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HESI PN EXAM 2025 LATEST REAL
QUESTIONS AND CORRECT ANSWERS
GRADE A
A nurse is assigned to care four clients on the medical-surgical unit. Which client should the nurse see first on the shift assessment? A) A client admitted with pneumonia with a fever of 100°F and some diaphoresis B) A client with congestive heart failure with clear lung sounds on the previous shift C) A client with new-onset of shortness of breath (SOB) and a history of pulmonary edema D) A client undergoing long-term corticosteroid therapy with mild bruising on the anterior surfaces of the arms - CORRECT ANSWER C) A client with new-onset of shortness of breath and history of pulmonary edema Rationale: The client who should be seen first is the one with SOB and a history of pulmonary edema. In light of such a history, SOB could indicate that fluid-volume overload has once again developed. The client with a fever and who is diaphoretic is at risk for insufficient fluid volume as a result of loss of fluid through the skin, but this client is not the priority. A client with gastroenteritis who has been vomiting and has diarrhea is admitted to the hospital with a diagnosis of dehydration. For which clinical manifestations that correlate with this fluid imbalance would the nurse assess the client? Select all that apply.
A) Decreased Pulse B) Decreased urine output C) Increased BP D) Increased RR E) Decreased respiratory depth - CORRECT ANSWER B, D Rationale: A client with dehydration has an increased depth and rate of respirations. The diminished fluid volume is perceived by the body as a decreased oxygen level (hypoxia), and increased respiration is an attempt to maintain oxygen delivery. Other assessment findings in insufficient fluid volume are decreased urine volume, increased pulse, weight loss, poor skin turgor, dry mucous membranes, concentrated urine with increased specific gravity, increased hematocrit, and altered level of consciousness. Increased blood pressure, decreased pulse, and increased urine output occur with fluid-volume overload. A nurse is reviewing the medical records of the clients for the assigned 7 a.m.- 7 p.m. shift. Which client will the nurse monitor most closely for excessive fluid volume? A) A 48yo client receiving diuretics to treat hypertension B) A 35yo client who is vomiting undigested food after eating C) An 85yo client receiving IV therapy at a rate of 100 mL/hr D) A 65yo client with an NG tube attached to low suction following partial gastrectomy - CORRECT ANSWER C) An 85yo client receiving IV therapy at a rate of 100mL/hr Rationale:
A) 3.1 mEq/L B) 4.2 mEq/L C) 4.5 mEq/L D) 5.4 mEq/L - CORRECT ANSWER A) 3.1 mEq/L Rationale: A serum potassium level below 3.5 mEq/L is indicative of hypokalemia, the most common electrolyte imbalance, which is potentially life-threatening. ECG changes in hypokalemia include peaked P waves, flat T waves, a depressed ST segment, and prominent U waves. Readings of 4.5 mEq/L and 4.2 mEq/L are normal potassium levels; 5.4 mEq/L indicates hyperkalemia. A health care provider writes a prescription for the administration of intravenous (IV) potassium chloride to a client with hypokalemia. The nurse should reinforce which client instructions? A) A catheter will be inserted to drain your bladder B) A large intravenous line will be inserted into your chest vein C) This infusion requires use of a large caliber IV tubing D) This medication is diluted in a large bag of IV fluid and infused slowly into your vein - CORRECT ANSWER D) The medication is diluted in a large bag of IV fluid and infused slowly into your vein Rationale: Potassium chloride administered IV must always be diluted in IV fluid. Undiluted potassium chloride given IV can cause cardiac arrest. Potassium chloride is never administered as a bolus (IV push) injection; an IV push would result in sudden severe hyperkalemia, which could precipitate cardiac arrest. Although urine output is monitored carefully during administration, it is not necessary to insert a
Foley catheter unless this is specifically prescribed. Potassium chloride should be administered with the use of a controlled IV infusion device to avoid bolus infusion and increased risk of cardiac arrest. A central IV line is not necessary; potassium chloride may be administered through a peripheral IV line. A nurse notes that a client's serum potassium level is 5.8 mEq/L. The nurse interprets this as an expected finding in the client with? A) Diarrhea B) Wound drainage C) Addison disease D) Heart failure being treated with loop diuretics - CORRECT ANSWER C) Addison disease Rationale: A serum potassium level greater than 5.1 mEq/L indicates hyperkalemia, and the nurse would report the finding to the health care provider. Adrenal insufficiency (Addison disease) is a cause of hyperkalemia. Other common causes of hyperkalemia include tissue damage, such as that in burn injuries, renal failure, and the use of potassium-sparing diuretics. The client with diarrhea or wound drainage or the client being treated with diuretics is at risk for hypokalemia. A nurse is caring for a client experiencing hyponatremia who was admitted to the medical-surgical unit with fluid-volume overload. For which clinical manifestations of this electrolyte imbalance does the nurse monitor this client? Select all that apply. A) Slow pulse B) Decreased urine output C) Skeletal muscle weakness
