,HESI A2 Nursing Entrance Exam Study Guide 2025 –
Comprehensive Practice Questions & Detailed Correct
Answers | HESI Admission Assessment Prep for RN &
LPN Programs | 100% Verified & Updated Content.
While preparing to insert a rectal suppository in a male adult client, the nurse observes that the
client is holding his breath while bearing down. What action should the nurse implement?
Instruct the client to take slow deep breaths and stop bearing down.
The nurse assesses an immobile, elderly male client and determines that his blood pressure is
138/60, his temperature is 95.8 F, and his output is 100 ml of concentrated urine during the last
hour. He has wet-sounding lung sounds, and increased respiratory secretions. Based on these
assessment findings, what nursing action is most important for the nurse to implement?
Turn the client q2h.
The home health nurse visits an elderly female client who had a stroke three months ago and is
now able to ambulate with the assistance of a quad cane. Which assessment finding has the
greatest implications for this client's care?
The nurse notes that there are numerous scatter rugs throughout the house.
In providing care for a terminally ill resident of a long-term care facility, the nurse determines
that the resident is exhibiting signs of impending death and has a "do not resuscitate" or DNR
status. What intervention should the nurse implement first?
Notify family members of the client's condition.
A healthcare provider is performing a sterile procedure at a client's bedside. Near the end of the
procedure, the nurse observes the healthcare provider contaminate a sterile glove and the
sterile field. What is the best action for the nurse to implement?
Identify the break in surgical asepsis and provide another set of sterile supplies.
The nurse is digitally removing a fecal impaction for a client. The nurse should stop the
procedure and take corrective action if which client reaction is noted?
Pulse rate decreases from 78 to 52 beats/min.
Which client care activity requires the nurse to wear barrier gloves as required by the protocol
for Standard Precautions?
,Emptying the urinary catheter drainage bag for a client with Alzheimer's disease.
A client in hospice care develops audible gurgling sounds on inspiration. Which nursing action
has the highest priority?
Inform the family that death is imminent.
A 73-year-old Hispanic client is seen at the community health clinic with a history of protein
malnutrition. What information should the nurse obtain first?
Foods and liquids consumed during the past 24 hours.
When caring for an immobile client, what nursing diagnosis has the highest priority?
Impaired gas exchange.
Which statement correctly identifies a written learning objective for a client with peripheral
vascular disease?
Upon discharge, the client will list three ways to protect the feet from injury.
Which nursing intervention is most beneficial in reducing the risk of urosepsis in a hospitalized
client with an indwelling urinary catheter?
Obtain a prescription for removal of the catheter as soon as possible.
The nurse is providing passive range of motion (ROM) exercises to the hip and knee for a client
who is unconscious.
After supporting the client's knee with one hand, what action should the nurse take next?
Cradle the client's heel.
Prior to administering a newly prescribed medication to a client, the nurse reviews the adverse
effects of the medication listed in a drug reference guide and determines the priority risks to the
client. While performing this action, the nurse is engaged in which step of the nursing process?
Analysis.
What action by the nurse demonstrates culturally sensitive care?
Asks permission before touching a client.
An older female client with rheumatoid arthritis is complaining of severe joint pain that is
caused by the weight of the linen on her legs. What action should the nurse implement first?
Drape the sheets over the footboard of the bed.
, An older client who is able to stand but not to ambulate receives a prescription to be mobilized
into a chair as tolerated during each day. What is the best action for the nurse to implement
when assisting the client from the bed to the chair?
Place a transfer belt around the client, assist to stand, and pivot to a chair that is placed at a
right angle to the bed.
The nurse removes the dressing on a client's heel that is covering a pressure sore one-inch in
diameter and finds that there is straw-colored drainage seeping from the wound. What
description of this finding should the nurse include in the client's record?
One-inch pressure sore draining serous fluid.
When the nurse enters a client's room to do an initial assessment, the client shouts, "Get out of
my room! I'm tired of being bothered!" How should the nurse respond?
"What is concerning you this morning?"
The nurse encounters resistance when inserting the tubing into a client's rectum for a tap water
enema. What action should the nurse implement?
Ask the client to relax and run a small amount of fluid into the rectum.
A client with Raynaud's disease asks the nurse about using biofeedback for self-management of
symptoms. What response is best for the nurse to provide?
Biofeedback allows the client to control involuntary responses to promote peripheral
vasodilation.
Which client assessment data is most important for the nurse to consider before ambulating a
postoperative client?
Respiratory rate.
A male client arrives at the outpatient surgery center for a scheduled needle aspiration of the
knee. He tells the nurse that he has already given verbal consent for the procedure to the
healthcare provider. What action should the nurse implement?
Witness the client's signature on the consent form.
A medication is prescribed to be given QID. What schedule should the nurse use to administer
this prescription?
