“HESI & ATI Nursing Exam 2025 Mega Pack | 120+ Verified NCLEX‑RN NGN Test Bank with A+ Rationales | Well‑Revised & Guaranteed Pass”

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“HESI & ATI Nursing Exam 2025 Mega Pack

| 120+ Verified NCLEX- RN NGN Test Bank

with A+ Rationales | Well- Revised &

Guaranteed Pass”



1. A 67-year-old patient with chronic heart failure (CHF) presents to the

emergency department with worsening dyspnea, bilateral crackles, and

2+ pitting edema in the lower extremities. The nurse notes that the

patient’s blood pressure is 98/60 mmHg, heart rate 110 bpm, and

oxygen saturation 89% on room air. Which intervention should the

nurse prioritize first?


A. Administer the scheduled oral furosemide dose

B. Place the patient in high Fowler’s position and apply oxygen

C. Prepare the patient for a chest x-ray to assess fluid overload

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D. Notify the healthcare provider about the hypotension

E. Insert a Foley catheter to monitor urine output


✅ Correct Answer: B. Place the patient in high Fowler’s position and

apply oxygen


Rationale:

The immediate priority in a patient with acute decompensated heart failure

and pulmonary edema is to optimize oxygenation and reduce the work of

breathing. Placing the patient in high Fowler’s position with

supplemental oxygen facilitates lung expansion and improves gas

exchange. After stabilizing the airway and breathing, diuretics like

furosemide (Option A) can be given to reduce fluid overload. Notifying the

provider (Option D) and preparing for imaging (Option C) are important but

not the first priority in the ABCs (Airway, Breathing, Circulation).

Inserting a Foley catheter (Option E) can help monitor output but is

secondary to stabilizing respiratory status.


2. A 45-year-old client with type 2 diabetes mellitus presents with

confusion, diaphoresis, and tremors. Blood glucose reads 48 mg/dL.

What is the priority nursing action?

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A. Administer subcutaneous insulin

B. Encourage oral fluids with electrolytes

C. Provide 15 g of rapid-acting carbohydrates

D. Start IV infusion of 0.9% normal saline

E. Notify the healthcare provider immediately


✅ Correct Answer: C. Provide 15 g of rapid-acting carbohydrates


Rationale:

Hypoglycemia (<70 mg/dL) requires immediate treatment to prevent

neurological complications such as seizures or coma. Providing 15 g of a

rapid-acting carbohydrate (e.g., 4 oz juice, glucose tablets) is the first-line

intervention. IV saline (Option D) does not correct low glucose.

Subcutaneous insulin (Option A) would worsen hypoglycemia. Oral fluids

(Option B) without sugar are insufficient. The provider (Option E) can be

notified after stabilizing the patient, as per ABCs and acute care

protocols.




3. A 72-year-old client with COPD presents with increased shortness of

breath, use of accessory muscles, and oxygen saturation of 85% on

room air. Which intervention should the nurse implement first?

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A. Apply 2 L/min oxygen via nasal cannula

B. Encourage the client to ambulate in the hall

C. Administer prescribed IV corticosteroid

D. Prepare for intubation immediately

E. Obtain a sputum culture for analysis


✅ Correct Answer: A. Apply 2 L/min oxygen via nasal cannula


Rationale:

Clients with COPD exacerbation are at risk for respiratory failure. The

first intervention is to apply low-flow oxygen to improve oxygenation

without suppressing hypoxic drive. Intubation (Option D) is considered only

if the patient fails noninvasive support. Corticosteroids (Option C) are

important but not the immediate priority. Ambulation (Option B) can worsen

hypoxia, and sputum culture (Option E) is a diagnostic step after

stabilization.




4. A 58-year-old client receiving chemotherapy for breast cancer reports

fever, sore throat, and fatigue. Laboratory results reveal WBC

1,200/mm³. Which nursing intervention is the highest priority?