HESI PN FUNDAMENTALS EXIT
EXAM LATEST ACTUAL EXAM
100 QUESTIONS AND CORRECT
ANSWERS WITH RATIOANLES
(VERIFIED ANSWERS)
you, and use the bathroom after you?" C. "What time of day do you take your
water pill?" D. "Do you drink any alcoholic beverages in the evening?" E.
"When did this pattern of urination start?" F. "Do you have any itching or
burning when you urinate?" - A, C, D, E, F Rationale: Asking if the spouse
also gets up at night does not relate to the clients' pattern of frequency of
urination at night. The goal of the assessment is to try and understand the
client's urinary usual patterns and to determine if there are any modifiable
factors that can decrease the frequency of urinating at night. Urinary
frequency is also a sign of a urinary tract infection. When performing sterile
wound care in the acute care setting, the nurse obtains a bottle of normal
saline from the bedside table that is labeled "opened" and dated 48 hours
prior to the current date. Which is the best action for the nurse to take? A. Use
the normal saline solution once more and then discard. B. Obtain a new
sterile syringe to draw up the labeled saline solution. C. Use the saline
solution and then relabel the bottle with the current date. D. Discard the saline
solution and obtain a new unopened bottle. - D Rationale: Solutions labeled
as opened within 24 hours may be used for clean procedures, but only newly
opened solutions are considered sterile. This solution is not newly opened
and is out of date, so it should be discarded. Options A, B, and C describe
incorrect procedures. Which action should the nurse implement when
providing wound care instructions to a client who does not speak English? A.
Ask an interpreter to provide wound care instructions. B. Speak directly to the
client, with an interpreter translating. C. Request the accompanying family
member to translate. D. Instruct a bilingual employee to read the instructions.
- B Rationale: Wound care instructions should be given directly to the client by
the nurse with an interpreter who is trained to provide accurate and objective
translation in the client's primary language so that the client has the
opportunity to ask questions during the teaching process. The interpreter
usually does not have any health care experience, so the nurse must provide
client teaching. Family members should not be used to translate instructions
because the client or family member may alter the instructions during
conversation or be uncomfortable with the topics discussed. The employee
should be a trained interpreter to ensure that the nurse's instructions are
understood accurately by the client. A 75-year-old client states to the nurse, "I
am just not hungry anymore." The client has lost 10 pounds/4.53 kg in the
past 4 months. Which snacks will the nurse recommend to the client? (Select
all that apply.) A. Nuts B. Milkshakes C. Chocolate candy bar D. Peanut butter
and crackers E. Glass of whole fat milk - A, B, D, E Rationale: The nurse must
,recommend high calorie/high nutrition foods for this client who is
unintentionally losing weight. The candy bar is high calorie, but empty in
nutritional value. The remaining selections are high calorie/high nutrition. A
client in a long-term care facility reports to the nurse, "I have not had a bowel
movement in 2 days." What is the nurse's first action? A. Instruct the caregiver
to offer a glass of warm prune juice at mealtimes. B. Notify the health care
provider and request a prescription for a large-volume enema. C. Assess the
client's medical record to determine the client's normal bowel pattern. D.
Instruct the caregiver to increase the client's fluids to five 8-ounce glasses per
day. - C Rationale: This client may not routinely have a daily bowel movement,
so the nurse should first assess this client's normal bowel habits before
attempting any intervention. Options A, B, or D may then be implemented, if
warranted. The postoperative client states to the nurse, "When I had surgery
last year I got constipated. It was miserable. What can I do to avoid
constipation after this surgery this time?" (Select all that apply.) A. "Drink
approximately 3000 mL of non-caffeinated fluid per day." B. "I will make sure
that you get out of bed an walk for 10 minutes, six times per day." C. "I will
administer your pain medication even if you do not have any pain." D. "I will
ask your healthcare provider for a prescription of docusate." E. "When you are
on a regular diet, make sure you order plenty of fruits and vegetables." F.
"When you are resting in bed, make sure you are flat on your back." - A, B, D,
E Rationale: Pain medication can be constipating, and should only be taken
when needed. When in bed, use gravity to help move the contents of the
bowel by sitting upright. The remaining selections are correct. When
postoperative, it may take up to 48 hours after a general diet is started to have
a bowel movement. The nurse is preparing to administer 0.32 mL of
medication subcutaneously. What supplies will the nurse need to deliver the
medication? (Select all that apply.) A. A 1 mL syringe B. A 3 mL syringe C.
Alcohol prep pads D. Sterile gloves E. A 24-gauge ¾″ needle F. A 20-gauge
1″ needle - A, C, E Rationale: The best syringe is a 1 mL syringe as it is
marked in 100ths; 3 mL syringes are marked off in 10ths. Clean, not sterile
gloves are needed. For sub-q, the 3/4″ needle is sufficient and less painful for
the client. When taking a client's blood pressure, the nurse is unable to
distinguish the point at which the first sound was heard. Which is the best
action for the nurse to take? A. Deflate the cuff completely and immediately
reattempt the reading. B. Reinflate the cuff completely and leave it inflated for
90 to 110 seconds before taking the second reading. C. Deflate the cuff to
zero and wait 30 to 60 seconds before reattempting the reading. D. Document
the exact level visualized on the sphygmomanometer where the first
fluctuation was seen. - C Rationale: Deflating the cuff for 30 to 60 seconds
allows blood flow to return to the extremity so that an accurate reading can be
obtained on that extremity a second time. Option A could result in a falsely
high reading. Option B reduces circulation, causes pain, and could alter the
reading. Option D is not an accurate method of assessing blood pressure.
