HESI ASSESSMENT Q & A 100% CORRECT TAED A+
2 The nurse has completed the diet teaching of a client who is being discharged following treatment of
a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the
client indicates that the teaching was effective?
a. A peanut butter sandwich with soda and
cookies. b. A tuna fish sandwich with
chips and ice cream.
c. Vegetable soup, crackers, and milk.
d. A salad with three kinds of lettuce and fruit.
3 The nurse implements a primary prevention program for sexually transmitted diseases in a nurse
managed health center. Which outcome indicates that the program was effective?
A. Average client scores improved on specific risk factor knowledge test.
B. More than half of at-risk client were diagnosed early in their process.
C. New screening protocols were developed, validated, and implemented.
D. Clients who incurred disease complications promptly received rehabilitation.
4 A young adult client is admitted to the emergency room following aA motor vehicle collision. The
client's head hit the dashboard. Admission assessments include blood pressure 85/45 mm Hg, oral
temperature 98.6° F (37° C), pulse 124 beats/minute, and respirations 22 breaths/minute. Based on
these data, the nurse formulates the first portion of a nursing problem as "Risk for injury". What term
best expresses the "related to" portion of the nursing problem?
a. head injury.
b. infection.
c. increased intracranial
pressure. d. shock.
5 A nurse working on an endocrine unit should see which client first.
a. An adolescent male with diabetes who is arguing about his insulin dose.
b. An older client with Addison’s disease whose current blood sugar level is 62mg/dl (3.44
mmol/l).
c. An adult with a blood sugar of 384mg/dl (21.31mmol/l) and urine output of 350
ml in the last hour. d. A client taking corticosteroids who has become disoriented
in the last two hours.
,HESI ASSESSMENT Q & A 100% CORRECT TAED A+
6 Following a gunshot wound, an adult client has a hemoglobin level of 4 grams/dl (40 mmol/L SI). The
nurse prepares to administer a unit of blood for an emergency transfusion. The client has AB negative
blood type and the blood bank sends a unit of Type A Rh negative, reporting that there is no Type AB
negative blood currently available. Which intervention should the nurse implement?
a. Transfuse Type A negative blood until Type AB negative is available.
b. Recheck the clienfs hemoglobin, blood type, and Rh factor.
c. Obtain additional consent for administration of Type A negative blood.
d. Administer normal saline solution until Type AB negative is available.
7 An older client who lives alone in a two-story home is admitted after falling while shopping. X-rays
reveal a fractured left hip. With no immediate family in the area, the client is concerned about the pets
at home. Which interventions should the nurse implement? (Select au that apply.)
A- Evaluate pain using a standard pain scale
B- Alert social worker of client's concerns.
C- Support left leg with two pillows.
D- Palpate and mark pedal pulses.
E- Assess ability to bear weight when standing
8 Which laboratory finding for an adult client is most critical for the nurse to report to the healthcare
provider? (Click on the correct location on the chart. To change, click on a new location.)
▪ Serum Sodio 142 mEq/L (142 mmol/L)
▪ Postassium 3.9 mEq/L (3.9 mmol'/L)
▪ Serum glucose 62 mg/dl (3.4 mmdl/L)
▪ Blood urea nitrogen 18 mg/dl (6.4 mmol/L)
9 An older adult client with heart failure (HF) develops cardiac tamponade. The client has muffled,
distant, heart sounds,
,HESI ASSESSMENT Q & A 100% CORRECT TAED A+
and is anxious and restless. After initiating oxygen therapy and IV hydration, which intervention is
most important for the nurse to implement?
a. Observe neck for jugular vein distention
b. Notify healthcare provider to prepare for pericardiocentesis
c. Asses for paradoxical blood pressure
d. Monitor oxygen saturation (Sp02) via continuous pulse oximetry
10 The parent of a child born with a cleft lip asks the nurse to explain why this happened. The parent is
concerned that they did something wrong that caused this to occur. Which response is most
helpful?
a. "You didn't do anything wrong."
b. "This must be a very difficult time for you."
c. "With surgery, your baby should have a full recovery.
d. "Is there any particular reason why you think this is your fault?
