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SPRING HESI FINAL ASSESSMENT 2025 ACTUAL
EXAM WITH COMPLETE 200 QUESTIONS AND
SOLUTION 100% VERIFIED ANSWERS A+ GRADED
NEWEST VERSION 2025
The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for disease and symptom management. Which statement by the client indicates understanding? A Using salt, herbs, and spices will improve the flavor of foods. B Get an eye examination with an ophthalmologist annually. C Arrange diet schedule around three regular meals a day.
D Inspect feet every month for ingrown nails, cuts, and calluses. - CORRECT ANSWER
>>> B Get an eye examination with an ophthalmologist annually.
The nurse is providing education to a client who experiences recurrent levels of moderate anxiety to situations and perceived stress. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching? A Center attention on positive upbeat music. B Find outlets for more social interaction. C Practice using muscle relaxation techniques.
D Think about reasons the episodes occur. - CORRECT ANSWER >>> C Practice using
muscle relaxation techniques.
The charge nurse is planning for the shift and has a registered nurse (RN) and a practical nurse (PN) on the team. Which client should the charge nurse assign to the RN? A A 75-year-old client with renal calculi who requires urine straining. B A 64-year-old client who had a total hip replacement the previous day. C A 30-year-old depressed client who admits to suicide ideation.
D An adolescent with multiple contusions due to a fall that occurred 2 days ago. - CORRECT
ANSWER >>> C A 30-year-old depressed client who admits to suicide ideation.
A client with pancreatitis complains of severe epigastric pain, so the nurse administers a prescribed narcotic analgesic. Ten minutes later, the client insists on sitting up and leaning forward. Which intervention should the nurse implement? A Raise head of bed until to a 90 degree angle. B Position bedside table so the client can lean across it. C Place bed in a reverse trendelenburg position.
D Encourage rest until the analgesic becomes effective. - CORRECT ANSWER >>> B
Position bedside table so the client can lean across it. The nurse is caring for a client who arrives to the emergency department with reports of experiencing dizziness and difficulty walking to the bathroom. The nurse observes right-sided weakness and sluggish enunciation of speech. The nurse should immediately take which action? A Maintain elevated positioning of the dependent joints on affected side.
E Include oatmeal for breakfast.
F Use a salt substitute. - CORRECT ANSWER >>> B Eat more canned vegetables.
C Consume foods with saturated fats. While caring for a toddler receiving oxygen via face mask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement? A Use a water soluble lubricant on affected oral and nasal mucosa. B Use a topical lidocaine analgesic for cracked lips. C Ask the mother what she usually uses on the child's lips and nose.
D Apply a petroleum jelly to the child's nose and lips. - CORRECT ANSWER >>> A Use a
water soluble lubricant on affected oral and nasal mucosa. When assessing a multigravida on the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths above the umbilicus. What action should the nurse implement first? A Increase intravenous infusion. B Massage the uterus to decrease atony. C Review the hemoglobin to determine hemorrhage.
D Check for a distended bladder. - CORRECT ANSWER >>> D Check for a distended
bladder.
The nurse is caring for a client on the first day postoperative for a descending aortic aneurysm repair. Which assessment finding should the nurse prioritize reporting to the healthcare provider? Reference Range Potassium (Reference Range: 3.5 to 5 mEq/L (3.5 to 5 mmol/L)] A Serum potassium 4.8 mEg/L (4.8 mmol/L). B Electrocardiogram ST segment elevation. C Urine output 30 mL/hour.
D Blood pressure 130/80. - CORRECT ANSWER >>> B Electrocardiogram ST segment
elevation. The healthcare provider prescribes a low-fiber diet for a client with ulcerative colitis. Which food selection indicate to the nurse that the client understand the prescribed diet? A Roast pork, fresh strawberries. B Baked potato with skin, raw carrots. C Roasted turkey, canned vegetables.
D Pancakes, whole-grain cereals. - CORRECT ANSWER >>> C Roasted turkey, canned
vegetables. The psychiatric nurse is caring for clients in an adolescent unit. Which client requires the nurse's immediate attention?
D Monitor amount of intake and infant's response to feedings. - CORRECT ANSWER >>> C
Initiate a continuous infusion of IV fluids per prescription. NGN: The client is a 26 yr old female who was in a car accident 6 months ago that killed her mother, husband, and 2 yr old son. She and her father were the only survivors of the crash. She is seeking care for depression. Choose the most likely options for the information missing from the statement by selecting from the list of options provided.
