HESI Live Review Test Bank for the NCLEX-RN Exam 2025.

A client reports to the nurse he has not had a BM in 2 days. Which intervention should the nurse implement first? A. instruct caregiver to offer a glass of prune juice B. notify HCP and request script for stool softener C. Assess client’s med rec and see normal BM pattern D. Instruct caregiver to increase clients’ fluids to five 8 ounce glasses per day. - C!! Always assess first. You dont know enough to ask for stool softener A client who has COPD is resting in semi fowlers w/ O2 BNC 2L. The client develops dyspnea. What action does the nurse take first? A. Call HCP B. Obtain bedside pulse ox C. Raise HOB D. Assess clients vital signs - C!! B and D are the same-- that is a flag A client who has hyperparathyroidism is scheduled to receive a prescribed dose of oral phosphate. The RN notes that the clients serum calcium level is 12.5mg/dL. What action should to nurse take? A. hold the phosphate and notify the HCP B. review clients serum PTH C. Give PRN IV Ca D. Admin oral dose of PO4 - D! Ca and PO4 have an inverse relationship In completing a clients pre-op routine, the RN finds that the consent has not been signed. The clients begins to ask more questions about the surgical procedure. What action should the nurse take next? A. Witness the client's signature on the consent B. Answer the clients questions about the surgery C. Inform the HCP that the client has questions about the surgery. D. Reassure client that the surgeon will answer questions before anesthetic is administered. - C! The nurses role with surgical consent is to witness-- the HCP needs to answer questions. What foods do you avoid within 1 hour of taking iron? - dairy and caffeine Do you give injections to pt with edema? - NO living will - a client documents his or her wishes regarding future care in the event of terminal illness. durable power of attorney - a client appoints a representative (healthcare proxy) to make healthcare decisions. An awake and alert client with impending pulmonary edema is brought to the emergency department. The client provides the nurse with a copy of a living will that states that no invasive medical procedures should be used to keep her alive. the healthcare team is questioning whether the client should be intubated. What information should guide the teams decision? A. the living will removes the obligation to involve the client in any medical decision making. B. The client is awake and alert, which makes the living will irrelevant and nonbinding. C. Lifesaving measures do not need to be explained to the client because of the signed will. D. The family should be contacted to determine who has durable POA for healthcare for a client. - B!! since the client is awake and alert, the living will is not indicated at the time. A family member of a client who is in a posey vest restraint asks why the restraint was applied. How should the nurse respond? A. The restraint was prescribed. B. There are not enough staff to keep client safe at all times. C. The other clients are upset when the client wanders at night. D. The client's actions place her at high risk for harming herself. - D!! What nursing action has the highest priority when admitting a client to a psychiatric unit on an involuntary basis? A. Reassure the client that the admission is only for a limited time. B. Offer the client and family the opportunity to share their feelings about the admission. C. Determine the behaviors that resulted in the need for admission. D. Advise the client about the legal rights of all hospitalized clients. - C!! SAFETY FIRST!! You need to know why they are there. What if they are there due to suicidal idealizations? you do not want to miss that. The nurse enters the room of a preoperative client to obtain the client's signature on the surgical consent form. Which question is most important for the nurse to ask the client? A. "When did the surgeon explain the procedure to you?" B. "Is any member of your family going ot be here during surgery?" C. "Have you been instructed in postoperative activities and restrictions?" D. "Have you received any preoperative pain medications?" - D!! It is MOST IMPORTANT because the client cannot sign if they have had pain meds and she is there to obtain a signature. The charge nurse confronts a staff nurse whose behavior has been resentful and negative behavior has been resentful and negative since a change in unit policy was announced. The staff nurse states, "Dont blame me; nobody likes