HESI NC2 CUSTOM QUESTIONS/HESI 1
1-A client with a history of chronic pain requests a nonopioid analgesic. The client is alert but has
difficulty describing the exact nature and location of the pain to the nurse. What action should the nurse
implement next?
a. Assess the client’s vital signs.
b. Observe the client’s pupils for dilation.
c. Document the client’s drug tolerance.
d. Administer the analgesic as requested
2-XXX An older female client has normal saline infusion at 45 mL/hour. She complains of pain at the
insertion site of the IV catheter. There is no redness or edema around the IV site. Which action should
the nurse take?
a. Determine what IV medications have recently been administered.
b. Explain that without redness or edema, there is no need to re-start the IV.
c. Consult with the health care provider about the best location to start a new IV.
d. Convert the IV to a saline lock and continue to monitor the site.
3-XXX The nurse is reviewing blood pressure readings for a group of clients on a medical unit. Which
client is at the highest risk for complications related to hypertension?
a. Older Asian male who eats a diet consisting of smoked, cured, and pickled foods.
b. Young adult Hispanic female who has a hemoglobin of 11 g/dL and drinks beer every day.
c. Post-menopausal Caucasian female who overeats and is 20% above ideal body weights.
d. Middle-aged African-American male who has a serum creatinine level of 2.9 Mg/dL.
4-XXX An 82-year-old female client with Type 2 diabetes and degenerative arthritis complains to the
nurse that she has a hard time cutting her toenails. Which should the nurse recommend?
a. Soak feet for 10 minutes before cutting nails.
b. As a family member to cut her toenails.
c. Seek routine nail care with a podiatrist.
d. Encourage monthly pedicures at a nail shop.
5-XXX The nurse is evaluating teaching about drug therapy to treat gout. Which statement by the client
demonstrates an understanding of the use of allopurinol to treat gout?
a. I need to take the prescribed amount of the drug to get rid of my gout.
b. The pain and swelling can be controlled by taking this drug every day.
c. I should take this drug when I have gout attacks to reduce symptoms.
d. I need to take this drug every day to keep from having any flare-ups.
?????6- The nurse is assessing a client who has herpes zoster (shingles). Which question will allow the
nurse to gather further information about this condition?
,HESI NC2 CUSTOM QUESTIONS/HESI 1
a. Has everyone at home already had varicella?
b. Do you have any dry patches on your feet and hands?
c. Do your family members share combs and brushes?
d. Have the antifungal creams been effective?
7- A community hit by a hurricane has suffered mass destruction and flooding. Sewage facilities are non-
functioning, and the area is contaminated with human excreta. The nurse is developing a plan of care for
clients diagnosed with cholera after an outbreak. Which intervention has the highest priority?
a. Isolate all infectious diarrhea victims.
b. Provide fluid and electrolyte replacement.
c. Administer prophylactic antibiotics as prescribed.
d. Administer cholera vaccine.
8- The nurse provides dietary instructions about iron rich foods to a client with iron deficiency anemia.
Which food selection made by the client indicates a need for additional instructions?
a. Liver
b. Oranges
c. Kidney beans
d. Leafy green vegetables
9- A male client with AIDS and Pneumocystis jirovenci pneumonia has a CD4 T cell count of 200
cells/microliter. The client asks the nurse why he keeps getting these massive infections. Which
pathophysiologic mechanism should the nurse describe in response to this client’s question?
a. Exposure to multiple environmental infectious agents overburdens the immune system until it
fails.
b. Inadequate numbers of T lymphocytes are available to initiate cellular immunity and
macrophages.
c. The humoral immune response lacks B cells that form antibodies and opportunistic infections
result.
d. Bone marrow suppression of white blood cells causes insufficient cells to phagocytize organisms.
10- Methotrexate is prescribed for a client with rheumatoid arthritis who is also taking aspirin. What is
the best explanation for the nurse to provide as to why a second medication has been added?
a. Methotrexate slows the disease progression while aspirin controls the symptoms.
b. Methotrexate enhances the effectiveness of the aspirin.
c. Methotrexate helps to reduce the side effects of the aspirin therapy.
d. Methotrexate has less harmful side effects than aspirin.
