ADULT HEALTH HESI ACTUAL EXAM
WITH COMPLETE QUESTIONS AND
CORRECT DETAILED ANSWERS
(100% VERIFIED ANSWERS) |
ALREADY GRADED A+ | ||PROFESSOR
VERIFIED|| ||BRANDNEW!!!|| 2026!!!!
A central venous catheter has been inserted via a jugular vein, and a radiograph has
confirmed placement. A prescription for a STAT medication is received, but IV
fluids have not started. Which action should the nurse take prior to administration?
A. Assess for signs of jugular venous distention.
B. Obtain the needed intravenous solution.
C. Flush the line with heparinized solution.
D. Flush the line with normal saline.
Answer: D
Rationale: Ensuring the patency of a central venous access device is the absolute priority
before introducing pharmacological agents. Even though a radiograph has confirmed the
anatomical position of the catheter tip, the nurse must mechanically verify that the lumen is
clear and functional. Flushing with normal saline is the standard evidence-based practice to
clear the line of any fibrin or blood remains. Normal saline is preferred over heparinized
solutions in many acute settings due to the risks of Heparin-Induced Thrombocytopenia
(HIT).
A client is ready for discharge following the creation of an ileostomy. Which
instruction should the nurse include in discharge teaching?
A. Replace the stoma appliance every day.
B. Use warm tap water to irrigate the ileostomy.
C. Change the bag when the seal is broken.
D. Measure and record the ileostomy output.
,Answer: C
Rationale: Post-operative ileostomy care focuses heavily on skin integrity because the
effluent is liquid and contains high concentrations of digestive enzymes. These enzymes are
highly caustic to the peri-stomal skin and can cause rapid excoriation if the seal is
compromised. Daily appliance changes are generally discouraged as the frequent removal of
adhesive can cause mechanical trauma. Unlike colostomies, ileostomies are never irrigated
because the stool is already liquid.
An older male client complains of pain in his left calf. The nurse notices a reddened
area on the calf that is warm to the touch. Which additional assessment is MOST
important for the nurse to perform?
A. Measure the client's calf circumference.
B. Auscultate the client's breath sounds.
C. Observe for ecchymosis and petechiae.
D. Obtain the client's blood pressure.
Answer: B
Rationale: When a nurse suspects thrombophlebitis or Deep Vein Thrombosis (DVT), the
most life-threatening complication to anticipate is a pulmonary embolism (PE). This occurs
when a portion of the thrombus dislodges and travels through the venous system into the
pulmonary vasculature. Auscultating breath sounds allows the nurse to assess for acute
respiratory changes, such as crackles or diminished sounds, which may indicate a PE.
Airway, Breathing, and Circulation (ABCs) always take priority.
A client with cirrhosis of the liver has a nasogastric tube draining bright red blood.
Hemoglobin and hematocrit levels are decreased. Which additional change in
laboratory data should the nurse expect?
A. Increased serum albumin level
B. Decreased serum creatinine
C. Decreased serum ammonia level
D. Increased liver function test results
Answer: C
Rationale: In patients with advanced liver disease, the liver cannot effectively convert
ammonia into urea. When a patient has a GI bleed, the blood acts as a massive protein load
in the gut. Bacteria break down this blood, leading to a spike in ammonia. By removing the
blood from the stomach via NG suctioning, the nurse removes the protein source before it
, reaches the lower intestines. This leads to a decrease in the production and subsequent serum
level of ammonia, preventing hepatic encephalopathy.
A nurse is assessing a client with acute pancreatitis. Which finding requires the
MOST immediate intervention by the nurse?
A. Serum amylase level three times higher than normal.
B. Development of carpal spasm while taking blood pressure.
C. Epigastric pain rated at 7 on a 1 to 10 scale.
D. Client statement regarding continued alcohol use.
Answer: B
Rationale: A carpal spasm (Trousseau’s sign) indicates severe hypocalcemia. In acute
pancreatitis, calcium becomes trapped in areas of fat necrosis (saponification). Hypocalcemia
is a medical emergency because it increases neuromuscular irritability, leading to tetany,
seizures, laryngospasm, and lethal cardiac arrhythmias. While amylase levels and pain are
expected findings, they are not immediately life-threatening in the same way as
neuromuscular tetany and potential respiratory collapse.
The nurse initiates neurologic checks for a client at risk for neurologic compromise.
Which manifestation typically provides the FIRST indication of altered neurologic
function?
A. Change in level of consciousness
B. Increasing muscular weakness
C. Changes in pupil size bilaterally
D. Progressive nuchal rigidity
Answer: A
Rationale: A decrease or change in the level of consciousness (LOC) is usually the first and
most sensitive indication of neurologic deterioration. This can manifest as restlessness,
irritability, or increased lethargy. While muscular weakness and pupil changes are
significant, they often occur later in the process of neurological decline. Nuchal rigidity is
specifically associated with meningeal irritation rather than general neurological
compromise.
A client newly diagnosed with Cushing syndrome is being monitored. Which nursing
intervention is MOST appropriate based on the clinical manifestations of this
syndrome?
