HESI VERSION 3 2023-2024
1. A client who has been in active labor for 12 hours suddenly tells the nurse that she has a strong urge
to have a bowel movement. What action should the nurse take?
A. Allow the client to use a bedpan.
B. Explain the fetal head is descending.
C. Perform a sterile vaginal exam.
D. Assist the client to the bathroom -ANS-C. Perform a sterile vaginal exam.
2. The nurse assesses a 78-year-old male client who has left sided heart failure. Which symptoms would
the nurse expect this client to exhibit?
A. Dyspnea, cough and fatigue.
B. Hepatomegaly and distended neck veins.
C. Pain over the pericardium and friction rub.
D. Narrowing pulse pressure and distant heart sounds. -ANS-A. Dyspnea, cough and fatigue.
3. A female client comes to the clinic complaining of fatigue and inability to sleep because she is the full-
time caretaker for a 22-year-old son who was paralyzed by a motor vehicle collision. She adds that her
husband left her because he says he can't take her behavior anymore since all she does is care for their
son. What intervention should the nurse implement?
A. Teach the client to problem-solve for herself and establish her own priorities.
B. Schedule a home visit in the afternoon to assess the son and client's role as caregiver.
C. Provide feedback to the client about her atonement for guilt about her son's impairment.
D. Acknowledge the client's stress and suggest that she consider respite care. -ANS-D. Acknowledge the
client's stress and suggest that she consider respite care.
4. The nurse plans to administer a scheduled dose of metoprolol (Toprol SR) at 0900 to a client with
hypertension. At 0800, the nurse notes that the client's telemetry pattern shows a second-degree heart
block with a ventricular rate of 50. What action should the nurse take?
A. Administer the Toprol immediately and monitor the client carefully until the heart rate increases.
B. Provide the dose of Toprol as scheduled and assign a UAP to monitor the client's BP q30 minutes.
C. Hold the scheduled dose of Toprol and notify the healthcare provider of the telemetry pattern.
,D. Give the Toprol as scheduled if the client's systolic blood pressure reading is greater than 180. -ANS-C.
Hold the scheduled dose of Toprol and notify the healthcare provider of the telemetry pattern.
5. A client who developed Syndrome of Inappropriate Antidiuretic Hormone (SIADH) associated with
small cell carcinoma of the lung is preparing for discharge. When teaching the client about self-
management with demeclocycline (Declomycin), the nurse should instruct the client to report which
condition to the healthcare provider?
A. Anxiety.
B. Insomnia.
C. Muscle cramping.
D. Increased appetite -ANS-C. Muscle cramping.
6. In determining the client position for insertion of an indwelling urinary catheter, it is most important
for the nurse to recognize which client condition?
A. High urinary pH.
B. Fever.
C. Abdominal ascites.
D. Orthopnea. -ANS-D. Orthopnea.
7. The nurse is reviewing a client's electrocardiogram and determines that the PR interval (PRI) is
prolonged. What does this finding indicate?
A. Inability of the SA node to initiate an impulse at the normal rate.
B. Initiation of the impulse from a location outside the SA node.
C. Increased conduction time from the SA node to the AV junction.
D. Interference with the conduction through one or both ventricles. -ANS-C. Increased conduction time
from the SA node to the AV junction.
8. The nurse is teaching a male client with multiple sclerosis how to empty his bladder using the Crede
Method. When performing a return demonstration, the client applies pressure to the umbilical area of
his abdomen. What instruction should the nurse provide?
A. Stroke the inner thigh below the perineum to initiate urinary flow.
B. Pour warm water over the external sphincter at the distal glans.
,C. Apply downward manual pressure at the suprapubic region.
D. Contract, hold, and then relax the pubococcygeal muscle. -ANS-C. Apply downward manual pressure
at the suprapubic region.
9. A 35-year-old female client has just been admitted to the postanesthesia recovery unit following a
partial thyroidectomy. Which statement reflects the nurse's accurate understanding of the expected
outcome for the client following this surgery?
A. Supplemental hormonal therapy will probably be unnecessary.
B. The thyroid will regenerate to a normal size within a few years.
C. The client will be restricted from eating seafood.
D. The remainder of the thyroid will be removed at a later date. -ANS-A. Supplemental hormonal
therapy will probably be unnecessary.
10. 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?
