1|Page
HESI COMPREHENSIVE REVIEW FOR THE NCLEX-RN
EXAMINATION NOTES
WITH REAL EXAM TESTBANK FOR A GUARANTEED PASS
ALL QUESTIONS UPDATED 2025
A nurse taking the vital signs of a client immediately after she has delivered a newborn notes that the
client's heart rate is 110 beats/min. What should the nurse do first?
Recheck the heart rate in 1 hour
Offer the client oral fluids
Check the uterus and amount of lochia discharge Correct
Document the findings
If tachycardia is noted, the nurse should first assess the location and firmness of the uterus and amount of
lochia. Additional assessments including blood pressure, estimated blood loss at delivery, and hemoglobin and
hematocrit determinations should be carried out. After delivery, the normal heart rate ranges from 60 to 90
beats/min. Tachycardia may indicate excitement, fatigue, dehydration, hypovolemia, pain, or infection.
Although the nurse would document the findings, it is most appropriate for the nurse to assess the client to
determine the cause of the tachycardia. Oral fluids are important if the client is dehydrated, but further
assessment of the problem is required and dehydration would first need to be confirmed. Rechecking the heart
rate in 1 hour will delay necessary interventions.
A nurse reviews the laboratory results of a hospitalized pregnant client with a diagnosis of sepsis who is
at risk for disseminated intravascular coagulopathy (DIC). Which laboratory finding would indicate to
the nurse that DIC has developed in the client?
Shortened prothrombin time
Increased platelet count
Positive result on d-dimer study Correct
Decreased fibrin-degradation products
The d-dimer study is used to confirm the presence of fibrin split products; a positive result is indicative of DIC.
DIC is a life-threatening defect in coagulation. As plasma factors are consumed, the circulating blood becomes
deficient in clotting factors and unable to clot. Even as anticoagulation is occurring, inappropriate coagulation is
also taking place in the microcirculation, and tiny clots form in the smallest blood vessels, blocking blood flow
to the organs and causing ischemia. Laboratory studies help establish a diagnosis. The fibrinogen value and
platelet count are usually decreased, prothrombin and activated partial thromboplastin times may be prolonged,
and levels of fibrin degradation products (the most sensitive measurement) are increased.
The nurse is assessing a client who has a history of Prinzmetal's angina. The nurse knows that what type
of medication is given to treat this condition?
Calcium channel blockers Correct
ACE inhibitors
Inotropes
Beta blockers
,2|Page
Prinzmetal's, or variant, angina is prolonged and severe and occurs at the same time each day, most often at rest.
The treatment of choice is usually a calcium channel blocker. Calcium channel blockers relax and dilate the
vascular smooth muscle, thus relieving the coronary artery spasm in variant angina. Inotropes, beta blockers,
and angiotensin-converting enzyme (ACE) inhibitors are not given to treat this disorder.
Ciprofloxacin hydrochloride is prescribed to a client with a urinary tract infection. The nurse provides
instruction about the medication. What does the nurse tell the client about how best to take the
medication?
With aluminum hydroxide
With an antacid
With milk
2 hours after meals Correct
Ciprofloxacin hydrochloride is an anti-infective in the fluoroquinolone family. It may be taken without regard to
meals, but the best dosing time is 2 hours after a meal. Milk may affect absorption. Antacids (here, aluminum
hydroxide) may reduce absorption and should be administered 2 hours apart from the ciprofloxacin
hydrochloride.
Ergotamine is prescribed to a client with cluster headaches. Which occurrence does the nurse tell the
client to report to the primary health care provider if she experiences them while taking the medication?
Fatigue and lethargy
Dizziness and fatigue
Numbness and tingling of the fingers or toes Correct
Cough
Ergotamine is an antimigraine medication. Prolonged administration or an excessive dosage may produce
ergotamine poisoning (ergotism). Signs/symptoms include nausea, vomiting, weakness in the legs, pain in the
limb muscles, and numbness and tingling of the fingers and toes. The client is instructed to report these
signs/symptoms to the primary health care provider if they occur. Cough, fatigue, lethargy, and dizziness are
side effects and not adverse effects of the medication.