The nurse is obtaining a lie-sit-stand blood pressure reading on a client.
Which action is most important for the nurse to take for this client? A. Stay
with the client while the client is standing. B. Record the findings on the
graphic sheet in the chart. C. Keep the blood pressure cuff on the same arm.
D. Record changes in the client's pulse rate. - A Rationale: Although all these
measures are important, option A is most important because it helps ensure
, client safety. Option B is necessary but does not have the priority of option A.
Options C and D are important measures to ensure accuracy of the recording
but are of less importance than providing client safety. The client 12 hours
after a laparotomy reports to the nurse a pain rating of 7 to 10. The nurse
reviews the medication orders and it is another hour before the client can
have another dose of pain medication. What actions can the nurse take to
assist the client? (Select all that apply.) A. Administer the IV pain medication
an hour early. B. Assist the client into side-lying, curled position. C. Obtain a
warm pack to apply to the site of the incision. D. Suggest to the client taking
10 deep breaths, in through the nose and out through the mouth. E. Help the
client with sustained concentration of a personally pleasant topic. - B, C, D, E
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. - 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.
Blind sweeps are not used as this action may push the object deeper into the
throat. The remaining steps are correct. 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 - B Rationale: Normal saline solution is the only solution that is
compatible with blood. 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. 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. - B Rationale: Option B describes the correct
positioning of the nurse and 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, with the back of the chair
toward the head of the bed. Clients should never be lifted under the axillae;
this could damage nerves and strain the nurse's back. The client should be
instructed to use the arms of the chair and should never place his or her arms
around the nurse's neck; this places undue stress on the nurse's neck and
back and increases the risk for a fall. How many mL will the nurse document
on the client's intake and output record from the items listed? _____ mL 1200
mL water 4 ounce container of gelatin 8 ounces of orange juice 355 mL can of
soda1 cup of soup - Answer: 2155 Rationale: 1200 + 240 (8 oz) + 240 (1 cup)
+ 120 (4 oz) + 355 = 2155 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. - B Rationale:
When obtaining the blood pressure in the lower extremities, the popliteal
EXAM LATEST ACTUAL EXAM
100 QUESTIONS AND CORRECT
ANSWERS WITH RATIOANLES
(VERIFIED ANSWERS)
you, and use the bathroom after you?" C. "What time of day do you take your
water pill?" D. "Do you drink any alcoholic beverages in the evening?" E.
"When did this pattern of urination start?" F. "Do you have any itching or
burning when you urinate?" - A, C, D, E, F Rationale: Asking if the spouse
also gets up at night does not relate to the clients' pattern of frequency of
urination at night. The goal of the assessment is to try and understand the
client's urinary usual patterns and to determine if there are any modifiable
factors that can decrease the frequency of urinating at night. Urinary
frequency is also a sign of a urinary tract infection. When performing sterile
wound care in the acute care setting, the nurse obtains a bottle of normal
saline from the bedside table that is labeled "opened" and dated 48 hours
prior to the current date. Which is the best action for the nurse to take? A. Use
the normal saline solution once more and then discard. B. Obtain a new
sterile syringe to draw up the labeled saline solution. C. Use the saline
solution and then relabel the bottle with the current date. D. Discard the saline
solution and obtain a new unopened bottle. - D Rationale: Solutions labeled
as opened within 24 hours may be used for clean procedures, but only newly
opened solutions are considered sterile. This solution is not newly opened
and is out of date, so it should be discarded. Options A, B, and C describe
incorrect procedures. Which action should the nurse implement when
providing wound care instructions to a client who does not speak English? A.
Ask an interpreter to provide wound care instructions. B. Speak directly to the
client, with an interpreter translating. C. Request the accompanying family
member to translate. D. Instruct a bilingual employee to read the instructions.
- B Rationale: Wound care instructions should be given directly to the client by
the nurse with an interpreter who is trained to provide accurate and objective
translation in the client's primary language so that the client has the
opportunity to ask questions during the teaching process. The interpreter
usually does not have any health care experience, so the nurse must provide
client teaching. Family members should not be used to translate instructions
because the client or family member may alter the instructions during
conversation or be uncomfortable with the topics discussed. The employee
should be a trained interpreter to ensure that the nurse's instructions are
understood accurately by the client. A 75-year-old client states to the nurse, "I
am just not hungry anymore." The client has lost 10 pounds/4.53 kg in the
past 4 months. Which snacks will the nurse recommend to the client? (Select
all that apply.) A. Nuts B. Milkshakes C. Chocolate candy bar D. Peanut butter
and crackers E. Glass of whole fat milk - A, B, D, E Rationale: The nurse must
,recommend high calorie/high nutrition foods for this client who is
unintentionally losing weight. The candy bar is high calorie, but empty in
nutritional value. The remaining selections are high calorie/high nutrition. A
client in a long-term care facility reports to the nurse, "I have not had a bowel
movement in 2 days." What is the nurse's first action? A. Instruct the caregiver
to offer a glass of warm prune juice at mealtimes. B. Notify the health care
provider and request a prescription for a large-volume enema. C. Assess the
client's medical record to determine the client's normal bowel pattern. D.