0800, 1200, 1600, 2000.
Comprehensive Practice Questions & Detailed Correct
Answers | HESI Admission Assessment Prep for RN &
LPN Programs | 100% Verified & Updated Content.
While preparing to insert a rectal suppository in a male adult client, the nurse observes that the
client is holding his breath while bearing down. What action should the nurse implement?
Instruct the client to take slow deep breaths and stop bearing down.
The nurse assesses an immobile, elderly male client and determines that his blood pressure is
138/60, his temperature is 95.8 F, and his output is 100 ml of concentrated urine during the last
hour. He has wet-sounding lung sounds, and increased respiratory secretions. Based on these
assessment findings, what nursing action is most important for the nurse to implement?
Turn the client q2h.
The home health nurse visits an elderly female client who had a stroke three months ago and is
now able to ambulate with the assistance of a quad cane. Which assessment finding has the
greatest implications for this client's care?
The nurse notes that there are numerous scatter rugs throughout the house.
In providing care for a terminally ill resident of a long-term care facility, the nurse determines
that the resident is exhibiting signs of impending death and has a "do not resuscitate" or DNR
status. What intervention should the nurse implement first?
Notify family members of the client's condition.
A healthcare provider is performing a sterile procedure at a client's bedside. Near the end of the
procedure, the nurse observes the healthcare provider contaminate a sterile glove and the
sterile field. What is the best action for the nurse to implement?
Identify the break in surgical asepsis and provide another set of sterile supplies.
The nurse is digitally removing a fecal impaction for a client. The nurse should stop the
procedure and take corrective action if which client reaction is noted?
Pulse rate decreases from 78 to 52 beats/min.
Which client care activity requires the nurse to wear barrier gloves as required by the protocol
for Standard Precautions?
,Emptying the urinary catheter drainage bag for a client with Alzheimer's disease.
A client in hospice care develops audible gurgling sounds on inspiration. Which nursing action
has the highest priority?
Inform the family that death is imminent.
A 73-year-old Hispanic client is seen at the community health clinic with a history of protein
malnutrition. What information should the nurse obtain first?
Foods and liquids consumed during the past 24 hours.
When caring for an immobile client, what nursing diagnosis has the highest priority?
Impaired gas exchange.
Which statement correctly identifies a written learning objective for a client with peripheral
vascular disease?
Upon discharge, the client will list three ways to protect the feet from injury.
Which nursing intervention is most beneficial in reducing the risk of urosepsis in a hospitalized
client with an indwelling urinary catheter?
Obtain a prescription for removal of the catheter as soon as possible.
The nurse is providing passive range of motion (ROM) exercises to the hip and knee for a client
who is unconscious.
After supporting the client's knee with one hand, what action should the nurse take next?
Cradle the client's heel.
Prior to administering a newly prescribed medication to a client, the nurse reviews the adverse
effects of the medication listed in a drug reference guide and determines the priority risks to the
client. While performing this action, the nurse is engaged in which step of the nursing process?
Analysis.
What action by the nurse demonstrates culturally sensitive care?
Asks permission before touching a client.
An older female client with rheumatoid arthritis is complaining of severe joint pain that is
caused by the weight of the linen on her legs. What action should the nurse implement first?
Drape the sheets over the footboard of the bed.
, An older client who is able to stand but not to ambulate receives a prescription to be mobilized
into a chair as tolerated during each day. What is the best action for the nurse to implement
when assisting the client from the bed to the chair?
Place a transfer belt around the client, assist to stand, and pivot to a chair that is placed at a
right angle to the bed.
The nurse removes the dressing on a client's heel that is covering a pressure sore one-inch in
diameter and finds that there is straw-colored drainage seeping from the wound. What
description of this finding should the nurse include in the client's record?
One-inch pressure sore draining serous fluid.
When the nurse enters a client's room to do an initial assessment, the client shouts, "Get out of
my room! I'm tired of being bothered!" How should the nurse respond?
"What is concerning you this morning?"
The nurse encounters resistance when inserting the tubing into a client's rectum for a tap water
enema. What action should the nurse implement?
Ask the client to relax and run a small amount of fluid into the rectum.
A client with Raynaud's disease asks the nurse about using biofeedback for self-management of
symptoms. What response is best for the nurse to provide?
Biofeedback allows the client to control involuntary responses to promote peripheral
vasodilation.
Which client assessment data is most important for the nurse to consider before ambulating a
postoperative client?
Respiratory rate.
A male client arrives at the outpatient surgery center for a scheduled needle aspiration of the
knee. He tells the nurse that he has already given verbal consent for the procedure to the
healthcare provider. What action should the nurse implement?
Witness the client's signature on the consent form.
A medication is prescribed to be given QID. What schedule should the nurse use to administer
this prescription?
0800, 1200, 1600, 2000.