WITH COMPLETE QUESTIONS AND
CORRECT DETAILED ANSWERS
(100% VERIFIED ANSWERS) |
ALREADY GRADED A+ | ||PROFESSOR
VERIFIED|| ||BRANDNEW!!!|| 2026!!!!
A central venous catheter has been inserted via a jugular vein, and a radiograph has
confirmed placement. A prescription for a STAT medication is received, but IV
fluids have not started. Which action should the nurse take prior to administration?
A. Assess for signs of jugular venous distention.
B. Obtain the needed intravenous solution.
C. Flush the line with heparinized solution.
D. Flush the line with normal saline.
Answer: D
Rationale: Ensuring the patency of a central venous access device is the absolute priority
before introducing pharmacological agents. Even though a radiograph has confirmed the
anatomical position of the catheter tip, the nurse must mechanically verify that the lumen is
clear and functional. Flushing with normal saline is the standard evidence-based practice to
clear the line of any fibrin or blood remains. Normal saline is preferred over heparinized
solutions in many acute settings due to the risks of Heparin-Induced Thrombocytopenia
(HIT).
A client is ready for discharge following the creation of an ileostomy. Which
instruction should the nurse include in discharge teaching?
A. Replace the stoma appliance every day.
B. Use warm tap water to irrigate the ileostomy.
C. Change the bag when the seal is broken.
D. Measure and record the ileostomy output.
,Answer: C
Rationale: Post-operative ileostomy care focuses heavily on skin integrity because the
effluent is liquid and contains high concentrations of digestive enzymes. These enzymes are
highly caustic to the peri-stomal skin and can cause rapid excoriation if the seal is
compromised. Daily appliance changes are generally discouraged as the frequent removal of
adhesive can cause mechanical trauma. Unlike colostomies, ileostomies are never irrigated
because the stool is already liquid.
An older male client complains of pain in his left calf. The nurse notices a reddened
area on the calf that is warm to the touch. Which additional assessment is MOST
important for the nurse to perform?
A. Measure the client's calf circumference.
B. Auscultate the client's breath sounds.
C. Observe for ecchymosis and petechiae.
D. Obtain the client's blood pressure.
Answer: B
Rationale: When a nurse suspects thrombophlebitis or Deep Vein Thrombosis (DVT), the
most life-threatening complication to anticipate is a pulmonary embolism (PE). This occurs
when a portion of the thrombus dislodges and travels through the venous system into the
pulmonary vasculature. Auscultating breath sounds allows the nurse to assess for acute
respiratory changes, such as crackles or diminished sounds, which may indicate a PE.
Airway, Breathing, and Circulation (ABCs) always take priority.
A client with cirrhosis of the liver has a nasogastric tube draining bright red blood.
Hemoglobin and hematocrit levels are decreased. Which additional change in
laboratory data should the nurse expect?
A. Increased serum albumin level
B. Decreased serum creatinine
C. Decreased serum ammonia level
D. Increased liver function test results
Answer: C
Rationale: In patients with advanced liver disease, the liver cannot effectively convert
ammonia into urea. When a patient has a GI bleed, the blood acts as a massive protein load
in the gut. Bacteria break down this blood, leading to a spike in ammonia. By removing the
blood from the stomach via NG suctioning, the nurse removes the protein source before it
, reaches the lower intestines. This leads to a decrease in the production and subsequent serum
level of ammonia, preventing hepatic encephalopathy.
A nurse is assessing a client with acute pancreatitis. Which finding requires the
MOST immediate intervention by the nurse?
A. Serum amylase level three times higher than normal.
B. Development of carpal spasm while taking blood pressure.
C. Epigastric pain rated at 7 on a 1 to 10 scale.
D. Client statement regarding continued alcohol use.
Answer: B
Rationale: A carpal spasm (Trousseau’s sign) indicates severe hypocalcemia. In acute
pancreatitis, calcium becomes trapped in areas of fat necrosis (saponification). Hypocalcemia
is a medical emergency because it increases neuromuscular irritability, leading to tetany,
seizures, laryngospasm, and lethal cardiac arrhythmias. While amylase levels and pain are
expected findings, they are not immediately life-threatening in the same way as
neuromuscular tetany and potential respiratory collapse.
The nurse initiates neurologic checks for a client at risk for neurologic compromise.
Which manifestation typically provides the FIRST indication of altered neurologic
function?
A. Change in level of consciousness
B. Increasing muscular weakness
C. Changes in pupil size bilaterally
D. Progressive nuchal rigidity
Answer: A
Rationale: A decrease or change in the level of consciousness (LOC) is usually the first and
most sensitive indication of neurologic deterioration. This can manifest as restlessness,
irritability, or increased lethargy. While muscular weakness and pupil changes are
significant, they often occur later in the process of neurological decline. Nuchal rigidity is
specifically associated with meningeal irritation rather than general neurological
compromise.
A client newly diagnosed with Cushing syndrome is being monitored. Which nursing
intervention is MOST appropriate based on the clinical manifestations of this
syndrome?