A. Lower the head of the bed and apply suprapubic pressure.
B. Encourage the client to move to a hands-and-knees position.
C. Prepare the client for an emergency cesarean birth.
D. Assist the client to sharply flex her thighs up against the abdomen. -ANS-D. Assist the client to sharply
flex her thighs up against the abdomen.
11. The nurse should observe most closely for drug toxicity when a client receives a medication that has
which characteristic?
A. Rapid onset of action.
B. Low bioavailability.
.C Narrow therapeutic index.
D. Short half-life. -ANS-C Narrow therapeutic index.
12. Following insertion of a LeVeen shunt in a client with cirrhosis of the liver, which assessment finding
indicates to the nurse that the shunt is effective?
A. Decreased abdominal girth.
, B. Increased blood pressure.
C. Clear breath sounds.
D. Decreased serum albumin. -ANS-A. Decreased abdominal girth.
13. When finding a client sitting on the floor, the nurse calls for help from the unlicensed assistive
personnel (UAP). Which task should the nurse ask the UAP to do?
A. Check for any abrasions or bruises.
B. Help the client to stand.
C. Get a blood pressure cuff.
D. Report the fall to the nurse-manager. -ANS-C. Get a blood pressure cuff.
14. During the initial newborn assessment, the nurse finds that a newborn's heart rate is irregular.
Which intervention should the nurse implement?
A. Notify the pediatrician immediately.
B. Teach the parents about congenital heart defects.
C. Document the finding in the infant's record.
D. Apply oxygen per nasal cannula at 3 L/min. -ANS-C. Document the finding in the infant's record.
15. A client is diagnosed with a frontal lobe glioma, which is a benign brain tumor. When teaching the
client about the tumor, which information should the nurse consider?
A. Surgery is not indicated unless the tumor becomes malignant.
B. Vision and hearing will be affected in the future.
C. If the tumor metastasizes, surgical intervention is necessary.
D. Personality changes or expressive aphasia are likely. -ANS-D. Personality changes or expressive
aphasia are likely.
16. A client who has suffered 3rd degree burns over 60% of the body is admitted to the emergency
department. The healthcare provider writes a prescription for "IV Lactated Ringer's 350 ml/hr". Which
intervention should the nurse implement?
A. Administer the Lactated Ringer's at 350 ml/hr via gravity infusion.
B. Collaborate with the pharmacist to recalculate the infusion rate.
1. A client who has been in active labor for 12 hours suddenly tells the nurse that she has a strong urge
to have a bowel movement. What action should the nurse take?
A. Allow the client to use a bedpan.
B. Explain the fetal head is descending.
C. Perform a sterile vaginal exam.
D. Assist the client to the bathroom -ANS-C. Perform a sterile vaginal exam.
2. The nurse assesses a 78-year-old male client who has left sided heart failure. Which symptoms would
the nurse expect this client to exhibit?
A. Dyspnea, cough and fatigue.
B. Hepatomegaly and distended neck veins.
C. Pain over the pericardium and friction rub.
D. Narrowing pulse pressure and distant heart sounds. -ANS-A. Dyspnea, cough and fatigue.
3. A female client comes to the clinic complaining of fatigue and inability to sleep because she is the full-
time caretaker for a 22-year-old son who was paralyzed by a motor vehicle collision. She adds that her
husband left her because he says he can't take her behavior anymore since all she does is care for their
son. What intervention should the nurse implement?
A. Teach the client to problem-solve for herself and establish her own priorities.
B. Schedule a home visit in the afternoon to assess the son and client's role as caregiver.
C. Provide feedback to the client about her atonement for guilt about her son's impairment.
D. Acknowledge the client's stress and suggest that she consider respite care. -ANS-D. Acknowledge the
client's stress and suggest that she consider respite care.
4. The nurse plans to administer a scheduled dose of metoprolol (Toprol SR) at 0900 to a client with
hypertension. At 0800, the nurse notes that the client's telemetry pattern shows a second-degree heart
block with a ventricular rate of 50. What action should the nurse take?
A. Administer the Toprol immediately and monitor the client carefully until the heart rate increases.
B. Provide the dose of Toprol as scheduled and assign a UAP to monitor the client's BP q30 minutes.
C. Hold the scheduled dose of Toprol and notify the healthcare provider of the telemetry pattern.
,D. Give the Toprol as scheduled if the client's systolic blood pressure reading is greater than 180. -ANS-C.
Hold the scheduled dose of Toprol and notify the healthcare provider of the telemetry pattern.
