HESI Level #2 Practice Questions, Answers
and Rationale (Best Revision Material)
HESI level 2 Exam Questions
What assessment finding should the nurse identify that indicates a client with an acute
asthma exacerbation is beginning to improve after treatment?
A. Vesicular breath sounds decrease
B. Bronchodilators stimulate coughing
C. Cough remains unproductive
D. Wheezing becomes louder ———- CORRECT ANSWER ——- Answer : Wheezing
becomes louder.
Rationale: In an acute asthma attack, air flow may be so significantly restricted that
wheezing is diminished. If the client is successfully responding to bronchodilators and
respiratory treatments, wheezing becomes louder (A) as air flow increases in the
airways. As the airways open and mucous is mobilized in response to treatment, the
cough becomes more productive, not (B). Vesicular sounds are soft, low-pitched,
gentle, rustling sounds heard over lung fields (C) and is not an indicator of improvement
during asthma treatment. Bronchodilators do not stimulate coughing (D).
A client with sickle cell anemia is admitted with severe abdominal pain and the
diagnosis is sickle cell crisis. What is the most important nursing action to implement?
A. Evaluate the effectiveness of narcotic analgesics.
B. Limit the client’s intake of oral fluids and food.
C. Teach the client about prevention of crises.
D. Encourage the client to ambulate as tolerated. ———- CORRECT ANSWER ——-
Answer: Evaluate the effectiveness of narcotic analgesics.
Rationale: Pain management is the priority for a client during sickle cell crisis.
Continuous narcotic analgesics are the mainstay of pain control, which should be
evaluated (B) frequently to determine if the client’s pain is adequately controlled. (A, C,
and D) are not indicated at this time.
The nurse is assessing a middle-aged male client for risk factors related to chronic
illness. Which finding should the nurse assess further?
A. Thinning hair and dry scalp.
B. Increase in muscle tone but decreased muscle strength.
C. Increase in abdominal fat deposits.
D. Increase in appetite and taste-bud acuity. ———- CORRECT ANSWER ——-
Answer: Increase in abdominal fat deposits.
Rationale: An increase in the abdominal girth (D) may be indicative of the onset of
metabolic syndrome, which places the client at risk for cardiac disease and requires
further assessment. During middle adulthood, common findings include thinning hair,
dry skin and scalp (A), changes in taste bud acuity (B), and muscle size and strength
(C), which are consistent with normal system functioning during aging.
The nurse is caring for a male client who had an inguinal herniorrhaphy 3 hours ago.
The nurse determines the client’s lower abdomen is distended and assesses dullness to
percussion. What is the priority nursing action?
A. Assessment of the client’s vital signs.
B. Determine the time the client last voided.
C. Document the finding as the only action.
D. Insert a rectal tube for the passage of flatus. ———- CORRECT ANSWER ——-
Answer: Determine the time the client last voided.
Rationale: Swelling at the surgical site in the immediate postoperative period can
impact the bladder and prostate area causing the client to experience difficulty voiding
due to pressure on the urethra. To provide additional data supporting bladder distention,
the last time the client voided (C) should be determined next. Documentation (B) should
be made, but the client’s distended bladder requires additional intervention. (A and D)
are not priority actions based on the client’s abdominal findings.
The nurse is giving discharge instructions to a client with chronic prostatitis. What
instruction should the nurse provide the client to reduce the risk of spreading the
infection to other areas of the client’s urinary tract?
A. Avoid consuming alcohol and caffeinated beverages.
B. Wear a condom when having sexual intercourse.
C. Have intercourse or masturbate at least twice a week.
D. Empty the bladder completely with each voiding. ———- CORRECT ANSWER ——-
Answer: Have intercourse or masturbate at least twice a week.
Rationale: The prostate is not easily penetrated by antibiotics and can serve as a
reservoir for microorganisms, which can infect other areas of the genitourinary tract.
Draining the prostate regularly through intercourse or masturbation (D) decreases the
number of microorganisms present and reduces the risk for further infection from stored
contaminated fluids. (A, B, and C) do not reduce the risk of spreading the infection
internally.
A 3-year-old boy is brought to the emergency room because of a possible diazepam
(Valium) overdose. He is lethargic and confused, and his vital signs are: pulse rate 100
beats/minute, respiratory rate 20 breaths/minute, and blood pressure 70/30. Which
nursing intervention has the highest priority?
A. Insert an orogastric tube for gastric lavage.
B. Prepare a set-up for an endotracheal intubation.
C.Draw blood for stat chemistries and blood gases.
D. Insert a Foley catheter to monitor renal functioning. ———- CORRECT ANSWER —-
— Answer: Prepare a set-up for an endotracheal intubation.
Rationale: Diazepam causes respiratory depression, so preparation for intubation (B)
to protect the airway is the priority intervention at this time. (A) may be necessary, but
the child is lethargic and confused, with a lowered respiratory rate, so (B) takes priority.
