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Adult Health II HESI Test Bank
– Complete Exam with 100+ Verified
Questions and Rationalized Correct Answers
| 100% Success Guaranteed
Question 1
What is the nurse’s priority action when a client with acute myocardial infarction (MI) reports
chest pain radiating to the left arm?
A) Administer aspirin orally
B) Administer nitroglycerin sublingually as ordered
C) Perform a 12-lead ECG
D) Document the pain intensity
Correct Answer: B
Rationale: Nitroglycerin relieves ischemic chest pain in MI by dilating coronary arteries,
improving myocardial oxygen supply. Aspirin is given for antiplatelet effects, ECG confirms
diagnosis, and documentation follows intervention (HESI Adult Health II, 2025).
Question 2
Which assessment finding in a client with chronic obstructive pulmonary disease (COPD)
indicates worsening respiratory status?
A) Barrel chest
B) Oxygen saturation 88%
C) Pursed-lip breathing
D) Clubbing of fingers
Correct Answer: B
Rationale: An oxygen saturation of 88% indicates hypoxemia, a sign of worsening COPD.
Barrel chest, pursed-lip breathing, and clubbing are chronic findings, not acute changes (HESI
Adult Health II, 2025).
Question 3
What is the most appropriate nursing intervention for a client with acute pancreatitis reporting
severe abdominal pain?
A) Administer morphine as ordered
, 2
B) Encourage oral fluid intake
C) Position the client supine
D) Apply a heating pad to the abdomen
Correct Answer: A
Rationale: Morphine relieves severe pain in pancreatitis without exacerbating the condition.
Oral fluids are restricted, supine positioning worsens pain, and heat increases inflammation
(HESI Adult Health II, 2025).
Question 4
Which action should the nurse take first when a client with a new tracheostomy develops
respiratory distress?
A) Notify the healthcare provider
B) Suction the tracheostomy tube
C) Administer oxygen via face mask
D) Remove the tracheostomy tube
Correct Answer: B
Rationale: Suctioning clears secretions or obstructions, restoring airway patency in
tracheostomy distress. Notification, face mask oxygen, or tube removal are secondary or
contraindicated (HESI Adult Health II, 2025).
Question 5
What is the priority nursing diagnosis for a client 48 hours post-total knee replacement with
swelling and warmth in the calf?
A) Acute pain
B) Risk for infection
C) Risk for impaired tissue perfusion
D) Impaired physical mobility
Correct Answer: C
Rationale: Calf swelling and warmth suggest deep vein thrombosis (DVT), impairing tissue
perfusion and risking pulmonary embolism. Pain, infection, and mobility are secondary concerns
(HESI Adult Health II, 2025).
Question 6
Which laboratory value is most concerning in a client with heart failure receiving furosemide?
A) Potassium 3.2 mEq/L
B) Sodium 138 mEq/L
C) Creatinine 1.2 mg/dL
D) BUN 18 mg/dL
, 3
Correct Answer: A
Rationale: Hypokalemia (3.2 mEq/L) from furosemide increases arrhythmia risk in heart failure.
Normal sodium, creatinine, and BUN are less urgent (HESI Adult Health II, 2025).
Question 7
What is the nurse’s priority action when a client with type 1 diabetes mellitus reports shakiness
and diaphoresis?
A) Administer insulin immediately
B) Provide 15 grams of carbohydrates
C) Monitor blood glucose in 30 minutes
D) Notify the healthcare provider
Correct Answer: B
Rationale: Shakiness and diaphoresis indicate hypoglycemia, requiring 15 grams of fast-acting
carbohydrates. Insulin worsens hypoglycemia, monitoring delays treatment, and notification
follows intervention (HESI Adult Health II, 2025).
Question 8
Which precaution is required for a client with Clostridium difficile infection?
A) Droplet precautions
B) Contact precautions
C) Airborne precautions
D) Standard precautions
Correct Answer: B
Rationale: C. difficile is transmitted via contact, requiring contact precautions (gloves, gown,
private room). Droplet and airborne precautions are for respiratory pathogens, and standard
precautions are insufficient (HESI Adult Health II, 2025).
