ALL HESI EXIT ACTUAL 2026
Page |
QUESTIONS AND CORRECT
1
RELIABLE ANSWERS |TEST BANK|
A+ RATED GUIDE
Question 1
A nurse is caring for a client with a chest tube to water seal drainage for a pneumothorax. Continuous bubbling in
the water seal chamber and the client reports sudden shortness of breath. What should the nurse do first?
A) Clamp the chest tube near the insertion site
B) Check all connections and tubing for an air leak
C) Increase the suction pressure
D) Document the finding and continue to monitor
Answer: B
Continuous bubbling in the water seal chamber indicates an air leak. The priority is to check for loose connections,
cracks in the tubing, or disconnecting. Clamping the tube can cause tension pneumothorax. Increasing suction
doesn’t fix the leak. Documentation is not the first action.
Question 2
A client with heart failure has crackles in the lung bases, 2+ pedal edema, and a weight gain of 5 pounds in 3 days.
Which intervention should the nurse implement first?
A) Restrict oral fluids to 1,500 mL/day
B) Administer furosemide as ordered
C) Place the client in high-Fowler’s position
D) Notify the provider for a dose increase
, Answer: C
High-Fowler’s position promotes lung expansion and oxygenation. While furosemide will be given, positioning is the
immediate priority to relieve dyspnea. Fluid restriction is a long-term measure.
Page |
2 Question 3
A client receiving total parenteral nutrition (TPN) has a blood glucose of 320 mg/dL and reports thirst and increased
urination. What is the priority action?
A) Stop the TPN infusion immediately
B) Administer sliding-scale insulin as ordered
C) Slow the TPN rate to half
D) Flush the central line with heparin
Answer: B
Hyperglycemia is common with TPN due to high dextrose. Insulin is needed to lower glucose. TPN should never be
stopped abruptly (risk of hypoglycemia). Slowing the rate without insulin does not correct hyperglycemia.
Question 4
A nurse is caring for a client with an indwelling urinary catheter. The nurse notes that the urine output has been 20
mL in the past 4 hours. BP is 80/50, HR 120. What should the nurse do first?
A) Irrigate the Foley catheter
B) Increase the IV fluid rate
C) Assess for bladder distention
D) Notify the provider
Answer: B
Hypotension and oliguria suggest hypovolemic shock. Increasing IV fluids is the priority to restore circulating
volume before further troubleshooting the catheter. Irrigation is not first-line without assessing for obstruction.
Question 5
A client with bipolar disorder presents to the emergency department with pressured speech, grandiosity, and
aggressive behavior. Which medication should the nurse anticipate administering?
A) Lithium 600 mg PO
B) Haloperidol 5 mg IM
C) Fluoxetine 20 mg PO
D) Buspirone 10 mg PO
, Answer: B
IM haloperidol (with or without lorazepam) is used for rapid calming in acute agitation/mania. Lithium takes days
to weeks, SSRIs can worsen mania, and buspirone is for anxiety.
Page |
3 Question 6
A nurse is providing discharge teaching to a client with a new prescription for warfarin. Which statement requires
immediate follow-up?
A) “I will eat a large spinach salad every day.”
B) “I will take my warfarin at the same time each evening.”
C) “I will report any dark, tarry stools to my provider.”
D) “I will get my INR checked as scheduled.”
Answer: A
Spinach is high in vitamin K, which can decrease warfarin’s anticoagulant effect. Consistent vitamin K intake is
recommended, but drastically increasing intake reduces INR and clot risk. Dark tarry stools indicate GI bleeding
and should be reported.
Question 7
A client receiving a blood transfusion develops chills, back pain, and hypotension 15 minutes after the start. What is
the priority action?
A) Slow the transfusion rate
B) Stop the transfusion and infuse normal saline
C) Administer diphenhydramine
D) Check a stat hemoglobin and hematocrit
Answer: B
Chills, back pain, and hypotension indicate an acute hemolytic transfusion reaction. The transfusion must be
stopped immediately, tubing changed, and normal saline infused to maintain access. The provider must be notified.
