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2025 HESI Assessment Exam Practice: 100
Comprehensive Review with High-Yield Questions,
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Question: A nurse completes the assessment of a female client who cannot function because of an impending divorce. What is the most effective nursing intervention at this time? Answer: 2. Assisting her in exploring new coping abilities ✅ Rationale:
- Encouraging new coping strategies helps the client actively manage emotional distress. Other options focus too much on analysis rather than action. Question: A client is admitted with a diagnosis of Cushing syndrome. Which clinical manifestations should the nurse expect the client to exhibit? Select all that apply. Choices:
- Polyuria
- Weakness ✅
- Hypertension ✅
- Truncal obesity ✅
- Intermittent tonic spasms Rationale:
- Weakness, hypertension, and truncal obesity are classic signs of Cushing syndrome due to excess corticosteroids.
- Polyuria and tonic spasms are not typical. Question: Which conservation exercises should the nurse include in the assessment process of a child who is 6 years of age? Select all that apply. Choices:
- Comparing the mass of two balls ✅
- Comparing the weight of two balls
- Comparing the length of pencils ✅
- Comparing the volume in two cups
- Comparing the number of marbles ✅ Rationale:
- Conservation tasks involving mass, number, and length are developmentally appropriate for a 6-year-old, according to Piaget’s concrete operational stage. Question: Listening to a client's heart sounds, the nurse hears a characteristic sound. What should the nurse document? Answer: 4. Pericardial friction rubs ✅ Rationale:
- A pericardial friction rub produces a high-pitched, scratchy sound associated with pericarditis. 2. Wound Dressing Asepsis Question: Which statement by a new nurse about wound dressing indicates the need for further teaching? Answer: 2. "I should take the cotton swab placed on the table." ✅ Rationale:
- Once a cotton swab is placed on a non-sterile surface, it is no longer sterile. 3. Malaria Clinical Indicators Question: Which clinical indicators are important in a client with malaria? Select all that apply. Choices:
- Polyuria
- Leukopenia
- Hyperthermia ✅
- Splenomegaly ✅
- Erythrocytosis Rationale:
- Hyperthermia (due to fever) and splenomegaly (due to RBC destruction) are common in malaria. 4. Very Low Birth Weight (VLBW)
- Presence of glucose and ketones in urine
- Flexion contracture of the lower extremities
- Overgrowth of genital wart-like lesions Correct Answer: 1. Whitish-yellow lesions in the oral cavity Rationale: Long-term antibiotic therapy can lead to fungal overgrowth, such as Candida albicans , which commonly presents with oral thrush (white lesions) and perianal candidiasis (itching, irritation). Diarrhea can also result from antibiotic-related flora disruption. The other options are unrelated to antibiotic use or are less commonly associated with this clinical presentation. Question: A client with schizophrenia is being treated with haloperidol. The nurse notes that the client has a rigid posture, shuffling gait, and tremors. What condition should the nurse suspect?
- Neuroleptic malignant syndrome
- Akathisia
- Tardive dyskinesia
- Pseudoparkinsonism Correct Answer: 4. Pseudoparkinsonism Rationale: Pseudoparkinsonism is an extrapyramidal side effect of antipsychotic medications like haloperidol, mimicking Parkinson’s disease symptoms (e.g., tremor, rigidity, bradykinesia). NMS includes fever and altered mental status; akathisia causes restlessness; and tardive dyskinesia is characterized by repetitive involuntary facial movements. Question: The nurse is teaching a pregnant client about iron supplementation. What should the nurse include in the teaching?
- Take with calcium-rich foods for better absorption.
- Take on an empty stomach with orange juice.
- Avoid taking iron with any source of vitamin C.
- Iron should only be taken after meals to prevent absorption issues.
Correct Answer: 2. Take on an empty stomach with orange juice. Rationale: Iron is best absorbed in an acidic environment, and vitamin C (e.g., orange juice) enhances its absorption. Calcium and dairy products can inhibit iron absorption. Although some clients may need to take it with food to avoid GI upset, absorption is more efficient on an empty stomach. Question: Which assessment finding in a newborn indicates a possible congenital diaphragmatic hernia?