this idea." What is the charge nurse's priority action? A. Confront the other staff members involved in the chane of unit policy B. Call a unit meting to review the reasons the change was made C. Develop a written unit policy for the expression of complaints D. Encourage the nurse to be accountable for he own behavior - D!! the democratic process of implementing a new policy has already taken place and now it is time to address the nurses actions, not policy. Which situation warrants an incident report by the nurse? A. A client refuses to take prescribed medication B. A client's status improves before completion of the course of medication C. A client has an allergic reaction to a prescribed medication. D. A client received medication prescribed for another client. - D!! this could cause harm to the client and it was by nurse error. A charge nurse is making assignments for 5 clients. The nursing team has an RN, a PN, and two UAPs. Which client would be assigned to the RN? A. A client from the previous shift with unstable angina. B. A client with a stage 3 pressure ulcer who needs a bed bath. C. A client with an enteral feeding absorbing at 30mL/hr. D. A cardiotomy client who is day 2 postop and who has chest tubes. E. A client with quadriplegia for whom urinary catheterization has been prescribed. - A & D!! 72 yr old client returned from surgery 6 hours ago. Client received hydromorphone 2mg IV 30mins ago for a pain rating of 8/10. The family member requests the nurse check on the client immediately. On arrival, the nurse finds that the client is difficult to arouse, which a respiratory rate of 6. What is the priority nursing action? A. Elevate HOB B. Admin naloxone 0.4mg IV C. Assess breath sounds D. Check vital signs and pulse oximetry. - B!! the nurse has already done assessments and narcan is indicated. The changes in causes fluid shifts. - osmolarity The ECF osmolarity is almost entirely due to - sodium The ICF osmolarity is related to many particles, but the main one is - potassium The client who is HIV positive, asks why it is necessary to have viral load study performed every 3 to 4 months. What would be the nurses best response? A. To determine the progression of the disease B. To evaluate the enzyme-liked immunobsorbent assay ELISA C. To monitor the effectiveness of the treatment D. To track the effectiveness of the vaccine - C!! this is asking about VIRAL LOAD, which you check with HAART every 3 to 4 months. alkaline phosphatase blood levels will be elevated with - liver disease or metastsis to the bone or liver calcitonin may be elevated when - cancer of thyroid, breast cancer, and oat cell cancer of the lung The charge nurse is assigning rooms for four new clients. Only one private room available on the oncology unit. Which client should be placed in the private room. A. the client with ovarian cancer who is receiving chemotherapy B. The client with breast cancer who is receiving external beam radiation C. The client with prostate cancer who has just had a TURP D. The client with cervical cancer who is receiving intra-cavitary radiation. - D!! someone with this is always exposing radiation to the external environment The CBC results for a client receiving chemo are hgb 5 and hematocrit 32%; WBC count, 6.5X 109. which meal choice is best for this client? A. Grilled chicken, rice, fresh fruit, milk B. Broiled steak, whole wheat rolls, spinach salad, coffee C. Smoked ham, mashed potatoes, applesauce, iced tea D. Tuna noodle cassarole, garden salad, lemonade - B!! they are anemic. This option gives iron in the meat and with the spinach to help bind. After the change of shift report, the nurse reviews her assignments. Which client should the RN asses first? A. the client receiving palliative care for heart failure who complains of constipation and nervousness B. The adult client who is 48 hours postop for a colectomy and is reported to be having nausea and vomiting. C. Middle age client with CRF whose urinary cath has been draining 95mL for 8 hours. D. The client who is 2 days postop for a thoracotemy and has chest tubes, is on O2 at 3L, and has a respiratory rate of 12 breaths/min. - B!! both acute and concerning and unexpected The nurse is monitoring the status of a client recovering from an MI. Which symptom indicates an evolving problem? A. a steady pulse of 88 beats/min B. Rising systolic pressure from 110 to 120mmHg C. thee premature ventricular contractions/min D. Central venous pressure of 8 mmHg - C!! they may be going into v-tach