11 After diagnosis and initial treatment of a 3-year-old with Cystic fibrosis, the nurse provides home care
instructions to the mother, which statement by the child's mother indicates that she understands
home care treatment to promote pulmonary functions?
a. Chest physiotherapy should be performed twice a day before a meal.
b. Administer a cough suppressant every 8 hours."
c. Energy should be conserved by scheduling minimally strenuous activities."
d. Maintain supplemental oxygen at 4 to 6 Uminute."
12 A client with deep vein thrombosis (DVT) is receiving a continuous intravenous heparin infusion. The
client now has tarry, black diarrhea and reports abdominal pain. Which actions should the nurse
implement? (Select all that apply.)
a. Auscultate bowel sounds in all quadrants.
b. Review last partial thromboplastin
time results. c. Assess characteristics of
pain.
d. Prepare to administer warfarin.
e. Monitor stools for presence of blood.
13 The nurse is developing a teaching program for the community. What population characteristic is
most influential when choosing strategies for implementing a teaching plan?
a. Literacy level.
, HESI ASSESSMENT Q & A 100% CORRECT TAED A+
b. Median age.
c. Prevalent learning style.
d. Percent with Internet access.
14 The nurse is conducting a visual screening of a group of older adults. Which finding should the nurse
report to the healthcare provider immediately?
a. Gradual onset of continuous eye pain and blurred vision.
b. Recent change in the ability to read and drive after dark.
c. Gray-white circle around the iris of both eyes.
d. Cloudy opacity of the crystalline lens.
15 While the nurse is assessing an older client's fall risk, the client reports living at home alone and
never falling. Which action should the nurse take?
a. Inform the client that falls occur more often in the hospital
than at home. b. Continue to obtain client data needed to
complete the fall risk survey.
c. Record a minimal risk for falls, documenting the client's statement.
d. Place the client on a high fall risk protocol because of advanced age.
16 A client with gestational diabetes is being induced for labor. Which assessment is most important for
the nurse to perform
prior to increasing the
oxytocin rate? a.
Contraction pattern.
b. Blood pressure.
c. Fingerstick glucose.
d. Vaginal exam.
2 The nurse has completed the diet teaching of a client who is being discharged following treatment of
a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the
client indicates that the teaching was effective?
a. A peanut butter sandwich with soda and
cookies. b. A tuna fish sandwich with
chips and ice cream.
c. Vegetable soup, crackers, and milk.
d. A salad with three kinds of lettuce and fruit.
3 The nurse implements a primary prevention program for sexually transmitted diseases in a nurse
managed health center. Which outcome indicates that the program was effective?
A. Average client scores improved on specific risk factor knowledge test.
B. More than half of at-risk client were diagnosed early in their process.
C. New screening protocols were developed, validated, and implemented.
D. Clients who incurred disease complications promptly received rehabilitation.
4 A young adult client is admitted to the emergency room following aA motor vehicle collision. The
client's head hit the dashboard. Admission assessments include blood pressure 85/45 mm Hg, oral
temperature 98.6° F (37° C), pulse 124 beats/minute, and respirations 22 breaths/minute. Based on
these data, the nurse formulates the first portion of a nursing problem as "Risk for injury". What term
best expresses the "related to" portion of the nursing problem?
a. head injury.
b. infection.
c. increased intracranial
pressure. d. shock.
5 A nurse working on an endocrine unit should see which client first.
a. An adolescent male with diabetes who is arguing about his insulin dose.
b. An older client with Addison’s disease whose current blood sugar level is 62mg/dl (3.44
mmol/l).
c. An adult with a blood sugar of 384mg/dl (21.31mmol/l) and urine output of 350
ml in the last hour. d. A client taking corticosteroids who has become disoriented
in the last two hours.
,HESI ASSESSMENT Q & A 100% CORRECT TAED A+
6 Following a gunshot wound, an adult client has a hemoglobin level of 4 grams/dl (40 mmol/L SI). The
nurse prepares to administer a unit of blood for an emergency transfusion. The client has AB negative
blood type and the blood bank sends a unit of Type A Rh negative, reporting that there is no Type AB
negative blood currently available. Which intervention should the nurse implement?
a. Transfuse Type A negative blood until Type AB negative is available.
b. Recheck the clienfs hemoglobin, blood type, and Rh factor.
c. Obtain additional consent for administration of Type A negative blood.
d. Administer normal saline solution until Type AB negative is available.