- Increased femoral pulses
- Loud bowel sounds in the chest
- Hyperresonant percussion over the liver
- Normal breath sounds bilaterally Correct Answer: 2. Loud bowel sounds in the chest Rationale: Congenital diaphragmatic hernia allows abdominal organs to move into the thoracic cavity, which may produce bowel sounds in the chest and cause respiratory distress. Other options are unrelated or suggest normal findings. What are the effects of long-term exposure to mustard gas? Select all that apply. A Skin burns B Skin blisters C Irritation of eyes D Pulmonary edema E Respiratory depression - - correct ans- - A,B,C A client is admitted via the emergency department with the tentative diagnosis of diverticulitis. Which test commonly is prescribed to assess for this problem? 1 Computed tomography (CT) scan
obtained by the nurse during the therapy indicates a positive outcome? Select all that apply. 1 Radial pulse: 70 2 Temperature: 37 °C 3 Respiratory rate: 14 4 Blood pressure: 110/ 5 Oxygen saturation: 92% - - correct ans- - 3,4, A 3-year-old child is brought to the emergency department by the mother, who reports that her child fell down the stairs and sustained injuries to the right arm and leg. During the physical assessment the nurse identifies a number of old bruises on the child's back, buttocks, and upper arms. What should the nurse say to the child to obtain additional information? 1 "Why did you fall down the stairs?" 2 "Did you really fall down those stairs?" 3 "Show me how you fell down the stairs." 4 "Your mommy must have told you to say you fell down the stairs." - - correct ans- - 3 Which positioning should be avoided while assessing a client with a history of asthma? 1 Sitting 2 Supine 3 Dorsal recumbent 4 Lateral recumbent - - correct ans- - 4 A client with a history of heart failure is admitted to the hospital with the diagnosis of pulmonary edema. For which signs and symptoms specific to pulmonary edema should the nurse assess the client? Select all that apply. 1 Crackles 2 Coughing 3 Orthopnea
4 Yellow sputum 5 Dependent edema - - correct ans- - 1,2, Which findings should the nurse expect to see in a client with chronic obstructive pulmonary disease? Select all that apply. 1 Elevated levels of partial arterial oxygen 2 Elevated levels of eosinophils 3 Elevated levels of neutrophils 4 Elevated levels of red blood cells 5 Elevated levels of peripheral capillary oxygen saturation - - correct ans- - 2,3, Which changes to the client's skin are caused by the atrophy of eccrine sweat glands? 1 Bruises 2 Dry skin 3 Wrinkles 4 Skin shearing - - correct ans- - 2 A multipara whose membranes have ruptured is admitted in early labor. Assessment reveals a breech presentation, cervical dilation of 3 cm, and fetal station at - 2. For what complication should the nurse assess when caring for this client? 1 Vaginal bleeding 2 Urinary tract infection 3 Prolapse of the umbilical cord 4 Meconium in the amniotic fluid - - correct ans- - 3 A woman is admitted to the emergency department with trauma that indicates possible abuse. List in priority order the appropriate nursing interventions. Correct
1 The iris dilator muscle 2 The iris sphincter muscle 3 The medial rectus muscle 4 The lateral rectus muscle - - correct ans- - 1 A client is admitted to the hospital due to inhaling noxious chemicals. During an examination, the primary healthcare provider identifies damage to the upper airway. Which manifestations will the nurse most likely observe related to upper airway damage? Select all that apply. 1 Edema 2 Stridor 3 Blisters 4 Dyspnea 5 Wheezing - - correct ans- - 1,2, The nurse instructs parents to avoid placing their infant in a prone position while sleeping. Which risk does the nurse seek to prevent with this instruction? 1 Otitis media of the ear 2 Conjunctivitis of the eye 3 Infantile colic or baby colic 4 Sudden infant death syndrome - - correct ans- - 4 A 6-month-old infant is admitted to the pediatric unit with severe diarrhea. What nursing assessment is most indicative of dehydration? 1 Level anterior fontanel 2 Decreased urine output 3 Warm skin temperature 4 Slow, labored respirations - - correct ans- - 2