A nurse is caring for a client with Crohn disease whose magnesium level is 1. mg/dL. Which assessment findings does the nurse expect to note? Select all that apply. A) Hypotension B) Abdominal distention C) Trousseau sign D) Skeletal muscle weakness E) Decreased deep tendon reflexes - CORRECT ANSWER B, C Rationale: The normal magnesium level is 1.6 to 2.6 mg/dL. A magnesium level of 1.0 mg/dL reflects hypomagnesemia. Assessment signs include hypertension; gastrointestinal manifestations such as anorexia, nausea, abdominal distention, and decreased bowel sounds; shallow respirations; neuromuscular manifestations such as twitches, paresthesias, hyperreflexia, and the Trousseau and Chvostek signs; and irritability and confusion. A nurse enters a client's room and finds the client unconscious. The nurse quickly determines that the client is not breathing. Which action does the nurse take first? A) Beginning chest compressions B) Checking the client's pulse oximetery reading C) Placing an oxygen mask on the client D) Counting the client's carotid pulse for 15 seconds - CORRECT ANSWER A) Beginning chest compressions Rationale: According to the American Heart Association, detecting a pulse may be difficult. The health care provider should take not more than 10 seconds to check for a pulse; if the rescuer does not definitely feel a pulse within that period, he or she
should start chest compressions. The acronym CAB (circulation, airway, and breathing) is used to prioritize the steps of cardiopulmonary resuscitation (CPR). Effective chest compressions are essential for providing blood flow during CPR. To provide effective chest compressions, the provider must push hard and fast. Current guidelines for CPR call for the initiation of compressions before ventilations. Oxygen may be helpful at some point, but the airway is opened before the administration of oxygen. Checking the client's pulse oximetry reading delays implementation of lifesaving measures. A nurse arrives at the scene of a client experiencing a cardiac/respiratory arrest and begins to assist with cardiopulmonary resuscitation (CPR) of an adult. The nurse delivers compressions by pushing down on the chest to which depth? A) 1 inch B) 1 1/2 inches C) 2 inches D) 4 inches - CORRECT ANSWER C) 2 inches Rationale: When CPR is being performed on an adult, the sternum should be depressed at least 2 inches (5 cm). The other options are incorrect because they are too shallow to be effective or are too deep, which can cause damage to internal organs. The rescuer should allow complete recoil of the chest after each compression to allow the heart to fill completely before the next compression. The nurse is administering cardiopulmonary resuscitation (CPR) to an adult client. Which compression/ventilation ratio is correct? A) 15: B) 15: C) 20:
Rationale: An infant's pulse should be checked at the brachial artery. The relatively short, fat neck of an infant makes palpation of the carotid artery (neck) difficult. Palpation of the pulse in the radial (wrist) and popliteal (behind the knee) area would also be difficult. A nurse is working in the emergency department. Which client should be assessed first? A) A client with new onset dizziness B) A client admitted with a recent ear injury C) A client who has been experiencing nausea and vomiting for 12 hours D) A client with new-onset atrial fibrillation with a rate of 118 - CORRECT ANSWER D) A client with new-onset atrial fibrillation with a rate of 118 Rationale: The client with new-onset atrial fibrillation is at risk for complications associated with the tachydysrhythmia. This dysrhythmia may result in decreased cardiac output because of ineffective atrial contractions. Thrombi form in the atria as a result of the pooling of blood. All of the other clients will require the nurse's attention, but the client who requires immediate attention and is the most hemodynamically unstable is the one with atrial fibrillation. A nurse is having dinner at a restaurant when a man sitting at the next table collapses and falls to the floor. The nurse yells for help and quickly notes that the client is not breathing and does not have a pulse. The nurse initiates cardiopulmonary resuscitation (CPR) immediately, and the restaurant manager rushes to the scene with an automatic external defibrillator (AED). What should the nurse do next? A) Use the AED
B) Stop resuscitation efforts C) Perform CPR until emergency medical services arrives D) Check for a pulse for 30 seconds before continuing CPR - CORRECT ANSWER A) Use the AED Rationale: Basic components of CPR include immediate recognition of the sudden cardiac arrest (unresponsiveness and absence of normal breathing) and activation of the emergency response system, early CPR, and rapid defibrillation with the use of an AED. A client with cancer of the larynx is receiving external radiation therapy of the neck. Which side effect related specifically to the site of irradiation does the nurse tell the client to expect? A) Diarrhea B) Dyspnea C) Headache D) Dysphagia - CORRECT ANSWER D) Dysphagia Rationale: In general, skin reactions and fatigue may occur with radiation therapy of any site, whereas other side effects occur only when a specific area lies in the treatment field. A client undergoing radiation therapy of the larynx is most likely to experience dysphagia. Diarrhea may occur with irradiation of the gastrointestinal tract. Dyspnea may occur with lung irradiation. Headache may occur with irradiation of the head.