Question 8
A nurse is assessing a client who is 2 hours post-op following a total knee arthroplasty. The client’s oxygen
saturation is 88% on room air, and the client reports sudden chest pain and dyspnea. What should the nurse suspect?
A) Atelectasis
B) Pulmonary embolism
C) Pneumonia
D) Fat embolism syndrome
, Answer: B
Sudden chest pain, dyspnea, and hypoxemia after surgery are classic signs of pulmonary embolism, especially after
lower extremity surgery. Atelectasis and pneumonia develop more slowly.
Page |
4 Question 9
A client with chronic kidney disease (stage 4) has a potassium of 6.5 mEq/L and ECG shows peaked T waves.
Which medication should the nurse prepare to administer first?
A) Sodium polystyrene sulfonate
B) IV calcium gluconate
C) IV insulin with dextrose
D) Albuterol nebulizer
Answer: B
IV calcium gluconate stabilizes the cardiac membrane and is given first for hyperkalemia with ECG changes. It does
not lower potassium but prevents dysrhythmias while other measures work.
Question 10
A nurse is caring for a client with a new tracheostomy. The client becomes cyanotic and the nurse cannot pass a
suction catheter through the tube. What should the nurse do first?
A) Deflate the cuff and remove the tube
B) Remove the inner cannula if present
C) Call a code blue
D) Manually ventilate with a bag-valve-mask over the stoma
Answer: B
If the tracheostomy tube has an inner cannula, removing it may clear an obstruction. If not, the tube should be
removed and replaced. This is an emergency, but removing the inner cannula is the immediate step.
Question 11
A client with diabetes mellitus type 1 has a blood glucose of 58 mg/dL and is alert. What should the nurse administer
first?
A) 4 oz of orange juice
B) 50 mL of 50% dextrose IV push
C) 1 mg of glucagon IM
D) A sandwich with peanut butter
Page |
QUESTIONS AND CORRECT
1
RELIABLE ANSWERS |TEST BANK|
A+ RATED GUIDE
Question 1
A nurse is caring for a client with a chest tube to water seal drainage for a pneumothorax. Continuous bubbling in
the water seal chamber and the client reports sudden shortness of breath. What should the nurse do first?
A) Clamp the chest tube near the insertion site
B) Check all connections and tubing for an air leak
C) Increase the suction pressure
D) Document the finding and continue to monitor
Answer: B
Continuous bubbling in the water seal chamber indicates an air leak. The priority is to check for loose connections,
cracks in the tubing, or disconnecting. Clamping the tube can cause tension pneumothorax. Increasing suction
doesn’t fix the leak. Documentation is not the first action.
Question 2
A client with heart failure has crackles in the lung bases, 2+ pedal edema, and a weight gain of 5 pounds in 3 days.
Which intervention should the nurse implement first?
A) Restrict oral fluids to 1,500 mL/day
B) Administer furosemide as ordered
C) Place the client in high-Fowler’s position
D) Notify the provider for a dose increase
, Answer: C
High-Fowler’s position promotes lung expansion and oxygenation. While furosemide will be given, positioning is the
immediate priority to relieve dyspnea. Fluid restriction is a long-term measure.
Page |
2 Question 3
A client receiving total parenteral nutrition (TPN) has a blood glucose of 320 mg/dL and reports thirst and increased
urination. What is the priority action?
A) Stop the TPN infusion immediately
B) Administer sliding-scale insulin as ordered
C) Slow the TPN rate to half
D) Flush the central line with heparin
Answer: B
Hyperglycemia is common with TPN due to high dextrose. Insulin is needed to lower glucose. TPN should never be
stopped abruptly (risk of hypoglycemia). Slowing the rate without insulin does not correct hyperglycemia.
