1
Hesi Version 1
1. Pregnancy Induced Hypertension: high blood pressure, blurred vision, headache, Proteinuria,
Abdominal pain
2. A client is comatose upon arrival to the emergency room department after falling from the
roof. The client flexes with painful stimuli, and the nurse determines the client’s Glasgow Coma
Scale (GCS) is 6. Which intervention should the nurse prepare to implement to maintain the
client’s airway. A nasopharyngeal tube.
3.A client with rheumatoid arthritis reports a new onset of increasing fatigue. What intervention
should the nurse implement first? Answer: Assess the client for pallor
4.A client experiencing intracranial hypertension from a traumatic brain injury is admitted to the
trauma unit. How should the nurse position the client? Elevated head of bed.
5. Risk management: pt fell while using some equipment… charge nurse trying to find out what
happened- how? - hospital polices
6. The nurse is assessing a 48-year-old client with Guillain-Barre syndrome. What symptom is
this client most likely to exhibit? Decreased mobility of the legs.
7. Preop pt should be npo and pt had a glass of h2o-what to do- Alert surgeon/physician.
8. The nurse is caring for a client diagnosed with myasthenia gravis. Which nursing action is best
to promote independence in this client? Teach the client and family energy conservation
techniques.
9. The nurse is assessing a 2-week-old breastfeeding infant. To obtain information about the
adequate nutrition, which question should the nurse ask the breastfeeding mother? “How many
diapers does the infant wet daily?”
10. Zyvox & suprainfection – stomatitis
11. Potassium Chloride- Client able to void, assuring kidney function is present.
12. The nurse has identified four nursing problems for a 13-year-old admitted for depression and
anxiety. What is the priority problem? Risk for self directed violence related to history of self
multilation.
13. (Audio/visual)- ask to hear heart sounds- murmur (know difference between S1/S2 sounds
14. The nurse is teaching a client newly diagnosed with diabetes mellitus the signs of
hypoglycemia. What symptom should be included in the description of early signs of
hypoglycemia? Tremors.
, 2
15. When you are giving asthma med… which one would you give 1st: 1. bronchodilator 2.
Steroid
16. A male client diagnosed with hypertension has a nursing goal of, “the client will be able to
verbalize ways to decrease blood pressure.” What statement by the client indicates that this
outcome has been met? “if I loose weight, quit smoking, and exercise regularly I may not have
to take any medication.
17. (Select all that apply) Determining pain level for 3mo old infant- infant will clinch fists,
increase pulse, restlessness, increased respiratory effort
18 Penicillin G procaine (Wycillin) 135,000 units IM is prescribed for an infant with a middle
ear infection. The drug is available in a vial of 1,200,000 units /2ml. How many ml should the
nurse administer? 0.23. 1,200,000 : 2 ml :: 135, 000 : X 270/1200X = 0.225 ml = 0.23ml
19. Depressed client and best activity- assist client with making cut out cookies
20.The nurse is teaching a client’s caregiver how to cleanse around a wound drain. What is the
besy way to explain the proper cleansing technique? Start at the drain site, to avoid bringing skin
bacteria toward the wound.
21. CPR priority Arrange in other -1. Establish unresponsiveness. 2. Call for help. 3. Assess
patent airway. 4. Assess pt carotid pulses. 155. A client with endometrial carcinoma is receiving
brachytherapy and has radioactive Cesium (Cs) loaded in a vaginal applicator. What action
should the nurse implement? Wear a dosimeter film badge when in the client’s room
22. Math question with heparin you are given the ml/hr and the units you have to figure out how
much the patient is receiving which the answer is 2500
23.Alupent administration- The usual single dose is two to three inhalations. With repetitive
dosing, inhalation should usually not be repeated more often than about every three to four
hours. Total dosage per day should not exceed 12 inhalations. Alupent (metaproterenol sulfate
USP) Inhalation aerosol is not recommended for children under 12 years of age.
24. In scheduling home visits, which client is best for the home health charge nurse to begin to
assign to the licensed practical nurse? A bedfast client who needs daily irrigation of a stage 4
pressure ulcer.
25. A 65-year-old female client arrives in the emergency department with shortness of breath
and chest pain. The nurse accidentally administers 10 mg of morphine sulfate instead of 4 mg as
prescribed by the healthcare provider. Later, the client's respiratory rate is 10 breaths/minute,
oxygen saturation is 98%, and she states that her pain has subsided. What is the legal status of
the nurse? Answer: The client would not be able to prove malpractice in court.
26. In completing the treatment plan for an 11-year-old who has bipolar disorder, the nurse plans
outcomes for the nursing diagnosis, “Risk for violence towards peers related to
, 3
impulsivity.”Which outcome is important? Seeks out staff when having thoughts of harming
others. The most important outcome is for the client to seek staff when thoughts of harming
others occur.