Rationale: The nurse would limit each visitor to a half-hour per day and be sure that visitors remain at least 6 feet from the radiation source. The nurse would wear the dosimeter badge when caring for the client. The dosimeter badge measures an individual's exposure to radiation and should be used by only one individual. The dosimeter badge is not left in the client's room. The client is assigned to a private room with a private bath to keep other clients from being exposed to radiation. A female client who has undergone placement of a sealed radiation implant asks the nurse whether she can take a walk around the nursing unit. How should the nurse respond to the client's request? A) Short walks are OK B) You need to stay in your room for now. C) Yes, it's fine to take a walk around the nursing unit D) Do you think that a walk around the unit will tire you out? - CORRECT ANSWER B) You need to stay in your room for now Rationale: The client with a sealed radiation implant must remain in a private room to keep others from being exposed to radiation. The other options are all incorrect. A nurse answers the call bell of a client who has been fitted with an internal cervical radiation implant, and the client states that she thinks that the implant has fallen out. The nurse checks the client and sees the implant lying in the bed. Which action should the nurse take first? A) Calling the HCP B) Reinserting the implant into the client's vagina C) Picking up the implant with gloved hands and placing it in sterile water
D) Using long-handled forceps to place the implant in a lead container - CORRECT ANSWER D) Using long-handled forceps to place the implant in a lead container Rationale: A lead container and long-handled forceps should be kept in the client's room at all times during internal radiation therapy. If the implant is dislodged, the nurse should pick it up with long-handled forceps and place it in the lead container. Reinserting the implant into the vagina and picking up the implant with gloved hands and placing it in sterile water are both incorrect nursing actions. The health care provider is called after action is taken to maintain the safety of the client. A client who experienced a brain attack (stroke) exhibits right-sided unilateral neglect. The nurse caring for this client plans to place the client's personal care items in which manner? A) Within the client's reach on the left side B) Within the client's reach on the right side C) Just out of the client's reach on the left side D) Just out of the client's reach on the right side. - CORRECT ANSWER B) Within the client's reach on the right side Rationale: Unilateral neglect is unawareness of one side of the body. The client behaves as if that part is not there. It is possible for the client to relearn to look for and to move the affected limb(s). Therefore in this condition the client's personal care items are placed within the client's reach on the right side. The client with one-sided hemiparesis benefits from having objects placed on the unaffected side and within reach. This reduces client frustration and aids in ensuring client safety because the client does not have to strain and reach for needed items. The nurse adapts the client's environment to the deficit by focusing on the client's unaffected side and by placing the client's personal care items on the affected side within reach.