Question 9
What is the most appropriate nursing intervention for a client with a chest tube reporting sudden
shortness of breath?
A) Clamp the chest tube
B) Assess for tube disconnection or kinks
C) Increase suction pressure
D) Administer oxygen without assessment
Correct Answer: B
Rationale: Assessing for disconnection or kinks addresses causes of shortness of breath (e.g., air
leaks). Clamping risks pneumothorax, increasing suction is inappropriate, and oxygen requires
assessment (HESI Adult Health II, 2025).
, 4
Question 10
Which finding indicates effective treatment in a client with acute kidney injury (AKI)?
A) Urine output 20 mL/hr
B) Serum creatinine 3.0 mg/dL
C) Urine output 40 mL/hr
D) Blood urea nitrogen (BUN) 45 mg/dL
Correct Answer: C
Rationale: Urine output of 40 mL/hr indicates improving kidney function in AKI. Low output,
elevated creatinine, and BUN suggest ongoing impairment (HESI Adult Health II, 2025).
Question 11
What is the nurse’s priority action for a client with a stage IV pressure injury?
A) Apply a dry gauze dressing
B) Consult for wound debridement
C) Leave the wound open to air
D) Use a hydrocolloid dressing
Correct Answer: B
Rationale: Stage IV pressure injuries require debridement to remove necrotic tissue. Dry gauze
may adhere, open-air exposure risks infection, and hydrocolloid is for earlier stages (HESI Adult
Health II, 2025).
Question 12
Which action should the nurse take when a client with a peripheral IV develops redness and
swelling at the site?
A) Continue the infusion at a slower rate
B) Stop the infusion and remove the IV
C) Apply a warm compress to the site
D) Flush the IV with saline
Correct Answer: B
Rationale: Redness and swelling indicate infiltration or phlebitis, requiring IV removal to
prevent tissue damage. Continuing infusion, compresses, or flushing are unsafe (HESI Adult
Health II, 2025).
Question 13
What is the priority nursing action for a client with a suspected stroke reporting sudden
weakness?
A) Administer aspirin immediately
Adult Health II HESI Test Bank
– Complete Exam with 100+ Verified
Questions and Rationalized Correct Answers
| 100% Success Guaranteed
Question 1
What is the nurse’s priority action when a client with acute myocardial infarction (MI) reports
chest pain radiating to the left arm?
A) Administer aspirin orally
B) Administer nitroglycerin sublingually as ordered
C) Perform a 12-lead ECG
D) Document the pain intensity
Correct Answer: B
Rationale: Nitroglycerin relieves ischemic chest pain in MI by dilating coronary arteries,
improving myocardial oxygen supply. Aspirin is given for antiplatelet effects, ECG confirms
diagnosis, and documentation follows intervention (HESI Adult Health II, 2025).
Question 2
Which assessment finding in a client with chronic obstructive pulmonary disease (COPD)
indicates worsening respiratory status?
A) Barrel chest
B) Oxygen saturation 88%
C) Pursed-lip breathing
D) Clubbing of fingers
Correct Answer: B
Rationale: An oxygen saturation of 88% indicates hypoxemia, a sign of worsening COPD.
Barrel chest, pursed-lip breathing, and clubbing are chronic findings, not acute changes (HESI
Adult Health II, 2025).
Question 3
What is the most appropriate nursing intervention for a client with acute pancreatitis reporting
severe abdominal pain?
A) Administer morphine as ordered
, 2
B) Encourage oral fluid intake
C) Position the client supine
D) Apply a heating pad to the abdomen
Correct Answer: A
Rationale: Morphine relieves severe pain in pancreatitis without exacerbating the condition.
Oral fluids are restricted, supine positioning worsens pain, and heat increases inflammation
(HESI Adult Health II, 2025).
Question 4
Which action should the nurse take first when a client with a new tracheostomy develops
respiratory distress?
A) Notify the healthcare provider
B) Suction the tracheostomy tube
C) Administer oxygen via face mask
D) Remove the tracheostomy tube
Correct Answer: B
Rationale: Suctioning clears secretions or obstructions, restoring airway patency in
tracheostomy distress. Notification, face mask oxygen, or tube removal are secondary or
contraindicated (HESI Adult Health II, 2025).