Question 4
A nurse is caring for a client with an indwelling urinary catheter. The nurse notes that the urine output has been 20
mL in the past 4 hours. BP is 80/50, HR 120. What should the nurse do first?
A) Irrigate the Foley catheter
B) Increase the IV fluid rate
C) Assess for bladder distention
D) Notify the provider
Answer: B
Hypotension and oliguria suggest hypovolemic shock. Increasing IV fluids is the priority to restore circulating
volume before further troubleshooting the catheter. Irrigation is not first-line without assessing for obstruction.
Question 5
A client with bipolar disorder presents to the emergency department with pressured speech, grandiosity, and
aggressive behavior. Which medication should the nurse anticipate administering?
A) Lithium 600 mg PO
B) Haloperidol 5 mg IM
C) Fluoxetine 20 mg PO
D) Buspirone 10 mg PO
, Answer: B
IM haloperidol (with or without lorazepam) is used for rapid calming in acute agitation/mania. Lithium takes days
to weeks, SSRIs can worsen mania, and buspirone is for anxiety.
Page |
3 Question 6
A nurse is providing discharge teaching to a client with a new prescription for warfarin. Which statement requires
immediate follow-up?
A) “I will eat a large spinach salad every day.”
B) “I will take my warfarin at the same time each evening.”
C) “I will report any dark, tarry stools to my provider.”
D) “I will get my INR checked as scheduled.”
Answer: A
Spinach is high in vitamin K, which can decrease warfarin’s anticoagulant effect. Consistent vitamin K intake is
recommended, but drastically increasing intake reduces INR and clot risk. Dark tarry stools indicate GI bleeding
and should be reported.
Question 7
A client receiving a blood transfusion develops chills, back pain, and hypotension 15 minutes after the start. What is
the priority action?
A) Slow the transfusion rate
B) Stop the transfusion and infuse normal saline
C) Administer diphenhydramine
D) Check a stat hemoglobin and hematocrit
Answer: B
Chills, back pain, and hypotension indicate an acute hemolytic transfusion reaction. The transfusion must be
stopped immediately, tubing changed, and normal saline infused to maintain access. The provider must be notified.
Question 8
A nurse is assessing a client who is 2 hours post-op following a total knee arthroplasty. The client’s oxygen
saturation is 88% on room air, and the client reports sudden chest pain and dyspnea. What should the nurse suspect?
A) Atelectasis
B) Pulmonary embolism
C) Pneumonia
D) Fat embolism syndrome
, Answer: B
Sudden chest pain, dyspnea, and hypoxemia after surgery are classic signs of pulmonary embolism, especially after
lower extremity surgery. Atelectasis and pneumonia develop more slowly.
Page |
4 Question 9
A client with chronic kidney disease (stage 4) has a potassium of 6.5 mEq/L and ECG shows peaked T waves.
Which medication should the nurse prepare to administer first?
A) Sodium polystyrene sulfonate
B) IV calcium gluconate
C) IV insulin with dextrose
D) Albuterol nebulizer
Answer: B
IV calcium gluconate stabilizes the cardiac membrane and is given first for hyperkalemia with ECG changes. It does
not lower potassium but prevents dysrhythmias while other measures work.
Question 10
A nurse is caring for a client with a new tracheostomy. The client becomes cyanotic and the nurse cannot pass a
suction catheter through the tube. What should the nurse do first?
A) Deflate the cuff and remove the tube
B) Remove the inner cannula if present
C) Call a code blue
D) Manually ventilate with a bag-valve-mask over the stoma
Answer: B
If the tracheostomy tube has an inner cannula, removing it may clear an obstruction. If not, the tube should be
removed and replaced. This is an emergency, but removing the inner cannula is the immediate step.
Question 11
A client with diabetes mellitus type 1 has a blood glucose of 58 mg/dL and is alert. What should the nurse administer
first?
A) 4 oz of orange juice
B) 50 mL of 50% dextrose IV push
C) 1 mg of glucagon IM
D) A sandwich with peanut butter