(C and D) are interventions that should be implemented, but they are both secondary to
ensuring an open airway.
The nurse is developing a plan of care for a newborn with a colostomy due to anal
agenesis, and the infant has had three loose stools since surgery yesterday. Which
nursing diagnosis has the highest priority?
A. Pain related to postoperative condition.
B. Potential for fluid volume deficit.
C. Alteration in bowel elimination.
D. Anxiety of parents related to newborn’s condition. ———- CORRECT ANSWER ——
- Answer: Potential for fluid volume deficit.
Rationale: All stated nursing diagnoses are appropriate for a postoperative colostomy
client. However, fluid balance is the priority concern (A) for any newborn infant. Though
three loose stools in 24-hours is not significant, depending on the amount of fluid lost
with each stool, potential for fluid volume deficit is always a concern for a postoperative
infant. Newborns are extremely vulnerable to fluid imbalances due to immature body
systems and a larger percentage of their body weight consisting of fluid. (B, C, and D)
do not have the priority of (A).
The community health nurse teaches the parents of school-aged children about the
need for fluoride as part of a dental health program. Which statement by the parents
indicates that they understand the teaching?
A. “Having our children brush with fluoride toothpaste is not effective.”
B. “Excessive amounts of fluoride will make teeth turn brittle and yellow.”
C. “Use of fluoride in water is mostly effective during initial tooth formation.”
D. “Dental caries can be prevented through fluoridation of public water.” ———-
CORRECT ANSWER ——- Answer: “Dental caries can be prevented through
fluoridation of public water.”
Rationale: Dental caries can be prevented through fluoridation of public water (D).
Large amounts of fluoride (A) produces yellow and discolored teeth, not brittle teeth. (B)
is effective for young teeth. Fluoride is effective throughout the life span, not just during
initial tooth formation (C).
A Spanish-speaking 5-year-old child starts kindergarten in an English-speaking school.
The child cries most of the time, appears helpless and unable to function in the new
situation. After assessing the child, how should the school nurse document the
situation?
A. Experiencing culture shock.
B. Refuses to participate in school activities.
C. Lacks the maturity needed in school.
D. Going through minority group discrimination. ———- CORRECT ANSWER ——-
Answer: Experiencing culture shock.
Rationale: An inability to function may apply to persons of all ages undergoing
transitions, such as moving to a new country and adjusting to a subculture within a
larger culture that is unfamiliar. Culture shock (A) describes feelings of discomfort and
disorientation when adapting to new cultural settings. Language barriers inhibit effective
communication, so a child who is unable to communicate in the spoken language in the
school environment may lack the skills necessary to participate, and is not refusing to
participate (C). The child may be adequately mature (B), accepted by peers (D) within
the environment, but continues to not join in because of the impact of culture shock.
The nurse is assessing a child’s skin turgor and grasps the skin on the abdomen
between the thumb and index finger, pulls it taut, and quickly releases it. The tissue
remains suspended and tented for a few seconds, then slowly falls back on the
abdomen. How should the nurse document this finding?
A. Assessment inconclusive.
B. Poor skin turgor.
C. Adequate hydration.
D. Normal skin elasticity ———- CORRECT ANSWER ——- Answer: Poor skin turgor
Rationale: Tissue turgor refers to the amount of elasticity in the skin and is one of the
best estimates of adequate hydration and nutrition. Elastic tissue immediately resumes
its normal position without residual marks or creases. In a child with poor turgor (B), the
skin remains tented or suspended for a few seconds before returning to a normal
position. (A, C and D) are inaccurate.
A 4-month-old breastfeeding infant is at the 10th percentile for weight and the 75th
percentile for height. How should the nurse interpret this finding?
A. Inadequate milk supply in mother.
B. Milk allergy.
C. Normal growth curve of a breast-fed infant.
D. Failure to thrive. ———- CORRECT ANSWER ——- Answer: Normal growth curve
of a breast-fed infant.
Rationale: When plotting weights and heights on a standard growth chart used for
both breast-fed and formula-fed infants, the breast-fed infant grows more rapidly during
the first 2 months of life, and then growth slows from 3 to 12 months. A breast-fed infant
is leaner and has less body fat than a formula-fed infant. Normal patterns of infants who
are breast fed (D) differ from those who are formula fed. (A) is an incorrect interpretation
of the data. This finding is not consistent with failure to thrive (B) or an inadequate milk
supply (C)
The nurse is instructing an adolescent with bulimia and a low potassium level about the
risk for complications. Which medical problem should be the focus of the nurse’s
instruction to this client?
A. Heightened neurologic reflexes.
B. Gastrointestinal reflux.
C. Anemia.
D. Cardiac arrhythmias. ———- CORRECT ANSWER ——- Answer: Cardiac
arrhythmias.
Rationale: An adolescent with bulimia who purges by frequent self-induced vomiting,
diuretic or laxative abuse can experience potassium depletion, which increases the risk
for cardiac arrhythmias (B). (A) is more likely related to inadequate iron intake and