.