A nurse working the evening shift is helping clients get ready for sleep. A female client diagnosed with
mania is hyperactive and pacing the hallway. What is the most appropriate action the nurse can take?
Tell the client that other clients are trying to sleep and that she is being disruptive
Take the client to the bathroom and provide her with a warm bath Correct
Stay with the client and observe her behavior
Tell the client that it is time for sleep and that she needs to go to her room
At bedtime, the nurse should take the client to the bathroom and provide warm baths, soothing music, and
medication when indicated. For the client with mania, the nurse needs to promote relaxation, rest, and sleep and
to minimize manic behavior. The nurse should encourage frequent rest periods during the day and keep the
client in areas of low stimulation. The client should not consume products containing caffeine. Staying with the
client and observing her behavior, telling the client that it is time to go to sleep and to go to her room, and
telling the client that other clients are trying to sleep and that she is being disruptive do not address the client's
needs and are not measures that will help the client relax and sleep.
,3|Page
A client diagnosed with type 1 diabetes mellitus has just been told that she is 6 weeks pregnant. The nurse
provides information to the client about dietary and insulin needs. What comment by the client suggests
an understanding of the information?
"I know I will have to increase my insulin during this time period."
"My insulin needs should decrease during the first trimester." Correct
"Needs for insulin will not change during the first 3 months of pregnancy."
"I will have to double up on the insulin dose during this time span."
Insulin needs generally decrease during the first trimester of pregnancy because the secretion of placental
hormones antagonistic to insulin remains low. An increase in insulin need, lack of change in insulin need, and
doubling of insulin need are all incorrect.
A nurse develops a list of home care instructions for a client who is wearing a halo fixation device after
sustaining a cervical fracture. Which instructions should the nurse include? Select all that apply.
Do not drive, because full range of vision is impaired with the device. Correct
Avoid sexual activity while the vest is in place.
Apply powder under the vest to prevent irritation.
Wear snug clothing to prevent the device from shifting.
Use caution when leaning forward or backward. Correct
Use a straw to drink. Correct
Straws are used to drink, and meat and other foods are cut into small pieces to facilitate swallowing. The weight
of the halo device alters balance; therefore the client should use caution when leaning forward or backward. The
client is also told not to drive, because full range of vision is impaired with the device. A halo fixation
(stabilization) device is used to prevent the head and neck from moving after a neck injury. The halo fixation
device is not removed. Sexual activity does not have to be avoided; the client is instructed to use a position of
comfort. Powders and lotions are used sparingly or not at all to prevent buildup of moisture and subsequent skin
breakdown. The client is instructed to wear loose clothing with a large neck. The halo fixation device should not
shift; if it does, the primary health care provider must be notified. The client is taught to sleep with the head
supported with a small pillow to prevent unnecessary pressure and discomfort.
Empyema develops in a client with an infected pleural effusion, and the nurse prepares the client for
thoracentesis. The nurse is assisting the primary health care provider with the procedure. What
characteristics of the fluid removed during thoracentesis should the nurse expect to note?
Clear and yellow
Thick and opaque Correct
Clear, with a foul odor
White and odorless
Empyema is the accumulation of pus in the pleural space. Empyema fluid is thick, opaque, exudative, and
intensely foul-smelling. Clear and yellow, white and odorless, and clear and foul-smelling are incorrect
descriptions of the fluid that occurs in this disorder.
A client who was involved in a high-speed motor vehicle crash is brought to the emergency department.
Which finding indicates to the nurse that the client has sustained a flail chest?
Asymmetrical chest movement Correct
, 4|Page
Increased breath sounds on auscultation
Deep respirations, 18 breaths/min
Complaints of mild chest discomfort
The nurse specifically notes paradoxical breathing (asymmetrical chest movement); oscillation of the
mediastinum; increasing dyspnea; rapid, shallow respirations; accessory muscle breathing; restlessness;
decreased breath sounds on auscultation; cyanosis; and anxiety related to difficulty breathing. The client will
also complain of severe chest pain. Flail chest is a thoracic injury resulting in paradoxical motion of the chest-
wall segment. This causes the mediastinal structures to swing back and forth with respiration.