The client is exhibiting symptoms of _________ relating to ___________ and __________. -
CORRECT ANSWER >>> The client is exhibiting symptoms of PTSD relating to
EXPERIENCING A LIFE-THREATENING EVENT and LOSING A LOVE ONE. NGN: After the examination by the physician, the client was diagnosed with depression and PSTD. The physician wrote orders for medication that need to be filled. The nurse speaks with the client again to educate her about her diagnose and medication. How can the nurse build a therapeutic relationship with the client? Select all that apply. A The nurse can establish a meaningful connection B The nurse can be open, honest, and sincere C The nurse can communicate acceptance of the client as she is D The nurse can talk as much as needed to get the client talking E The nurse can focus energy on the client
F The nurse can show no emotion when talking to the client - CORRECT ANSWER >>> A
The nurse can establish a meaningful connection
B The nurse can be open, honest, and sincere C The nurse can communicate acceptance of the client as she is NGN: During the conversation with the client, the nurse documents a statement by the client about wishing she had died in the crash. Choose the most likely options for the information missing from the statement by selecting the list of options provided.
The statement by the client represents _______ and should be followed up with __________. -
CORRECT ANSWER >>> The statement by the client represents SUICIDAL IDEATION and
should be followed up with AN ASSESSMENT OF RISK FACTORS FOR SUICIDE. NGN: What would be some effective strategies that the nurse could use to decrease the client's risk of suicide in the future? Select all that apply. A Have the client sign a no-suicide contract B Refer the client for cognitive behavioral therapy C Make the client feel too guilty to commit suicide D Place the client in a locked unit E Have the client remove any sharp objects from the home
F Help the client enlist the help of friends and family - CORRECT ANSWER >>> A Have the
client sign a no-suicide contract F Help the client enlist the help of friends and family Dopamine 5 mcg/kg/minute IV is prescribed for a client who weighs 132 pounds. The pharmacy dispenses a 500 mL IV solution of 0.9% normal saline with dopamine 1600 mg. The nurse
CORRECT ANSWER >>> C Reassure the client that skin flushing is a common side effect
of the medication. An adult client experiences a gasoline tank fire when riding a motorcycle and is admitted to the emergency department (ED) with full thickness burns to all surfaces of both lower extremities.
Which percentage of body surface area should the nurse document in the electronic medical record (EMR)? A 9%. B 36%. C 18%.
D 45 %. - CORRECT ANSWER >>> B 36%.
An unlicensed assistive personnel (UP) leaves the unit without notifying the staff. In which order should the unit manager implement these interventions to address the UP's behavior? (Place
the actions in order from first on top to last on bottom.) - CORRECT ANSWER >>> 1 Note
date and time of the behavior. 2 Discuss the issue privately with the UAP. 3 Plan for scheduled break times. 4 Evaluate the UP for signs of improvement. What nursing intervention is particularly indicated for the second stage of labor? A Assessing the fetal heart rate and pattern for signs of fetal distress. B Monitoring effects gf oxytocin administration to help achieve cervical dilation. C Providing pain medication to increase the client's tolerance of labor pains.
D Assisting the client to push effectively so that expulsion of the fetus can be achieved. -
CORRECT ANSWER >>> D Assisting the client to push effectively so that expulsion of the
fetus can be achieved.
The nurse is planning care for a client who admits having suicidal thoughts. Which client behavior indicates the highest risk for the client acting on these suicidal thoughts? A Begins to show signs of improvement in effect. B Expresses feelings of sadness and loneliness. C Neglects personal hygiene and has no appetite.
D Lacks interest in the activities of family and friends. - CORRECT ANSWER >>> A Begins to
show signs of improvement in effect. NGN: The client is a 42 yr old female who had a right above the knee amputation for osteomyelitis. The client has a drain in place and a surgical dressing that will need to be changed by the surgeon on post-op day 1. The nurse is discussing the client's pain management with a student nurse. Choose the most likely options for the information missing from the statement (s) by selecting from the lists of options provided. Morphine is a(n) __________ and it activates __________ receptors and is used to relieve
_________. - CORRECT ANSWER >>> Morphine is a(n) AGONIST-ANTAGONIST OPIOD and
it activates BETA receptors and is used to relieve PAIN. NGN: The client is a 42 yr old female who had a right above the knee amputation for osteomyelitis. The client has a drain in place and a surgical dressing that will need to be changed by the surgeon on post-op day 1.
