ESTUDYR
HESI RN FUNDAMENTALS EXIT LATEST EXAM
ACTUAL 65 QUESTIONS AND CORRECT ANSWERS
WITH RATIOANLES (VERIFIED)
1. The nurse is called to the waiting room of a pediatric clinic. The frantic mother states, "I
think my 4-month-old baby is choking!" What steps will the nurse take? (Select all that
apply.)
A. Compress the chest once between the nipples with two fingers.
B. Note any obstruction or absence of breathing.
C. Deliver five backslaps between the shoulder blades.
D. Place the infant over the nurse's arm.
E. Perform a blind finger sweep.
Correct Answer: B, C, D
Rationale: * The fingers are placed at the same location on an infant as chest compressions for
CPR; however, the nurse must deliver five chest thrusts after the five back slaps. * The infant
should be positioned over the nurse's arm to support the head and neck while delivering back
slaps. * Note: Blind finger sweeps are not used as this action may push the object deeper into the
throat.
2. Which fluid will the nurse select to administer with the prescribed blood transfusion?
A. 5% Dextrose and water
B. Normal saline
C. Lactated Ringers solution
D. 5% Dextrose and lactated ringers
Correct Answer: B
Rationale: * Normal saline solution is the only solution that is compatible with blood
administration. Dextrose and Lactated Ringers can cause hemolysis or clotting within the line.
3. When assisting a client from the bed to a chair, which procedure is best for the nurse to
follow?
A. Place the chair parallel to the bed, with its back toward the head of the bed and assist
the client in moving to the chair.
,ESTUDYR
B. With the nurse's feet spread apart and knees aligned with the client's knees,
stand and pivot the client into the chair.
C. Assist the client to a standing position by gently lifting upward, underneath the axillae.
D. Stand beside the client, place the client's arms around the nurse's neck, and gently
move the client to the chair.
Correct Answer: B
Rationale: * Standing with feet spread and knees aligned describes the correct positioning of the
nurse; it affords the nurse a wide base of support while stabilizing the client's knees when
assisting to a standing position. * The chair should be placed at a 45-degree angle to the bed, not
parallel. * Clients should never be lifted under the axillae as this could damage nerves. * Clients
should never place arms around the nurse's neck as this places undue stress on the nurse's neck
and back.
4. How many mL will the nurse document on the client's intake and output record from the
items listed?
1200 mL water
4 ounce container of gelatin
8 ounces of orange juice
355 mL can of soda
1 cup of soup
Correct Answer: 2155 mL
Rationale: * Calculation: $1200 + 120 (4 oz \times 30 mL) + 240 (8 oz \times 30 mL) + 355 +
240 (1 cup = 8 oz \times 30 mL) = 2155$.
5. The nurse observes a UAP taking a client's blood pressure in the lower extremity. Which
observation of this procedure requires the nurse to intervene with the UAP's approach?
A. The cuff wraps around the girth of the leg.
B. The UAP auscultates the popliteal pulse with the cuff on the lower leg.
C. The client is placed in a prone position.
D. The systolic reading is 20 mm Hg higher than the blood pressure in the client's arm.
Correct Answer: B
Rationale: * The nurse should intervene because when obtaining blood pressure in the lower
extremities, the cuff is applied around the thigh and the popliteal pulse is the site for auscultation.
, ESTUDYR
Applying the cuff to the lower leg is incorrect. * Systolic pressure in the popliteal artery is
usually 10 to 40 mm Hg higher than in the brachial artery, which is a normal finding.
6. During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is
often awake until midnight playing and is then very difficult to awaken in the morning for
school. Which assessment data should the nurse obtain in response to the mother's
concern?
A. The occurrence of any episodes of sleep apnea
B. The child's blood pressure, pulse, and respirations
C. Length of rapid eye movement (REM) sleep that the child is experiencing
D. Description of the family's home environment
Correct Answer: D
Rationale: * School-age children often resist bedtime. * The nurse should begin by assessing the
environment of the home to determine factors that may not be conducive to the establishment of
bedtime rituals that promote sleep.
7. The nurse identifies a potential for infection in a client with partial-thickness (second-
degree) and full-thickness (third-degree) burns. What action has the highest priority in
decreasing the client's risk of infection?
A. Administration of plasma expanders
B. Use of careful handwashing technique
C. Application of a topical antibacterial cream
D. Limiting visitors to the client with burns
Correct Answer: B
Rationale: * Careful handwashing technique is the single most effective intervention for the
prevention of contamination to all clients. * Options C and D are recommended but are
secondary to the primary effectiveness of handwashing.
8. The nurse assesses a 2-year-old who is admitted for dehydration and finds that the
peripheral IV rate by gravity has slowed, even though the venous access site is healthy.
What should the nurse do next?