27. The nurse is teaching a childbirth education class t prospective parents and describing
possible signs of labor. Class participants should be taught that which sign should be reported to
the healthcare provider immediately? Answer Leaking of fluid from the vagina
28.The nurse is performing a surgical hand scrub prior to entering the operating room. In what
order should the nurse perform the steps of this procedure? (Arrange from first on top on the last
bottom). Scrape under the nails with a nail pick. Rinse from the fingertips to the elbow. Use a
soapy brush to scrub the hands. Cleanse the arm with a lathered brush
29. How to do surgical scrubbing ( arrange in order)= clean nails, then hands, than arm, than u
rinse the whole thing off starting from fingertips to upper arm
30. An elderly client is admitted with a diagnosis of pneumonia. What sign or symptom would
require immediate intervention by the nurse? Has become agitated, aggressive and cinfused.
31. A client with gestational diabetes at 39-weeks gestation is in the second stage of labor. After
delivery of the fetal head, the nurse recognizes that shoulder dystocia is occurring. What
intervention should the nurse implement first? Answer Assist the client to sharply flex her thighs
up against the abdomen
32.While assessing a client’s blood pressure using an aneroid sphygmomanometer, the nurse
inflates the cuff to an initial reading of 160 mm calibration. Upon release of the air valve, the
nurse immediately hears loud Korotkoff sounds. What action should the nurse implement next?
Answer: Release the air and reinflate the cuff to 30 mm Hg above the client’s previous systolic
reading.
33. A 6-month-old male with bronchiolitis is admitted to the hospital. I monitoring the
respiratory status of the child, which symptom indicates to the nurse that he is experiencing
respiratory distress? Respiratory rate of 62 breaths/minute
34.Child w/ scabies what would u do to prevent complication- cut the nails and put mitten on
35 The healthcare provider prescribes oxytocin synthetic (Pitocin), 10 units/L via IV drip to
augment a client’s labor because she is experiencing a prolonged active phase. Because the
client is receiving Pitocin, the nurse should closely monitor for which complication? Uterine
Tetany
36. Hepatic encepahlopathy – Ammonia.
37. A client with a deep vein thrombosis is receiving a heparin protocol based on a target partial
thromboplastin time (PPT) of 65 to 95 seconds. The client’s current PTT result is 35 seconds.
What action should the nurse implement? Increasing the rate of the heparin infusion. Heparin
, 4
acts to block the conversion of prothrombin, which will effectively inhibit the formation of new
clots. To achieve a therapeutic heparinization and anticoagulation, the client’s PTT should be
within the therapeutic target range of 65 to 95 seconds, so the nurse should increase the heparin
infusion rate per protocol.
38. Female pt who being sexually and physically abused by bf and states I cant take it anymore=
ask her if she is thinking about suicide
39. A male Muslim client with pneumonia is scheduled to receive a dose of an intravenous
antibiotic but refuses to allow the nurse to begin the medication, stating he cannot allow fluids to
enter his body once he is cleansed for prayer. What action should the nurse implement?
Reschedule administration of the antibiotic until after he completes his prayers
40. Following the vaginal delivery of a 10-pound infant, the nurse assesses a new mother’s
vaginal bleeding and finds that she has saturated two pads in 30 minutes and has a boggy uterus.
What action should the nurse take first? Perform fundal massage until firm
41. A 16-year-old female client who attempted suicide that morning is admitted to the
psychiatric unit. To determine the seriousness of the adolescent’s suicide attempt which question
is most important for the nurse to ask the family? How did she attempt to kill herself
42. What nursing intervention should the nurse include in the plan of care for a client following
a bone marrow aspiration? Use of a compression dressing for firm pressure to the site.
43.A client is admitted to the emergency room because of an overdose of acetaminophen
(Tylenol). Following gastric lavage, the nurse should expect to administer which medication?
Answer Acetylcysteine (Mucomyst) The antidote for acetaminophen (Tylenol) is acetylcysteine
(Mucomyst)
44. The nurse observes that a client who is to avoid any weight-bearing on the left leg is using a
3-point crutch gait for ambulation. What is the best action for the nurse to initiate? Encourage
continues use of the 3-point gait by the client
45.For increase magnesium level - Give calcium gluconate.
46.The practical nurse (PN) reports the patterns of urinary frequency and volume for several
clients. Which finding necessaitates assessment by the RN? Voiding 50ml cloudy urine every
hour. The symptoms of voiding cloudy urine, at frequent intervals, in small amounts is abnormal
and may indicate urinary retention and infection.
47. Feedings for low albumin – Nepro, Ensure or TPN if pt is NPO.
48. Prioritrize question about tube feeding and how do you check it. Label, patient ID band,
against the MAR, and the physicians order.