and this indicates an EVOLVING PROBLEM Increases preload - crystalloids and colloids Decreases preload - nitrates, diuretics, morphine Increases afterload - vasopressors Decrease afterload - ACE inhibitors and ARBS Increase contractility - dobutamine, dopamine, and digoxin Decrease contractility - beta-blockers, calcium channel blockers Known side effect of ACE inhibitors (prils) - coughing and anaphylaxis in African Americans that is out of nowhere Safety with ARBS (sartans) - orthostatic hypotension A client in shock develops a MAP of 60mmHg and a heart rate of 110 beats/min. Which prescribed intervention should the nurse implement first? A. Increase the rate of O2 flow B. Obtain ABG C. Insert an indwelling urinary catheter D. Increase rate of IV fluids - D!! MAP is low and HR is high! Not O2 bc can have a fluid imbalance without resp depression A client is admitted to the acute care unit with stable angina. At 7:00am the client has had stable vital signs and is on 2L nasal canula. At 10:00am the client reports chest pain as 6 on a scale of 1 to 10, is slightly diaphoretic and pale, blood pressure is 100/52, and respiratory rate is 24. Which action will the nurse implement first? A. Apply 4L O2 as ordered B. Administer a fluid bolus of 0.9% NS C. Administer the prescribed opioid for pain control D. Obtain a full set of vital signs including temperature - A!! Chest pain--- give O2 or increase O2 if already present! A client with burn injuries has lost a significant amount of body fluid. An IV of LR is infusing at 200mL/hr, with urine output for the past 8 hours is 400mL. Which sign or symptom relates to early distributive shock? A. Change in BP from 118/60 to 102/68 B. A change in LOC from awake to restless C. A decrease in O2 saturation from 98% to 93%. D. A decrease in urine output over 8 hours from 400 to 240 mL - B!! EARLY A client recovering from ARDS is awake and alert, has residual fatigue and generalized weakness. His current VS are HR 83, blood pressure 104/64, respiratory rate 25, SpO2 on 2L/min nasal oxygen air is 92%. Which value should the UAP report immediately to the nurse? A. HR of 88 B. BP of 104/64 C. Respiratory rate of 25 resps D. SpO2 92% - C!! they are recovering from ARDS, most related and this will tire them out quicker An elderly clients VS are 103F, HR 109, RR 37, BP 86/42. After an infusion of 1L of 0.9 NS IV there are few changes in vital signs. The nurse assesses the client and determines that more fluids would be appropriate based on which parameters? select all that apply A. Urinary output of 40mL in last hour B. Central venous pressure of 5mmHg C. HR increase from 109 to 129 when sitting D. Peripheral pulse change from +2 to +1 E. MAP of 70 - A, B, C-- all pertain to fluid problems A 22 year-old client is admitted through the ED with a 2 day hx of cough, fever, and fatigue. The medical hx is positive for T1DM and recent URTI. Vital signs are HR 109, BP 102/58, RR 24, temp 104, and SpO2 92% on 2L NC. Which is the priority? A. Initiate large bore IV B. Draw 2 sets of blood cultures C. Administer the ordered IV products D. Draw serum lactate and glucose level - B!! We are MOST concerned about what kind of infection this is. on NCLEX, you pick what is most important, not what you do in practice in order, that is why A is not right. A client with a hx of uterine fibroids had a c section delivery 12 hours earlier and delivered healthy twin girls. At shift change, the nurse assesses the client and notes SOB, cool extremities, and oozing bood from the incision site. Based on the clients presentation, what action is the highest priority? A. assess temp B. notify HCP C. clean blood from incision site D. draw labs for PT, PTT, CBC, fibrinogen - B!! this is deadly, doc needs to know ASAP The cardiac monitor alarm goe off, and the nurse arrives to find the 59 year old client slumped in the chair. Place the actions in order of priority A. activate the code team and get defib B. determine unresponsiveness C. Assess rhythm using quick look paddles D. Asses for a pulse ( carotid) E. Open airways and give two rescue breaths by bag valve mask F. Move the client to a flat position in bed or on the floor G. Begin compressions - B, A, D, F, G, E, C Goal of triage - START simple triage and rapid treatment method Four clients arrive in the ED after an explosion at an apartment complex. IN which order should they be assessed? A. 70 year old who is complaining of a pain level of 8/10 from a hand burn B. 35 year old with partial and full thickness