A. Apply a warm compress proximal to the site.
B. Check for kinks in the tubing and raise the IV pole.
HESI RN FUNDAMENTALS EXIT LATEST EXAM
ACTUAL 65 QUESTIONS AND CORRECT ANSWERS
WITH RATIOANLES (VERIFIED)
1. The nurse is called to the waiting room of a pediatric clinic. The frantic mother states, "I
think my 4-month-old baby is choking!" What steps will the nurse take? (Select all that
apply.)
A. Compress the chest once between the nipples with two fingers.
B. Note any obstruction or absence of breathing.
C. Deliver five backslaps between the shoulder blades.
D. Place the infant over the nurse's arm.
E. Perform a blind finger sweep.
Correct Answer: B, C, D
Rationale: * The fingers are placed at the same location on an infant as chest compressions for
CPR; however, the nurse must deliver five chest thrusts after the five back slaps. * The infant
should be positioned over the nurse's arm to support the head and neck while delivering back
slaps. * Note: Blind finger sweeps are not used as this action may push the object deeper into the
throat.
2. Which fluid will the nurse select to administer with the prescribed blood transfusion?
A. 5% Dextrose and water
B. Normal saline
C. Lactated Ringers solution
D. 5% Dextrose and lactated ringers
Correct Answer: B
Rationale: * Normal saline solution is the only solution that is compatible with blood
administration. Dextrose and Lactated Ringers can cause hemolysis or clotting within the line.
3. When assisting a client from the bed to a chair, which procedure is best for the nurse to
follow?
A. Place the chair parallel to the bed, with its back toward the head of the bed and assist
the client in moving to the chair.
,ESTUDYR
B. With the nurse's feet spread apart and knees aligned with the client's knees,
stand and pivot the client into the chair.
C. Assist the client to a standing position by gently lifting upward, underneath the axillae.
D. Stand beside the client, place the client's arms around the nurse's neck, and gently
move the client to the chair.
Correct Answer: B
Rationale: * Standing with feet spread and knees aligned describes the correct positioning of the
nurse; it affords the nurse a wide base of support while stabilizing the client's knees when
assisting to a standing position. * The chair should be placed at a 45-degree angle to the bed, not
parallel. * Clients should never be lifted under the axillae as this could damage nerves. * Clients
should never place arms around the nurse's neck as this places undue stress on the nurse's neck
and back.
4. How many mL will the nurse document on the client's intake and output record from the
items listed?
1200 mL water
4 ounce container of gelatin
8 ounces of orange juice
355 mL can of soda
1 cup of soup
Correct Answer: 2155 mL
Rationale: * Calculation: $1200 + 120 (4 oz \times 30 mL) + 240 (8 oz \times 30 mL) + 355 +
240 (1 cup = 8 oz \times 30 mL) = 2155$.
5. The nurse observes a UAP taking a client's blood pressure in the lower extremity. Which
observation of this procedure requires the nurse to intervene with the UAP's approach?
A. The cuff wraps around the girth of the leg.
B. The UAP auscultates the popliteal pulse with the cuff on the lower leg.
C. The client is placed in a prone position.
D. The systolic reading is 20 mm Hg higher than the blood pressure in the client's arm.
Correct Answer: B
Rationale: * The nurse should intervene because when obtaining blood pressure in the lower
extremities, the cuff is applied around the thigh and the popliteal pulse is the site for auscultation.
, ESTUDYR
Applying the cuff to the lower leg is incorrect. * Systolic pressure in the popliteal artery is
usually 10 to 40 mm Hg higher than in the brachial artery, which is a normal finding.
6. During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is
often awake until midnight playing and is then very difficult to awaken in the morning for
school. Which assessment data should the nurse obtain in response to the mother's
concern?
A. The occurrence of any episodes of sleep apnea
B. The child's blood pressure, pulse, and respirations
C. Length of rapid eye movement (REM) sleep that the child is experiencing
D. Description of the family's home environment
Correct Answer: D
Rationale: * School-age children often resist bedtime. * The nurse should begin by assessing the
environment of the home to determine factors that may not be conducive to the establishment of
bedtime rituals that promote sleep.
7. The nurse identifies a potential for infection in a client with partial-thickness (second-
degree) and full-thickness (third-degree) burns. What action has the highest priority in
decreasing the client's risk of infection?
A. Administration of plasma expanders
B. Use of careful handwashing technique
C. Application of a topical antibacterial cream
D. Limiting visitors to the client with burns
Correct Answer: B
Rationale: * Careful handwashing technique is the single most effective intervention for the
prevention of contamination to all clients. * Options C and D are recommended but are
secondary to the primary effectiveness of handwashing.
8. The nurse assesses a 2-year-old who is admitted for dehydration and finds that the
peripheral IV rate by gravity has slowed, even though the venous access site is healthy.
What should the nurse do next?
A. Apply a warm compress proximal to the site.
B. Check for kinks in the tubing and raise the IV pole.