The nurse is caring for a newborn with caput succedaneum. The nurse is able to differentiate caput succedaneum from cephalhematoma because of what characteristic of the scalp edema in caput succedaneum? 1 Becomes ecchymotic 2 Crosses the suture line 3 Increases after several hours 4 Is tender in the surrounding area - - correct ans- - 2 A 9-year-old child is admitted to the pediatric unit with a tentative diagnosis of an infratentorial brain tumor. What presenting sign does the nurse anticipate when assessing the child? 1 Ataxia 2 Papilledema 3 Cranial enlargement 4 Generalized seizures - - correct ans- - 1 What should the nurse ask while assessing a Latina woman with depression for the risk of self-harm? 1 "When did you last spend time with friends?" 2 "How do you express yourself when you're angry?" 3 "When did you first notice that you were depressed?" 4 "Do you have interests outside your work and home?" - - correct ans- - 2 While conducting an assessment, the nurse finds that the client shivers uncontrollably and experiences memory loss, depression, and poor judgment. What might the client's body temperature be? 1 29° C 2 33° C 3 36° C
"How would you get what you need to end your life?" - - correct ans- - ... Which statement does the nurse know is true regarding a grade 2 goiter? 1 A goiter mass is impalpable. 2 A goiter is usually asymmetrical. 3 A goiter mass moves up while swallowing. 4 A goiter is invisible with the neck in normal position. - - correct ans- - 2 A nurse is determining a client's heart rate on an ECG strip. Which action should the nurse take? 1 Count the P waves 2 Count the T waves 3 Count the PR interval 4 Count the QRS complexes - - correct ans- - 4 A nurse inserts a nasogastric tube into a preterm infant's esophagus for feedings. Which assessment findings signify correct placement of the tube? Select all that apply. 1 The infant cries without noise. 2 Aspiration produces a small quantity of light-yellow or light-green liquid. 3 The tube is inserted to a depth from the ear to the tip of the nose to the sternum. 4 A whooshing sound is auscultated in the epigastric area when air is introduced into the tube. 5 Testing of the aspirate with the use of a Nitrazine strip reveals that the gastric fluid is acidic. - - correct ans- - 2, A nurse is assessing a 38-year-old female client who has been admitted for a biopsy of a lump in her right breast. Which finding may indicate a malignancy?
1 A soft mass that is movable and nontender 2 Hard, hot, reddened areas that are tender and painful 3 Multiple bilateral lesions that are well delineated and movable 4 A lesion in the upper outer quadrant that is poorly delineated and immobile - - correct ans-
- 4 In which stage of Kohlberg's theory of moral development does the nurse anticipate a client to realize there is more than one right point of view? 1 Stage 1 2 Stage 2 3 Stage 3 4 Stage 4 - - correct ans- - 2 While caring for a client with heat stroke, the nurse measured the temperature and noted it as 109o F. Convert this temperature into Celsius and record your number using one decimal place. _____o C - - correct ans- - 42. Which symptoms are common during the fulminant stage of inhalation of anthrax? Select all that apply. 1 Dyspnea 2 Dry cough 3 Diaphoresis 4 Mild chest pain 5 High temperature - - correct ans- - 1,3, A nurse is working with a couple and their two children. The 14-year-old son has been in trouble at school because of truancy and poor grades. The 16-year-old daughter is quiet and withdrawn and refuses to talk to her parents. The parents have had severe marital problems for the past 10 years. What is the priority nursing concern at this time? 1 How the parents can set limits on their children's behavior
The nurse is assessing a client with severe nodule-forming rheumatoid arthritis for possible Felty syndrome. Which assessment findings are consistent with Felty syndrome? Select all that apply. 1 Itchy eyes 2 Dry mouth 3 Leukopenia 4 Splenomegaly 5 Photosensitivity - - correct ans- - 3, While assessing a client recovering from a head injury, the nurse notices a loss of movement in the client's tongue while attempting to talk. Which could be the possible reason for the client's condition? 1 Damage to the facial nerve 2 Damage to the trigeminal nerve 3 Damage to the hypoglossal nerve 4 Damage to the glossopharyngeal nerve - - correct ans- - 3 After breast cancer is diagnosed, the client decides on a modified radical mastectomy followed by a combination therapy protocol that includes doxorubicin. What assessment finding does the nurse recognize as a toxic effect of this drug? 1 Paralytic ileus 2 Red-tinged urine 3 Cardiac dysrhythmias 4 Increased serum magnesium - - correct ans- - 3 An electrocardiogram (ECG) is prescribed for a client who reports chest pain. Which early finding does the nurse expect on the lead over the infarcted area? 1 Flattened T waves 2 Absence of P waves 3 Elevated ST segments