burns to the anterior and posterior chest C. 25 year old with a superficial burn to the right anterior arm and lateral chest D. 42 year old with a partial thickness burn to the anterior lower extremity and confusion - B, D, A, C look at area that was burned. Further, shock is reversible in the first stage, and it is indicated that D is in a later stage of shock, so B would be best to go to first when you see burns think - fluid status, hypovolemic shock what do you treat anthrax poisoning with? - cipro Which precautions are used for anthrax? - airborne, contact, droplet, and standard when you see v-fib, if you dont see an answer that says shake and shout, what do you do? - SHOCK EM The nurse is caring for a client in shock of unknown etiology and observes the above rhythm on the monitor. What is the nurses first priority? A. check carotid pulse B. Defibrillator the patient with 360 joules of energy C. Administer an IV saline bolus D. Give 2 breaths via Ambu bag - B!! if its v-fib, Defib!! even if a lead was off, you would not see v fib on a monitor. the monitor is a sure sign for v fib. how much drainage from a chest tube in one hour should be concerning enough to contact the hcp? - more than 70mL/hr chest tube dislodgement interventions - 1. cover with dry, sterile dressing 2. if air leak is noted, tape the dressing on three sides only to allow air to escape and prevent tension pneumothorax 3. urgently notify hcp A client who is 1 day postop from a left pneumonectomy is lying on their right side with the HOB elevated 10 degrees. The nurse assesses his resp rate at 32 breaths/min. What action should the nurse take first? A. further elevate HOB B. assist the client to a supine position C. measure the clients O2 sat D. administer IV PRN morphine - B!! when the pt is in distress, do not assess- ACT! also they should NOT BE ON THEIR SIDE penicillins pt teaching - allergies??, may get rash, GI problems common tetracycline pt teaching - avoid dairy, photosensitivity, and they stain teeth aminoglycosides (gentamycin and vanc) pt teaching - ototoxic, nephrotoxic, and hepatoxic cephalosporins (ceftriaxone) pt teaching - are you allergic to PCN?? (can have anaphylaxis) macrolides (clarithromycin)pt teaching - GI issues fluoriquinolones (cirpoflaxin) pt teaching - tendon rupture inhaled anticholinergics - ipratropium and aclidinium bromide beta 2 agonists work on - the lungs, but can also have cardiac effects LABA - salmeterol The nurse palpates a crackling sensation of the skin around the insertion site of a chest tube in a client who has had thoracic surgery. What action should the nurse take? A. Return the client to surgery B. Prepare for insertion of a larger chest tube C. Increase water-seal suction pressure D. Continue to monitor the insertion - D!! watch it to make sure it doesnt get bigger! crackles at the site are okay unless it enlarges The nurse is preparing to administer a Mantoux test to a client who is entering nursing school. Which action by the nurse is of highest priority? A. Prepare 0.1mL soln per tB syringe. B. Assess the skin condition on the forearm. C. Teach the client about positive findings. D. Inquire about bacillus Calmette-Geurin vaccine history - D!! this vaccine has a bad interaction with the tb injection. Tb interventions - airborne preacution isolation, single occupancy room with neg pressure and air flow 6-12 exchanges per hour, wear high efficiency particulate air (HEPA) masks, and notify public health department Tb medications - INH, rifampin, pyrazinimide, ethambutol. -will take for a long time - take all doses - your secretions (urine, tears, etc) may turn orange or blue - may cause GI irritation - may cause joint pain - do not use alcohol -hepatotoxicity- do LFTs -decreased red-green discrimination A client who is receiving a transfusion of PRBCs has an inflamed IV site. Which action should the nurse take? A. Double check the blood type of the transfusing unit of blood with another nurse. B. Discontinue the transfusion and send the remainng blood and tubing to the lab. C. Immediately start another IV at another site and resume the transfusion at the new site. D. Continue to monitor the site for signs of infection and notify the HCP - C!! don't keep an inflamed site, always change that! it doesn't take much time and ensures safety. Further, this is not a systemic reaction, it is just irritation, so not an emergency reaction. CABG pt teaching - get up and walk ASAP. may have a chest tube. pain management. splint coughing