49. A client with endometrial carcinoma is receiving brachytherapy and has radioactive Cesium
Hesi Version 1
1. Pregnancy Induced Hypertension: high blood pressure, blurred vision, headache, Proteinuria,
Abdominal pain
2. A client is comatose upon arrival to the emergency room department after falling from the
roof. The client flexes with painful stimuli, and the nurse determines the client’s Glasgow Coma
Scale (GCS) is 6. Which intervention should the nurse prepare to implement to maintain the
client’s airway. A nasopharyngeal tube.
3.A client with rheumatoid arthritis reports a new onset of increasing fatigue. What intervention
should the nurse implement first? Answer: Assess the client for pallor
4.A client experiencing intracranial hypertension from a traumatic brain injury is admitted to the
trauma unit. How should the nurse position the client? Elevated head of bed.
5. Risk management: pt fell while using some equipment… charge nurse trying to find out what
happened- how? - hospital polices
6. The nurse is assessing a 48-year-old client with Guillain-Barre syndrome. What symptom is
this client most likely to exhibit? Decreased mobility of the legs.
7. Preop pt should be npo and pt had a glass of h2o-what to do- Alert surgeon/physician.
8. The nurse is caring for a client diagnosed with myasthenia gravis. Which nursing action is best
to promote independence in this client? Teach the client and family energy conservation
techniques.
9. The nurse is assessing a 2-week-old breastfeeding infant. To obtain information about the
adequate nutrition, which question should the nurse ask the breastfeeding mother? “How many
diapers does the infant wet daily?”
10. Zyvox & suprainfection – stomatitis
11. Potassium Chloride- Client able to void, assuring kidney function is present.
12. The nurse has identified four nursing problems for a 13-year-old admitted for depression and
anxiety. What is the priority problem? Risk for self directed violence related to history of self
multilation.
13. (Audio/visual)- ask to hear heart sounds- murmur (know difference between S1/S2 sounds
14. The nurse is teaching a client newly diagnosed with diabetes mellitus the signs of
hypoglycemia. What symptom should be included in the description of early signs of
hypoglycemia? Tremors.
, 2
15. When you are giving asthma med… which one would you give 1st: 1. bronchodilator 2.
Steroid
16. A male client diagnosed with hypertension has a nursing goal of, “the client will be able to
verbalize ways to decrease blood pressure.” What statement by the client indicates that this
outcome has been met? “if I loose weight, quit smoking, and exercise regularly I may not have
to take any medication.
17. (Select all that apply) Determining pain level for 3mo old infant- infant will clinch fists,
increase pulse, restlessness, increased respiratory effort
18 Penicillin G procaine (Wycillin) 135,000 units IM is prescribed for an infant with a middle
ear infection. The drug is available in a vial of 1,200,000 units /2ml. How many ml should the
nurse administer? 0.23. 1,200,000 : 2 ml :: 135, 000 : X 270/1200X = 0.225 ml = 0.23ml
19. Depressed client and best activity- assist client with making cut out cookies
20.The nurse is teaching a client’s caregiver how to cleanse around a wound drain. What is the
besy way to explain the proper cleansing technique? Start at the drain site, to avoid bringing skin
bacteria toward the wound.
21. CPR priority Arrange in other -1. Establish unresponsiveness. 2. Call for help. 3. Assess
patent airway. 4. Assess pt carotid pulses. 155. A client with endometrial carcinoma is receiving
brachytherapy and has radioactive Cesium (Cs) loaded in a vaginal applicator. What action
should the nurse implement? Wear a dosimeter film badge when in the client’s room
22. Math question with heparin you are given the ml/hr and the units you have to figure out how
much the patient is receiving which the answer is 2500
23.Alupent administration- The usual single dose is two to three inhalations. With repetitive
dosing, inhalation should usually not be repeated more often than about every three to four
hours. Total dosage per day should not exceed 12 inhalations. Alupent (metaproterenol sulfate
USP) Inhalation aerosol is not recommended for children under 12 years of age.
24. In scheduling home visits, which client is best for the home health charge nurse to begin to
assign to the licensed practical nurse? A bedfast client who needs daily irrigation of a stage 4
pressure ulcer.
25. A 65-year-old female client arrives in the emergency department with shortness of breath
and chest pain. The nurse accidentally administers 10 mg of morphine sulfate instead of 4 mg as
prescribed by the healthcare provider. Later, the client's respiratory rate is 10 breaths/minute,
oxygen saturation is 98%, and she states that her pain has subsided. What is the legal status of
the nurse? Answer: The client would not be able to prove malpractice in court.
26. In completing the treatment plan for an 11-year-old who has bipolar disorder, the nurse plans
outcomes for the nursing diagnosis, “Risk for violence towards peers related to
, 3
impulsivity.”Which outcome is important? Seeks out staff when having thoughts of harming
others. The most important outcome is for the client to seek staff when thoughts of harming
others occur.
