HESI Nuring Assessment

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Sample questions from HESI Nuring Assessment

This material has 90 questions with answers and rationales. Here are the first 5.

1. 1.A 68-year-old client is in the emergency department with sudden shortness of breath. The client is restless, has an oxygen saturation of 84% on room air, respiratory rate 32/min, and audible wheezing. Which assessment should the nurse perform first?

   • A.Assess airway patency and work of breathing
   • B.Obtain a complete medication history
   • C.Ask about recent travel
   • D.Inspect the client's lower extremities for edema

   Rationale: Airway patency and breathing take priority because the client has severe hypoxemia and respiratory distress. A medication history, travel history, and edema assessment may help identify the cause but do not address the immediate threat. The exam takeaway is to use ABCs when prioritizing an unstable client.

2. 2.A 74-year-old client on a medical unit becomes newly confused. The client is afebrile, has a blood pressure of 88/54 mm Hg, pulse 118/min, and oxygen saturation 95% on room air. Which action should the nurse take first?

   • A.Check a bedside blood glucose level
   • B.Reorient the client to the date
   • C.Request a prescription for a sedative
   • D.Document the confusion and reassess in 1 hour

   Rationale: A bedside glucose is a rapid assessment for a reversible cause of acute confusion, while the hypotension and tachycardia also require prompt escalation after immediate checks. Reorientation is supportive but does not identify an urgent physiologic cause; sedation could worsen the condition, and delayed reassessment is unsafe. The exam takeaway is to assess acute mental-status changes for reversible causes and instability.

3. 3.A 52-year-old client is admitted to a medical unit with abdominal pain. The client reports pain of 8/10, has a rigid abdomen, temperature 38.4 C, pulse 122/min, and blood pressure 96/60 mm Hg. Which finding should the nurse report immediately?

   • A.Rigid abdomen with hypotension and tachycardia
   • B.Pain rated 8/10
   • C.Temperature of 38.4 C
   • D.The client's report of nausea

   Rationale: A rigid abdomen with hypotension and tachycardia may indicate an acute abdominal emergency with compromised perfusion and requires immediate reporting. Pain, fever, and nausea are important findings, but none is as urgent in isolation as signs of possible peritonitis and instability. The exam takeaway is to prioritize objective cues suggesting life-threatening deterioration.

4. 4.A 35-year-old client arrives at an urgent care clinic after a bee sting. The client has generalized hives, hoarseness, audible stridor, and a blood pressure of 82/48 mm Hg. Which assessment finding is the highest priority?

   • A.Stridor and hoarseness
   • B.The location of the sting
   • C.The extent of the hives
   • D.The client's history of seasonal allergies

   Answer and rationale are in the full material.

5. 5.A 79-year-old client in a long-term care facility reports dizziness when standing. Supine blood pressure is 138/76 mm Hg with pulse 78/min; standing blood pressure is 106/62 mm Hg with pulse 96/min. Which nursing action is most appropriate?

   • A.Assist the client to sit or lie down and report the orthostatic change
   • B.Encourage the client to walk to improve circulation
   • C.Repeat the standing measurement after 30 minutes of walking
   • D.Document the result as an expected age-related change

   Answer and rationale are in the full material.