A nurse is preparing a pregnant client in the third trimester for an amniocentesis. What does the nurse
tell the client is the reason amniocentesis is often performed during the third trimester?
To establish an accurate age for the fetus
To assess the degree of fetal lung maturity Correct
To discover genetic characteristics
To know the sex of the fetus
Amniocentesis is the aspiration of fluid from the amniotic sac for examination. Common indications for
amniocentesis during the third trimester include assessment of fetal lung maturity and evaluation of fetal
condition when the woman has Rh isoimmunization. A common purpose of amniocentesis in the second
trimester is to examine fetal cells in the amniotic fluid to identify chromosomal abnormalities. Other methods of
genetic analysis, such as those for metabolic defects in the fetus, may be performed on the cells as well. The sex
and age of the fetus are not determined with the use of amniocentesis.
A nurse is caring for a client with sarcoidosis. The client is upset because he has missed work and worried
about how he will care financially for his wife and three small children. On the basis of the client's
concern, which problem does the nurse identify?
Powerlessness
Disruption of thought processes
Anxiety Correct
Inability to maintain health
Anxiety is a vague, uneasy feeling of apprehension. Some related factors include a threat or perceived threat to
physical or emotional integrity or self-concept, changes in function in one's role, and threats to or changes in
socioeconomic status. The client experiencing powerlessness expresses feelings of having no control over a
situation or outcome. Disruption of thought processes involves disturbance of cognitive abilities or thought.
Inability to maintain health is being incapable of seeking out help needed to maintain health.
A nurse is caring for a client with open-angle glaucoma. The nurse knows that what agents are used to
treat this condition?
Myotic agents Correct
Anticholinergic agents
Mydriatric agents
Cycloplegic agents
HESI COMPREHENSIVE REVIEW FOR THE NCLEX-RN
EXAMINATION NOTES
WITH REAL EXAM TESTBANK FOR A GUARANTEED PASS
ALL QUESTIONS UPDATED 2025
A nurse taking the vital signs of a client immediately after she has delivered a newborn notes that the
client's heart rate is 110 beats/min. What should the nurse do first?
Recheck the heart rate in 1 hour
Offer the client oral fluids
Check the uterus and amount of lochia discharge Correct
Document the findings
If tachycardia is noted, the nurse should first assess the location and firmness of the uterus and amount of
lochia. Additional assessments including blood pressure, estimated blood loss at delivery, and hemoglobin and
hematocrit determinations should be carried out. After delivery, the normal heart rate ranges from 60 to 90
beats/min. Tachycardia may indicate excitement, fatigue, dehydration, hypovolemia, pain, or infection.
Although the nurse would document the findings, it is most appropriate for the nurse to assess the client to
determine the cause of the tachycardia. Oral fluids are important if the client is dehydrated, but further
assessment of the problem is required and dehydration would first need to be confirmed. Rechecking the heart
rate in 1 hour will delay necessary interventions.
A nurse reviews the laboratory results of a hospitalized pregnant client with a diagnosis of sepsis who is
at risk for disseminated intravascular coagulopathy (DIC). Which laboratory finding would indicate to
the nurse that DIC has developed in the client?
Shortened prothrombin time
Increased platelet count
Positive result on d-dimer study Correct
Decreased fibrin-degradation products
The d-dimer study is used to confirm the presence of fibrin split products; a positive result is indicative of DIC.
DIC is a life-threatening defect in coagulation. As plasma factors are consumed, the circulating blood becomes
deficient in clotting factors and unable to clot. Even as anticoagulation is occurring, inappropriate coagulation is
also taking place in the microcirculation, and tiny clots form in the smallest blood vessels, blocking blood flow
to the organs and causing ischemia. Laboratory studies help establish a diagnosis. The fibrinogen value and
platelet count are usually decreased, prothrombin and activated partial thromboplastin times may be prolonged,
and levels of fibrin degradation products (the most sensitive measurement) are increased.