11- A government office worker is seen in the emergency room after opening an envelope containing a
powder-like substance which is being tested for anthrax. Which discharge instruction should the nurse
provide the client concerning inhalation anthrax?
,HESI NC2 CUSTOM QUESTIONS/HESI 1
a. Cleanse all surfaces touched with pre-moistened anti-bacterial wipes.
b. Return to the emergency room if flu-like symptoms develop within 42 days.
c. Isolation from friends and family members is recommended for 3 weeks.
d. Notify co-workers to get the anthrax vaccine at the public health department.
12- A healthcare worker with no known exposure to tuberculosis has received a Mantoux tuberculosis
skin test. The nurse’s assessment of the test after 62 hours indicates 5 mm of erythema without
induration. Which is the best initial nursing action?
a. Document negative results in the client’s medical record.
b. Review client’s history for possible exposure to TB.
c. Refer client to a healthcare provider for isoniazid therapy.
d. Instruct the client to return for a repeat test in 1 week.
13- A 55 year old client with osteoarthritis asks which form of exercise would be most beneficial. What is
the best response by the nurse?
a. Limit your exercise to just your daily activities.
b. Jogging or running are excellent aerobic exercises.
c. Swimming is an excellent exercise for you.
d. Tennis or racquetball will increase your muscle strength.
14- The nurse is triaging clients who have been injured during a tornado. Which client requires
immediate action?
a. An adult male with type 1 diabetes who is ambulatory with capillary refill of 2 seconds and
respirations at 22 breaths/minute.
b. A middle aged female with a broken humerus who is unable to follow commands and is crying.
c. A middle aged male with acute anxiety, a laceration on his left cheek, and respirations of 24
breaths/minute.
d. An older female with degenerative disk disease who is hard of hearing and continues to ask
questions.
15- The nurse working in a disaster area assesses an adult male who has partial-thickness burns on his
lower legs, on approximately 10 % of his lower body. Which color of triage tag should the nurse place on
this client?
a. Black
b. Red
c. Yellow
d. Green
16- An adult client who received partial thickness and full thickness burns over 40% of the body in a
house fire is admitted to the inpatient burn unit. Which fluid should the nurse prepare to administer
during the acute phase of the client’s burn recovery?
, HESI NC2 CUSTOM QUESTIONS/HESI 1
a. 5% dextrose in water.
b. 5% dextrose in 0.25 normal saline.
c. Total parenteral nutrition.
d. Lactate Ringer’s
17- A unlicensed assistive personnel reports to the nurse that a client with a postoperative wound
infection has a temperature of 103.8 F, blood pressure of 90/70, pulse of 124/minute, and respirations of
28/minute. When the nurse assesses the client, findings include mottled skin appearance and confusion.
Which action should the nurse take first?
a. Transfer the client to ICU.
b. Initiate an infusion of IV fluids.
c. Obtain a wound specimen for culture.
d. Assess the client’s core temperature.
18- Which nursing diagnosis should be selected for a client who is receiving thrombolytic infusions for
treatment of an acute myocardial infarction?
a. Deficient knowledge related to a new medication regimen.
b. Risk for injury related to effects of thrombolysis.
c. Activity intolerance related to ischemia.
d. Ineffective breathing pattern related to adverse drug effects.
????? 19- A client with partial thickness burns to the lower extremities is scheduled for whirlpool
therapy to debride the burned area. Which intervention should the nurse implement before transporting
the client to the physical therapy department?
a. Obtain supplies to redress the burn area.
b. Perform active range of motion exercises.
c. Verify the client’s signed consent form.
d. Give a prescribed narcotic analgesic agent.
20- Based on this strip, what is the interpretation of this rhythm?
a. First degree AV heart block.
b. Junctional escape rhythm.
c. Sinus bradycardia.
d. Normal sinus rhythm.