What actions should the nurse take to assure safety during morphine administration? Select all that apply. A Have a manual resuscitation bag at the bedside B Ask the client about other medications she takes C Perform a 12-lead electrocardiogram D Take an initial respiratory rate E Suction the client to clear the airway
F Restrain the client with soft restraints - CORRECT ANSWER >>> B Ask the client about
other medications she takes D Take an initial respiratory rate NGN: The client is a 42 yr old female who had a right above the knee amputation for osteomyelitis. The client has a drain in place and a surgical dressing that will need to be changed by the surgeon on post-op day 1. What other medications would the nurse expect the surgeon to prescribe along with Morphine? Select all that apply. A Docusate sodium B Methadone C Propofol D Naloxone E Senna
B Obtain vital signs every 2 hours during hospitalization. C Provide an eye shield to be worn while sleeping.
D Teach a family member to administer eye drops. - CORRECT ANSWER >>> C Provide an
eye shield to be worn while sleeping. An adult client is admitted to the critical care unit with systemic inflammatory response syndrome (SIRS) as a result of a postbur infection. The client has a long line peripherally inserted IV catheter for fluid and medication administration and current vital signs include temperature 102.8° F (39.3° C), heart rate 108 beats/minute, respirations 32 breaths/minute. Which action should the nurse implement first? A Provide bedside equipment for transmission and protective precautions. B Culture sputum, urine, burn wound, and all intravenous access sites. C Implement central line-associated bloodstream infection (CLABSI) protocols.
D Evaluate daily serum electrolytes and hydration status. - CORRECT ANSWER >>> B
Culture sputum, urine, burn wound, and all intravenous access sites. Five days after surgical fixation of a fractured femur, a client suddenly reports chest pain and difficulty in breathing. The nurse suspects that the client may have had a pulmonary embolus. Which action should the nurse take first? A Bring the emergency crash cart to the bedside. B Prepare a continuous heparin infusion per protocol. C Notify the healthcare provider.
D Provide supplemental oxygen. - CORRECT ANSWER >>> D Provide supplemental oxygen.
The nurse is preparing a dose of 60 mcg of teriparatide. The medication is labeled "750 mcg/2. mL.". How many mL should the nurse administer? (Enter numeric value only. If rounding is
required, round to the nearest tenth.) - CORRECT ANSWER >>> 0.2 mL
In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider? A Watery diarrhea. B Increased fatigue. C Yellow-tinged sputum.
D Nausea and headache. - CORRECT ANSWER >>> A Watery diarrhea.
The nurse observes an unlicensed assistive personnel (UP) applying an alcohol-based hand rub while leaving a client's room after taking vital signs. Which action should the nurse take? A Instruct the UP to return to the client's room to perform hand washing. B Advise the UP to wear gloves when obtaining vital signs for all clients. C Supervise the UP in the next client's room to evaluate hand hygiene.
D Remind the UAP to continue rubbing the hands together until they are dry. - CORRECT
ANSWER >>> D Remind the UAP to continue rubbing the hands together until they are dry.
The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing action(s) should the nurse assign to the PN? (Select all that apply.)
C Maintain intravenous therapy.
D Identify potential sources of infection. - CORRECT ANSWER >>> C Maintain intravenous
therapy. NGN: The client is 74 yr old female with a hx of HTN and HLD. She takes lisinopril, simvastatin, and melatonin for sleep. She was admitted today for pneumonia. She visited her PCP last week, and she has lost 2.8kg since that visit. Complete the diagram by dragging from the choices below to specify 1 potential condition the client is most likely experiencing. 2 actions the nurse would take to address that condition, and 2 parameters the nurse would monitor to assess the client's progress. 1 Potential Condition: dehydration, malnutrition, hypoxia, CVA 2 Actions to take: Measure BP, ask the client for a nutrition hx, perform chest physiotherapy, encourage the client to drink, administer O
2 Parameters to monitor: Capillary refill, BG, pupil size, albumin level - CORRECT ANSWER
>>> Potential Condition: dehydration
Actions to take: Measure BP and Ask the client for a nutrition hx Parameters to monitor: Capillary refill and BG
The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having sex with someone who had many partners. Which response should the nurse provide? A Inform that follow-up may end after the treatment is finished. B Emphasize that using safe sex practices removes the risk of STIs. C Clarify that all STIs are transmitted through sexual intercourse.
D Remain non-judgmental and assure the client of confidentiality. - CORRECT ANSWER
>>> D Remain non-judgmental and assure the client of confidentiality.
A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin 500 mg PO twice daily. Which information should the nurse include in this client's teaching plan? (Select all that apply.) A Report persistent polyuria to the healthcare provider. B Use sliding scale insulin for fingerstick glucose elevations. C Take metformin with the morning and evening meal. D Recognize signs and symptoms of hypoglycemia.
E Take an additional dose for signs of hyperglycemia. - CORRECT ANSWER >>> A Report
persistent polyuria to the healthcare provider. C Take metformin with the morning and evening meal. D Recognize signs and symptoms of hypoglycemia.