Question 5
What is the priority nursing diagnosis for a client 48 hours post-total knee replacement with
swelling and warmth in the calf?
A) Acute pain
B) Risk for infection
C) Risk for impaired tissue perfusion
D) Impaired physical mobility
Correct Answer: C
Rationale: Calf swelling and warmth suggest deep vein thrombosis (DVT), impairing tissue
perfusion and risking pulmonary embolism. Pain, infection, and mobility are secondary concerns
(HESI Adult Health II, 2025).
Question 6
Which laboratory value is most concerning in a client with heart failure receiving furosemide?
A) Potassium 3.2 mEq/L
B) Sodium 138 mEq/L
C) Creatinine 1.2 mg/dL
D) BUN 18 mg/dL
, 3
Correct Answer: A
Rationale: Hypokalemia (3.2 mEq/L) from furosemide increases arrhythmia risk in heart failure.
Normal sodium, creatinine, and BUN are less urgent (HESI Adult Health II, 2025).
Question 7
What is the nurse’s priority action when a client with type 1 diabetes mellitus reports shakiness
and diaphoresis?
A) Administer insulin immediately
B) Provide 15 grams of carbohydrates
C) Monitor blood glucose in 30 minutes
D) Notify the healthcare provider
Correct Answer: B
Rationale: Shakiness and diaphoresis indicate hypoglycemia, requiring 15 grams of fast-acting
carbohydrates. Insulin worsens hypoglycemia, monitoring delays treatment, and notification
follows intervention (HESI Adult Health II, 2025).
Question 8
Which precaution is required for a client with Clostridium difficile infection?
A) Droplet precautions
B) Contact precautions
C) Airborne precautions
D) Standard precautions
Correct Answer: B
Rationale: C. difficile is transmitted via contact, requiring contact precautions (gloves, gown,
private room). Droplet and airborne precautions are for respiratory pathogens, and standard
precautions are insufficient (HESI Adult Health II, 2025).
Question 9
What is the most appropriate nursing intervention for a client with a chest tube reporting sudden
shortness of breath?
A) Clamp the chest tube
B) Assess for tube disconnection or kinks
C) Increase suction pressure
D) Administer oxygen without assessment
Correct Answer: B
Rationale: Assessing for disconnection or kinks addresses causes of shortness of breath (e.g., air
leaks). Clamping risks pneumothorax, increasing suction is inappropriate, and oxygen requires
assessment (HESI Adult Health II, 2025).
, 4
Question 10
Which finding indicates effective treatment in a client with acute kidney injury (AKI)?
A) Urine output 20 mL/hr
B) Serum creatinine 3.0 mg/dL
C) Urine output 40 mL/hr
D) Blood urea nitrogen (BUN) 45 mg/dL
Correct Answer: C
Rationale: Urine output of 40 mL/hr indicates improving kidney function in AKI. Low output,
elevated creatinine, and BUN suggest ongoing impairment (HESI Adult Health II, 2025).
Question 11
What is the nurse’s priority action for a client with a stage IV pressure injury?
A) Apply a dry gauze dressing
B) Consult for wound debridement
C) Leave the wound open to air
D) Use a hydrocolloid dressing
Correct Answer: B
Rationale: Stage IV pressure injuries require debridement to remove necrotic tissue. Dry gauze
may adhere, open-air exposure risks infection, and hydrocolloid is for earlier stages (HESI Adult
Health II, 2025).
Question 12
Which action should the nurse take when a client with a peripheral IV develops redness and
swelling at the site?
A) Continue the infusion at a slower rate
B) Stop the infusion and remove the IV
C) Apply a warm compress to the site
D) Flush the IV with saline
Correct Answer: B
Rationale: Redness and swelling indicate infiltration or phlebitis, requiring IV removal to
prevent tissue damage. Continuing infusion, compresses, or flushing are unsafe (HESI Adult
Health II, 2025).
Question 13
What is the priority nursing action for a client with a suspected stroke reporting sudden
weakness?
A) Administer aspirin immediately