1-A client with a history of chronic pain requests a nonopioid analgesic. The client is alert but has
difficulty describing the exact nature and location of the pain to the nurse. What action should the nurse
implement next?
a. Assess the client’s vital signs.
b. Observe the client’s pupils for dilation.
c. Document the client’s drug tolerance.
d. Administer the analgesic as requested
2-XXX An older female client has normal saline infusion at 45 mL/hour. She complains of pain at the
insertion site of the IV catheter. There is no redness or edema around the IV site. Which action should
the nurse take?
a. Determine what IV medications have recently been administered.
b. Explain that without redness or edema, there is no need to re-start the IV.
c. Consult with the health care provider about the best location to start a new IV.
d. Convert the IV to a saline lock and continue to monitor the site.
3-XXX The nurse is reviewing blood pressure readings for a group of clients on a medical unit. Which
client is at the highest risk for complications related to hypertension?
a. Older Asian male who eats a diet consisting of smoked, cured, and pickled foods.
b. Young adult Hispanic female who has a hemoglobin of 11 g/dL and drinks beer every day.
c. Post-menopausal Caucasian female who overeats and is 20% above ideal body weights.
d. Middle-aged African-American male who has a serum creatinine level of 2.9 Mg/dL.
4-XXX An 82-year-old female client with Type 2 diabetes and degenerative arthritis complains to the
nurse that she has a hard time cutting her toenails. Which should the nurse recommend?
a. Soak feet for 10 minutes before cutting nails.
b. As a family member to cut her toenails.
c. Seek routine nail care with a podiatrist.
d. Encourage monthly pedicures at a nail shop.
5-XXX The nurse is evaluating teaching about drug therapy to treat gout. Which statement by the client
demonstrates an understanding of the use of allopurinol to treat gout?
a. I need to take the prescribed amount of the drug to get rid of my gout.
b. The pain and swelling can be controlled by taking this drug every day.
c. I should take this drug when I have gout attacks to reduce symptoms.
d. I need to take this drug every day to keep from having any flare-ups.
?????6- The nurse is assessing a client who has herpes zoster (shingles). Which question will allow the
nurse to gather further information about this condition?
,HESI NC2 CUSTOM QUESTIONS/HESI 1
a. Has everyone at home already had varicella?
b. Do you have any dry patches on your feet and hands?
c. Do your family members share combs and brushes?
d. Have the antifungal creams been effective?
7- A community hit by a hurricane has suffered mass destruction and flooding. Sewage facilities are non-
functioning, and the area is contaminated with human excreta. The nurse is developing a plan of care for
clients diagnosed with cholera after an outbreak. Which intervention has the highest priority?
a. Isolate all infectious diarrhea victims.
b. Provide fluid and electrolyte replacement.
c. Administer prophylactic antibiotics as prescribed.
d. Administer cholera vaccine.
8- The nurse provides dietary instructions about iron rich foods to a client with iron deficiency anemia.
Which food selection made by the client indicates a need for additional instructions?
a. Liver
b. Oranges
c. Kidney beans
d. Leafy green vegetables
9- A male client with AIDS and Pneumocystis jirovenci pneumonia has a CD4 T cell count of 200
cells/microliter. The client asks the nurse why he keeps getting these massive infections. Which
pathophysiologic mechanism should the nurse describe in response to this client’s question?
a. Exposure to multiple environmental infectious agents overburdens the immune system until it
fails.
b. Inadequate numbers of T lymphocytes are available to initiate cellular immunity and
macrophages.
c. The humoral immune response lacks B cells that form antibodies and opportunistic infections
result.
d. Bone marrow suppression of white blood cells causes insufficient cells to phagocytize organisms.
10- Methotrexate is prescribed for a client with rheumatoid arthritis who is also taking aspirin. What is
the best explanation for the nurse to provide as to why a second medication has been added?
a. Methotrexate slows the disease progression while aspirin controls the symptoms.
b. Methotrexate enhances the effectiveness of the aspirin.
c. Methotrexate helps to reduce the side effects of the aspirin therapy.
d. Methotrexate has less harmful side effects than aspirin.