4 Disappearance of Q waves - - correct ans- - 3 The nurse is assessing a client with multiple injuries due to a severe motor vehicle accident. Which nursing intervention should the nurse perform first? 1 Providing bag-valve-mask ventilation 2 Administering glucose by intravenous (IV) route 3 Applying direct pressure to the severe bleeding areas 4 Inserting large bore peripheral IV lines in the antecubital area - - correct ans- - 1 A nurse is assessing a client with the diagnosis of primary hypertension. Which clinical finding does the nurse identify as an indicator of primary hypertension? 1 Mild but persistent depression 2 Transient temporary memory loss 3 Occipital headache in the morning 4 Cardiac palpitation during periods of stress - - correct ans- - 3 Why is it important for the nurse to know the infant's gestational age and how it compares with the birth weight? 1 Potential problems may be identified. 2 Infants lose weight during the first few days of life. 3 Hospitals need this information to calculate census. 4 Infants' weight must be included on the admission record. - - correct ans- - 1 A client is bleeding excessively after the birth of her newborn. The healthcare provider prescribes fundal massage and an IV infusion containing 10 units of oxytocin at a rate of 100 mL/hr. The nurse's evaluation of the client's responses to these interventions reveals a blood pressure of 135/90 mm Hg, a boggy uterus 3 cm above the umbilicus and displaced to the right, and a perineal pad saturated with bright-red lochia. What is the nurse's next action? 1 Increasing the infusion rate 2 Checking for a distended bladder
A client with kidney dysfunction is about to undergo renal testing using a contrast medium. Which nursing interventions should be conducted before the procedure to ensure the client's safety? Select all that apply. 1 Assessing the client for a history of cirrhosis 2 Asking the client if he or she has a known shellfish allergy 3 Assessing the client for a history of lactic acidosis 4 Assessing the client's hydration status by checking blood pressure and respiratory rate 5 Asking the client to discontinue metformin 12 hours before the procedure - - correct ans- 1,2, A nursing instructor asks a nursing student about tips for examining a 4-year-old sick child. Which statements made by the nurse indicate adequate teaching? Select all that apply. 1"I should call the child as 'Mr.' or 'Ms.'" 2 "I should give the child time to play around." 3 "I should start the examination with the child's fingers and hands." 4 "I should gather all information related to the child's sickness from the parents." 5 "I should make judgments when parents share the details of their child's sickness." - - correct ans- - 2,3, Which is the most common opportunistic infection in a client infected with human immunodeficiency virus (HIV)? 1 Oropharyngeal candidiasis 2 Cryptosporidiosis 3 Toxoplasmosis encephalitis 4 Pneumocystis jiroveci pneumonia - - correct ans- - 1 A nurse is assessing a female client with Cushing syndrome. Which clinical findings can the nurse expect to identify? Select all that apply. 1 Hirsutism
2 Menorrhagia 3 Buffalo hump 4 Dependent edema 5 Migraine headaches - - correct ans- - 1, The nurse is teaching the client about wound healing. Which feature is associated with the "maturation phase" of normal wound healing? 1 The scar is firm and inelastic on palpation. 2 Fibrin strands form a scaffold or framework. 3 White blood cells migrate into the wound. 4 Epithelial cells are grown over the granulation tissue bed. - - correct ans- - 1 During a client's routine physical examination, an abdominal aortic aneurysm is diagnosed. The client is admitted to the hospital immediately, and surgery is scheduled for the next morning. Which clinical finding should the nurse expect when completing the admission assessment? 1 Signs of shock 2 Visible peristaltic waves 3 Radiating abdominal pain 4 Pulsating abdominal mass - - correct ans- - 4 For what clinical indicator should a nurse assess a client who is having a gastric lavage? 1 Decreased serum pH 2 Increased serum oxygen level 3 Increased serum bicarbonate level 4 Decreased serum osmotic pressure - - correct ans- - 3 A nurse who is assessing a full-term newborn elicits the Babinski reflex. How is this reflex elicited? 1 Striking the surface of the crib suddenly