27. The nurse is teaching a childbirth education class t prospective parents and describing
possible signs of labor. Class participants should be taught that which sign should be reported to
the healthcare provider immediately? Answer Leaking of fluid from the vagina
28.The nurse is performing a surgical hand scrub prior to entering the operating room. In what
order should the nurse perform the steps of this procedure? (Arrange from first on top on the last
bottom). Scrape under the nails with a nail pick. Rinse from the fingertips to the elbow. Use a
soapy brush to scrub the hands. Cleanse the arm with a lathered brush
29. How to do surgical scrubbing ( arrange in order)= clean nails, then hands, than arm, than u
rinse the whole thing off starting from fingertips to upper arm
30. An elderly client is admitted with a diagnosis of pneumonia. What sign or symptom would
require immediate intervention by the nurse? Has become agitated, aggressive and cinfused.
31. A client with gestational diabetes at 39-weeks gestation is in the second stage of labor. After
delivery of the fetal head, the nurse recognizes that shoulder dystocia is occurring. What
intervention should the nurse implement first? Answer Assist the client to sharply flex her thighs
up against the abdomen
32.While assessing a client’s blood pressure using an aneroid sphygmomanometer, the nurse
inflates the cuff to an initial reading of 160 mm calibration. Upon release of the air valve, the
nurse immediately hears loud Korotkoff sounds. What action should the nurse implement next?
Answer: Release the air and reinflate the cuff to 30 mm Hg above the client’s previous systolic
reading.
33. A 6-month-old male with bronchiolitis is admitted to the hospital. I monitoring the
respiratory status of the child, which symptom indicates to the nurse that he is experiencing
respiratory distress? Respiratory rate of 62 breaths/minute
34.Child w/ scabies what would u do to prevent complication- cut the nails and put mitten on
35 The healthcare provider prescribes oxytocin synthetic (Pitocin), 10 units/L via IV drip to
augment a client’s labor because she is experiencing a prolonged active phase. Because the
client is receiving Pitocin, the nurse should closely monitor for which complication? Uterine
Tetany
36. Hepatic encepahlopathy – Ammonia.
37. A client with a deep vein thrombosis is receiving a heparin protocol based on a target partial
thromboplastin time (PPT) of 65 to 95 seconds. The client’s current PTT result is 35 seconds.
What action should the nurse implement? Increasing the rate of the heparin infusion. Heparin
, 4
acts to block the conversion of prothrombin, which will effectively inhibit the formation of new
clots. To achieve a therapeutic heparinization and anticoagulation, the client’s PTT should be
within the therapeutic target range of 65 to 95 seconds, so the nurse should increase the heparin
infusion rate per protocol.
38. Female pt who being sexually and physically abused by bf and states I cant take it anymore=
ask her if she is thinking about suicide
39. A male Muslim client with pneumonia is scheduled to receive a dose of an intravenous
antibiotic but refuses to allow the nurse to begin the medication, stating he cannot allow fluids to
enter his body once he is cleansed for prayer. What action should the nurse implement?
Reschedule administration of the antibiotic until after he completes his prayers
40. Following the vaginal delivery of a 10-pound infant, the nurse assesses a new mother’s
vaginal bleeding and finds that she has saturated two pads in 30 minutes and has a boggy uterus.
What action should the nurse take first? Perform fundal massage until firm
41. A 16-year-old female client who attempted suicide that morning is admitted to the
psychiatric unit. To determine the seriousness of the adolescent’s suicide attempt which question
is most important for the nurse to ask the family? How did she attempt to kill herself
42. What nursing intervention should the nurse include in the plan of care for a client following
a bone marrow aspiration? Use of a compression dressing for firm pressure to the site.
43.A client is admitted to the emergency room because of an overdose of acetaminophen
(Tylenol). Following gastric lavage, the nurse should expect to administer which medication?
Answer Acetylcysteine (Mucomyst) The antidote for acetaminophen (Tylenol) is acetylcysteine
(Mucomyst)
44. The nurse observes that a client who is to avoid any weight-bearing on the left leg is using a
3-point crutch gait for ambulation. What is the best action for the nurse to initiate? Encourage
continues use of the 3-point gait by the client
45.For increase magnesium level - Give calcium gluconate.
46.The practical nurse (PN) reports the patterns of urinary frequency and volume for several
clients. Which finding necessaitates assessment by the RN? Voiding 50ml cloudy urine every
hour. The symptoms of voiding cloudy urine, at frequent intervals, in small amounts is abnormal
and may indicate urinary retention and infection.
47. Feedings for low albumin – Nepro, Ensure or TPN if pt is NPO.
48. Prioritrize question about tube feeding and how do you check it. Label, patient ID band,
against the MAR, and the physicians order.
49. A client with endometrial carcinoma is receiving brachytherapy and has radioactive Cesium