necessary to wear the glasses 24 hours a day. The client should keep objects in the intact field of vision whenever possible. An eye patch is of no use because the client does not have double vision. A nurse is reviewing home care instructions to a client with Parkinson disease about measures to avoid rigidity and to overcome tremor and bradykinesia. The nurse reinforces which information? A) Sit in soft, deep chairs B) Rock back and forth to start movement C) Exercise in the evening to combat fatigue D) Perform tasks with only the hand that has the tremor - CORRECT ANSWER B) Rock back and forth to start movement. Rationale: The client with Parkinson disease should rock back and forth to initiate movement with bradykinesia (slowed movement). The client should avoid sitting in soft, deep chairs to prevent rigidity and because they are difficult to get up from. The client should exercise in the morning, when the energy level is at its highest. The client with a tremor is instructed to use both hands to accomplish a task. A client with a spinal cord injury suddenly complains of a pounding headache. The nurse quickly arrives at the bedside and notes that the client is diaphoretic, his blood pressure has increased, and his heart rate has slowed. Suspecting that the client is experiencing autonomic dysreflexia, the nurse elevates the head of the client's bed and takes which immediate action? A) Documents the event B) Notifies the HCP C) Checks the client's bladder for distention
D) Checks to see whether the client has a prescription for an antihypertensive - CORRECT ANSWER C) Checks the client's bladder for distention Rationale: Autonomic dysreflexia is an emergency that occurs as a result of exaggerated autonomic responses to stimuli that are innocuous in normal individuals. It occurs only after spinal shock has resolved. A variety of stimuli may trigger this response, including a distended bladder (the most common cause); distention or contraction of the visceral organs, especially the bowel (as a result of constipation or impaction); or stimulation of the skin. When autonomic dysreflexia occurs, the client is immediately placed in a sitting position to lower the blood pressure. The nurse then performs a rapid assessment to identify and alleviate the cause. The client's bladder is emptied immediately by way of a urinary catheter, the rectum is checked for the presence of a fecal mass, and the skin is examined for areas of pressure, irritation, or compromise. The health care provider is notified, and then the nurse documents the occurrence and the actions taken. A nurse is monitoring a client who has just undergone radical neck dissection. The nurse notes that the client's blood pressure has dropped from 132/84 to 90/ mm Hg and that the pulse has increased from 78 to 96 beats/min. On the basis of these findings, the nurse takes which immediate action? A) Suctions the client B) Contacts the HCP C) Obtains a pulse oximeter D) Increases the rate of the client's IV solution - CORRECT ANSWER B) Contacts the HCP Rationale; In the immediate postoperative period, the nurse assesses the client for signs of bleeding. A drop in blood pressure and an increase in pulse are indicators of
D) Nonproductive cough - CORRECT ANSWER D) Nonproductive cough Rationale: The client with P. jiroveci infection usually has a cough as the first symptom, which begins as nonproductive then progresses to productive. Later signs include fever, dyspnea on exertion, and finally dyspnea at rest. A client arrives at the emergency department with complaints of a headache, hives, itching, and difficulty swallowing. The client states that he took ibuprofen (Motrin) 1 hour earlier and believes that he is experiencing an allergic reaction to this medication. After ensuring that the client has a patent airway, which intervention does the nurse prepare the client for first? A) Administration of normal saline solution B) Administration of IV glucocorticoid C) Administration of pain medication to relieve the client's headache D) Administration of a subcutaneous injection of epinephrine (Adrenalin) - CORRECT ANSWER A) Administration of a subcutaneous injection of epinephrine Rationale: Once airway has been established, the client would be given subcutaneous epinephrine. IV corticosteroids and IV fluids may also be prescribed. Pain medication may or may not be prescribed. The nurse is participating in a care planning conference for a patient with acquired immunodeficiency syndrome (AIDS). What is the nurse's highest priority in providing care to this client? A) Providing emotional support to the client
B) Discussing the cause of AIDS with the client C) Instituting measures to prevent infection in the client D) Identifying risk factors related to contracting AIDS with the client - CORRECT ANSWER C) Instituting measures to prevent infection in the client Rationale: The client with AIDS has inadequate immune bodies and is at risk for infection. The priority nursing intervention is protecting the client from infection. The nurse would also provide emotional support to the client. Discussing the cause of AIDS and the ways in which AIDS is contracted are not priority interventions. A client who sustained a fracture of the left arm requires the application of a plaster cast. The nurse tells the client that the procedure for applying the cast involves which step? A) Administering a local anesthetic to the fractured arm B) Soaking the left arm in a warm-water bath for 2 hours before cast application C) Debriding any open wounds and applying antibiotic ointment before the cast material is applied D) Applying soft padding and stockinette over the fractured arm, followed by the application of the cast material - CORRECT ANSWER D) Applying soft padding and stockinette over the fractured arm, followed by the application of the cast material Rationale: o apply a cast, the skin is washed and dried well, but it is not soaked in a warmwater bath. Padding is applied and a stockinette is placed smoothly and evenly over the area to be casted. The plaster is then rolled onto the padding and the edges are trimmed or smoothed as needed. Local anesthesia of the fractured extremity is not necessary, although an analgesic may be administered to alleviate