11- A government office worker is seen in the emergency room after opening an envelope containing a
powder-like substance which is being tested for anthrax. Which discharge instruction should the nurse
provide the client concerning inhalation anthrax?
,HESI NC2 CUSTOM QUESTIONS/HESI 1
a. Cleanse all surfaces touched with pre-moistened anti-bacterial wipes.
b. Return to the emergency room if flu-like symptoms develop within 42 days.
c. Isolation from friends and family members is recommended for 3 weeks.
d. Notify co-workers to get the anthrax vaccine at the public health department.
12- A healthcare worker with no known exposure to tuberculosis has received a Mantoux tuberculosis
skin test. The nurse’s assessment of the test after 62 hours indicates 5 mm of erythema without
induration. Which is the best initial nursing action?
a. Document negative results in the client’s medical record.
b. Review client’s history for possible exposure to TB.
c. Refer client to a healthcare provider for isoniazid therapy.
d. Instruct the client to return for a repeat test in 1 week.
13- A 55 year old client with osteoarthritis asks which form of exercise would be most beneficial. What is
the best response by the nurse?
a. Limit your exercise to just your daily activities.
b. Jogging or running are excellent aerobic exercises.
c. Swimming is an excellent exercise for you.
d. Tennis or racquetball will increase your muscle strength.
14- The nurse is triaging clients who have been injured during a tornado. Which client requires
immediate action?
a. An adult male with type 1 diabetes who is ambulatory with capillary refill of 2 seconds and
respirations at 22 breaths/minute.
b. A middle aged female with a broken humerus who is unable to follow commands and is crying.
c. A middle aged male with acute anxiety, a laceration on his left cheek, and respirations of 24
breaths/minute.
d. An older female with degenerative disk disease who is hard of hearing and continues to ask
questions.
15- The nurse working in a disaster area assesses an adult male who has partial-thickness burns on his
lower legs, on approximately 10 % of his lower body. Which color of triage tag should the nurse place on
this client?
a. Black
b. Red
c. Yellow
d. Green
16- An adult client who received partial thickness and full thickness burns over 40% of the body in a
house fire is admitted to the inpatient burn unit. Which fluid should the nurse prepare to administer
during the acute phase of the client’s burn recovery?
, HESI NC2 CUSTOM QUESTIONS/HESI 1
a. 5% dextrose in water.
b. 5% dextrose in 0.25 normal saline.
c. Total parenteral nutrition.
d. Lactate Ringer’s
17- A unlicensed assistive personnel reports to the nurse that a client with a postoperative wound
infection has a temperature of 103.8 F, blood pressure of 90/70, pulse of 124/minute, and respirations of
28/minute. When the nurse assesses the client, findings include mottled skin appearance and confusion.
Which action should the nurse take first?
a. Transfer the client to ICU.
b. Initiate an infusion of IV fluids.
c. Obtain a wound specimen for culture.
d. Assess the client’s core temperature.
18- Which nursing diagnosis should be selected for a client who is receiving thrombolytic infusions for
treatment of an acute myocardial infarction?
a. Deficient knowledge related to a new medication regimen.
b. Risk for injury related to effects of thrombolysis.
c. Activity intolerance related to ischemia.
d. Ineffective breathing pattern related to adverse drug effects.
????? 19- A client with partial thickness burns to the lower extremities is scheduled for whirlpool
therapy to debride the burned area. Which intervention should the nurse implement before transporting
the client to the physical therapy department?
a. Obtain supplies to redress the burn area.
b. Perform active range of motion exercises.
c. Verify the client’s signed consent form.
d. Give a prescribed narcotic analgesic agent.
20- Based on this strip, what is the interpretation of this rhythm?
a. First degree AV heart block.
b. Junctional escape rhythm.
c. Sinus bradycardia.
d. Normal sinus rhythm.