7 An older client who lives alone in a two-story home is admitted after falling while shopping. X-rays
reveal a fractured left hip. With no immediate family in the area, the client is concerned about the pets
at home. Which interventions should the nurse implement? (Select au that apply.)
A- Evaluate pain using a standard pain scale
B- Alert social worker of client's concerns.
C- Support left leg with two pillows.
D- Palpate and mark pedal pulses.
E- Assess ability to bear weight when standing
8 Which laboratory finding for an adult client is most critical for the nurse to report to the healthcare
provider? (Click on the correct location on the chart. To change, click on a new location.)
▪ Serum Sodio 142 mEq/L (142 mmol/L)
▪ Postassium 3.9 mEq/L (3.9 mmol'/L)
▪ Serum glucose 62 mg/dl (3.4 mmdl/L)
▪ Blood urea nitrogen 18 mg/dl (6.4 mmol/L)
9 An older adult client with heart failure (HF) develops cardiac tamponade. The client has muffled,
distant, heart sounds,
,HESI ASSESSMENT Q & A 100% CORRECT TAED A+
and is anxious and restless. After initiating oxygen therapy and IV hydration, which intervention is
most important for the nurse to implement?
a. Observe neck for jugular vein distention
b. Notify healthcare provider to prepare for pericardiocentesis
c. Asses for paradoxical blood pressure
d. Monitor oxygen saturation (Sp02) via continuous pulse oximetry
10 The parent of a child born with a cleft lip asks the nurse to explain why this happened. The parent is
concerned that they did something wrong that caused this to occur. Which response is most
helpful?
a. "You didn't do anything wrong."
b. "This must be a very difficult time for you."
c. "With surgery, your baby should have a full recovery.
d. "Is there any particular reason why you think this is your fault?
11 After diagnosis and initial treatment of a 3-year-old with Cystic fibrosis, the nurse provides home care
instructions to the mother, which statement by the child's mother indicates that she understands
home care treatment to promote pulmonary functions?
a. Chest physiotherapy should be performed twice a day before a meal.
b. Administer a cough suppressant every 8 hours."
c. Energy should be conserved by scheduling minimally strenuous activities."
d. Maintain supplemental oxygen at 4 to 6 Uminute."
12 A client with deep vein thrombosis (DVT) is receiving a continuous intravenous heparin infusion. The
client now has tarry, black diarrhea and reports abdominal pain. Which actions should the nurse
implement? (Select all that apply.)
a. Auscultate bowel sounds in all quadrants.
b. Review last partial thromboplastin
time results. c. Assess characteristics of
pain.
d. Prepare to administer warfarin.
e. Monitor stools for presence of blood.
13 The nurse is developing a teaching program for the community. What population characteristic is
most influential when choosing strategies for implementing a teaching plan?
a. Literacy level.
, HESI ASSESSMENT Q & A 100% CORRECT TAED A+
b. Median age.
c. Prevalent learning style.
d. Percent with Internet access.
14 The nurse is conducting a visual screening of a group of older adults. Which finding should the nurse
report to the healthcare provider immediately?
a. Gradual onset of continuous eye pain and blurred vision.
b. Recent change in the ability to read and drive after dark.
c. Gray-white circle around the iris of both eyes.
d. Cloudy opacity of the crystalline lens.
15 While the nurse is assessing an older client's fall risk, the client reports living at home alone and
never falling. Which action should the nurse take?
a. Inform the client that falls occur more often in the hospital
than at home. b. Continue to obtain client data needed to
complete the fall risk survey.
c. Record a minimal risk for falls, documenting the client's statement.
d. Place the client on a high fall risk protocol because of advanced age.
16 A client with gestational diabetes is being induced for labor. Which assessment is most important for
the nurse to perform
prior to increasing the
oxytocin rate? a.
Contraction pattern.
b. Blood pressure.
c. Fingerstick glucose.
d. Vaginal exam.