The nurse is assessing a client who has a history of Prinzmetal's angina. The nurse knows that what type
of medication is given to treat this condition?
Calcium channel blockers Correct
ACE inhibitors
Inotropes
Beta blockers
,2|Page
Prinzmetal's, or variant, angina is prolonged and severe and occurs at the same time each day, most often at rest.
The treatment of choice is usually a calcium channel blocker. Calcium channel blockers relax and dilate the
vascular smooth muscle, thus relieving the coronary artery spasm in variant angina. Inotropes, beta blockers,
and angiotensin-converting enzyme (ACE) inhibitors are not given to treat this disorder.
Ciprofloxacin hydrochloride is prescribed to a client with a urinary tract infection. The nurse provides
instruction about the medication. What does the nurse tell the client about how best to take the
medication?
With aluminum hydroxide
With an antacid
With milk
2 hours after meals Correct
Ciprofloxacin hydrochloride is an anti-infective in the fluoroquinolone family. It may be taken without regard to
meals, but the best dosing time is 2 hours after a meal. Milk may affect absorption. Antacids (here, aluminum
hydroxide) may reduce absorption and should be administered 2 hours apart from the ciprofloxacin
hydrochloride.
Ergotamine is prescribed to a client with cluster headaches. Which occurrence does the nurse tell the
client to report to the primary health care provider if she experiences them while taking the medication?
Fatigue and lethargy
Dizziness and fatigue
Numbness and tingling of the fingers or toes Correct
Cough
Ergotamine is an antimigraine medication. Prolonged administration or an excessive dosage may produce
ergotamine poisoning (ergotism). Signs/symptoms include nausea, vomiting, weakness in the legs, pain in the
limb muscles, and numbness and tingling of the fingers and toes. The client is instructed to report these
signs/symptoms to the primary health care provider if they occur. Cough, fatigue, lethargy, and dizziness are
side effects and not adverse effects of the medication.
A nurse working the evening shift is helping clients get ready for sleep. A female client diagnosed with
mania is hyperactive and pacing the hallway. What is the most appropriate action the nurse can take?
Tell the client that other clients are trying to sleep and that she is being disruptive
Take the client to the bathroom and provide her with a warm bath Correct
Stay with the client and observe her behavior
Tell the client that it is time for sleep and that she needs to go to her room
At bedtime, the nurse should take the client to the bathroom and provide warm baths, soothing music, and
medication when indicated. For the client with mania, the nurse needs to promote relaxation, rest, and sleep and
to minimize manic behavior. The nurse should encourage frequent rest periods during the day and keep the
client in areas of low stimulation. The client should not consume products containing caffeine. Staying with the
client and observing her behavior, telling the client that it is time to go to sleep and to go to her room, and
telling the client that other clients are trying to sleep and that she is being disruptive do not address the client's
needs and are not measures that will help the client relax and sleep.
,3|Page
A client diagnosed with type 1 diabetes mellitus has just been told that she is 6 weeks pregnant. The nurse
provides information to the client about dietary and insulin needs. What comment by the client suggests
an understanding of the information?
"I know I will have to increase my insulin during this time period."
"My insulin needs should decrease during the first trimester." Correct
"Needs for insulin will not change during the first 3 months of pregnancy."
"I will have to double up on the insulin dose during this time span."
Insulin needs generally decrease during the first trimester of pregnancy because the secretion of placental
hormones antagonistic to insulin remains low. An increase in insulin need, lack of change in insulin need, and
doubling of insulin need are all incorrect.
A nurse develops a list of home care instructions for a client who is wearing a halo fixation device after
sustaining a cervical fracture. Which instructions should the nurse include? Select all that apply.
Do not drive, because full range of vision is impaired with the device. Correct
Avoid sexual activity while the vest is in place.