5. A client who developed Syndrome of Inappropriate Antidiuretic Hormone (SIADH) associated with
small cell carcinoma of the lung is preparing for discharge. When teaching the client about self-
management with demeclocycline (Declomycin), the nurse should instruct the client to report which
condition to the healthcare provider?
A. Anxiety.
B. Insomnia.
C. Muscle cramping.
D. Increased appetite -ANS-C. Muscle cramping.
6. In determining the client position for insertion of an indwelling urinary catheter, it is most important
for the nurse to recognize which client condition?
A. High urinary pH.
B. Fever.
C. Abdominal ascites.
D. Orthopnea. -ANS-D. Orthopnea.
7. The nurse is reviewing a client's electrocardiogram and determines that the PR interval (PRI) is
prolonged. What does this finding indicate?
A. Inability of the SA node to initiate an impulse at the normal rate.
B. Initiation of the impulse from a location outside the SA node.
C. Increased conduction time from the SA node to the AV junction.
D. Interference with the conduction through one or both ventricles. -ANS-C. Increased conduction time
from the SA node to the AV junction.
8. The nurse is teaching a male client with multiple sclerosis how to empty his bladder using the Crede
Method. When performing a return demonstration, the client applies pressure to the umbilical area of
his abdomen. What instruction should the nurse provide?
A. Stroke the inner thigh below the perineum to initiate urinary flow.
B. Pour warm water over the external sphincter at the distal glans.
,C. Apply downward manual pressure at the suprapubic region.
D. Contract, hold, and then relax the pubococcygeal muscle. -ANS-C. Apply downward manual pressure
at the suprapubic region.
9. A 35-year-old female client has just been admitted to the postanesthesia recovery unit following a
partial thyroidectomy. Which statement reflects the nurse's accurate understanding of the expected
outcome for the client following this surgery?
A. Supplemental hormonal therapy will probably be unnecessary.
B. The thyroid will regenerate to a normal size within a few years.
C. The client will be restricted from eating seafood.
D. The remainder of the thyroid will be removed at a later date. -ANS-A. Supplemental hormonal
therapy will probably be unnecessary.
10. 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?
A. Lower the head of the bed and apply suprapubic pressure.
B. Encourage the client to move to a hands-and-knees position.
C. Prepare the client for an emergency cesarean birth.
D. Assist the client to sharply flex her thighs up against the abdomen. -ANS-D. Assist the client to sharply
flex her thighs up against the abdomen.
11. The nurse should observe most closely for drug toxicity when a client receives a medication that has
which characteristic?
A. Rapid onset of action.
B. Low bioavailability.
.C Narrow therapeutic index.
D. Short half-life. -ANS-C Narrow therapeutic index.
12. Following insertion of a LeVeen shunt in a client with cirrhosis of the liver, which assessment finding
indicates to the nurse that the shunt is effective?
A. Decreased abdominal girth.
, B. Increased blood pressure.
C. Clear breath sounds.
D. Decreased serum albumin. -ANS-A. Decreased abdominal girth.
13. When finding a client sitting on the floor, the nurse calls for help from the unlicensed assistive
personnel (UAP). Which task should the nurse ask the UAP to do?
A. Check for any abrasions or bruises.
B. Help the client to stand.
C. Get a blood pressure cuff.
D. Report the fall to the nurse-manager. -ANS-C. Get a blood pressure cuff.
14. During the initial newborn assessment, the nurse finds that a newborn's heart rate is irregular.
Which intervention should the nurse implement?
A. Notify the pediatrician immediately.
B. Teach the parents about congenital heart defects.
C. Document the finding in the infant's record.
D. Apply oxygen per nasal cannula at 3 L/min. -ANS-C. Document the finding in the infant's record.
15. A client is diagnosed with a frontal lobe glioma, which is a benign brain tumor. When teaching the
client about the tumor, which information should the nurse consider?
A. Surgery is not indicated unless the tumor becomes malignant.
B. Vision and hearing will be affected in the future.
C. If the tumor metastasizes, surgical intervention is necessary.
D. Personality changes or expressive aphasia are likely. -ANS-D. Personality changes or expressive
aphasia are likely.
16. A client who has suffered 3rd degree burns over 60% of the body is admitted to the emergency
department. The healthcare provider writes a prescription for "IV Lactated Ringer's 350 ml/hr". Which
intervention should the nurse implement?
A. Administer the Lactated Ringer's at 350 ml/hr via gravity infusion.
B. Collaborate with the pharmacist to recalculate the infusion rate.