Apply powder under the vest to prevent irritation.
Wear snug clothing to prevent the device from shifting.
Use caution when leaning forward or backward. Correct
Use a straw to drink. Correct
Straws are used to drink, and meat and other foods are cut into small pieces to facilitate swallowing. The weight
of the halo device alters balance; therefore the client should use caution when leaning forward or backward. The
client is also told not to drive, because full range of vision is impaired with the device. A halo fixation
(stabilization) device is used to prevent the head and neck from moving after a neck injury. The halo fixation
device is not removed. Sexual activity does not have to be avoided; the client is instructed to use a position of
comfort. Powders and lotions are used sparingly or not at all to prevent buildup of moisture and subsequent skin
breakdown. The client is instructed to wear loose clothing with a large neck. The halo fixation device should not
shift; if it does, the primary health care provider must be notified. The client is taught to sleep with the head
supported with a small pillow to prevent unnecessary pressure and discomfort.
Empyema develops in a client with an infected pleural effusion, and the nurse prepares the client for
thoracentesis. The nurse is assisting the primary health care provider with the procedure. What
characteristics of the fluid removed during thoracentesis should the nurse expect to note?
Clear and yellow
Thick and opaque Correct
Clear, with a foul odor
White and odorless
Empyema is the accumulation of pus in the pleural space. Empyema fluid is thick, opaque, exudative, and
intensely foul-smelling. Clear and yellow, white and odorless, and clear and foul-smelling are incorrect
descriptions of the fluid that occurs in this disorder.
A client who was involved in a high-speed motor vehicle crash is brought to the emergency department.
Which finding indicates to the nurse that the client has sustained a flail chest?
Asymmetrical chest movement Correct
, 4|Page
Increased breath sounds on auscultation
Deep respirations, 18 breaths/min
Complaints of mild chest discomfort
The nurse specifically notes paradoxical breathing (asymmetrical chest movement); oscillation of the
mediastinum; increasing dyspnea; rapid, shallow respirations; accessory muscle breathing; restlessness;
decreased breath sounds on auscultation; cyanosis; and anxiety related to difficulty breathing. The client will
also complain of severe chest pain. Flail chest is a thoracic injury resulting in paradoxical motion of the chest-
wall segment. This causes the mediastinal structures to swing back and forth with respiration.
A nurse is preparing a pregnant client in the third trimester for an amniocentesis. What does the nurse
tell the client is the reason amniocentesis is often performed during the third trimester?
To establish an accurate age for the fetus
To assess the degree of fetal lung maturity Correct
To discover genetic characteristics
To know the sex of the fetus
Amniocentesis is the aspiration of fluid from the amniotic sac for examination. Common indications for
amniocentesis during the third trimester include assessment of fetal lung maturity and evaluation of fetal
condition when the woman has Rh isoimmunization. A common purpose of amniocentesis in the second
trimester is to examine fetal cells in the amniotic fluid to identify chromosomal abnormalities. Other methods of
genetic analysis, such as those for metabolic defects in the fetus, may be performed on the cells as well. The sex
and age of the fetus are not determined with the use of amniocentesis.
A nurse is caring for a client with sarcoidosis. The client is upset because he has missed work and worried
about how he will care financially for his wife and three small children. On the basis of the client's
concern, which problem does the nurse identify?
Powerlessness
Disruption of thought processes
Anxiety Correct
Inability to maintain health
Anxiety is a vague, uneasy feeling of apprehension. Some related factors include a threat or perceived threat to
physical or emotional integrity or self-concept, changes in function in one's role, and threats to or changes in
socioeconomic status. The client experiencing powerlessness expresses feelings of having no control over a
situation or outcome. Disruption of thought processes involves disturbance of cognitive abilities or thought.
Inability to maintain health is being incapable of seeking out help needed to maintain health.
A nurse is caring for a client with open-angle glaucoma. The nurse knows that what agents are used to
treat this condition?
Myotic agents Correct
Anticholinergic agents
Mydriatric agents
Cycloplegic agents