Instruct the caregiver to increase the client's fluids to five 8-ounce glasses per
day. - C Rationale: This client may not routinely have a daily bowel movement,
so the nurse should first assess this client's normal bowel habits before
attempting any intervention. Options A, B, or D may then be implemented, if
warranted. The postoperative client states to the nurse, "When I had surgery
last year I got constipated. It was miserable. What can I do to avoid
constipation after this surgery this time?" (Select all that apply.) A. "Drink
approximately 3000 mL of non-caffeinated fluid per day." B. "I will make sure
that you get out of bed an walk for 10 minutes, six times per day." C. "I will
administer your pain medication even if you do not have any pain." D. "I will
ask your healthcare provider for a prescription of docusate." E. "When you are
on a regular diet, make sure you order plenty of fruits and vegetables." F.
"When you are resting in bed, make sure you are flat on your back." - A, B, D,
E Rationale: Pain medication can be constipating, and should only be taken
when needed. When in bed, use gravity to help move the contents of the
bowel by sitting upright. The remaining selections are correct. When
postoperative, it may take up to 48 hours after a general diet is started to have
a bowel movement. The nurse is preparing to administer 0.32 mL of
medication subcutaneously. What supplies will the nurse need to deliver the
medication? (Select all that apply.) A. A 1 mL syringe B. A 3 mL syringe C.
Alcohol prep pads D. Sterile gloves E. A 24-gauge ¾″ needle F. A 20-gauge
1″ needle - A, C, E Rationale: The best syringe is a 1 mL syringe as it is
marked in 100ths; 3 mL syringes are marked off in 10ths. Clean, not sterile
gloves are needed. For sub-q, the 3/4″ needle is sufficient and less painful for
the client. When taking a client's blood pressure, the nurse is unable to
distinguish the point at which the first sound was heard. Which is the best
action for the nurse to take? A. Deflate the cuff completely and immediately
reattempt the reading. B. Reinflate the cuff completely and leave it inflated for
90 to 110 seconds before taking the second reading. C. Deflate the cuff to
zero and wait 30 to 60 seconds before reattempting the reading. D. Document
the exact level visualized on the sphygmomanometer where the first
fluctuation was seen. - C Rationale: Deflating the cuff for 30 to 60 seconds
allows blood flow to return to the extremity so that an accurate reading can be
obtained on that extremity a second time. Option A could result in a falsely
high reading. Option B reduces circulation, causes pain, and could alter the
reading. Option D is not an accurate method of assessing blood pressure.
The nurse is obtaining a lie-sit-stand blood pressure reading on a client.
Which action is most important for the nurse to take for this client? A. Stay
with the client while the client is standing. B. Record the findings on the
graphic sheet in the chart. C. Keep the blood pressure cuff on the same arm.
D. Record changes in the client's pulse rate. - A Rationale: Although all these
measures are important, option A is most important because it helps ensure
, client safety. Option B is necessary but does not have the priority of option A.
Options C and D are important measures to ensure accuracy of the recording
but are of less importance than providing client safety. The client 12 hours
after a laparotomy reports to the nurse a pain rating of 7 to 10. The nurse
reviews the medication orders and it is another hour before the client can
have another dose of pain medication. What actions can the nurse take to
assist the client? (Select all that apply.) A. Administer the IV pain medication
an hour early. B. Assist the client into side-lying, curled position. C. Obtain a
warm pack to apply to the site of the incision. D. Suggest to the client taking
10 deep breaths, in through the nose and out through the mouth. E. Help the
client with sustained concentration of a personally pleasant topic. - B, C, D, E
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. - 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.
Blind sweeps are not used as this action may push the object deeper into the
throat. The remaining steps are correct. 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 - B Rationale: Normal saline solution is the only solution that is
compatible with blood. 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. 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. - B Rationale: Option B describes the correct
positioning of the nurse and 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, with the back of the chair
toward the head of the bed. Clients should never be lifted under the axillae;
this could damage nerves and strain the nurse's back. The client should be
instructed to use the arms of the chair and should never place his or her arms
around the nurse's neck; this places undue stress on the nurse's neck and
back and increases the risk for a fall. How many mL will the nurse document
on the client's intake and output record from the items listed? _____ mL 1200
mL water 4 ounce container of gelatin 8 ounces of orange juice 355 mL can of
soda1 cup of soup - Answer: 2155 Rationale: 1200 + 240 (8 oz) + 240 (1 cup)
+ 120 (4 oz) + 355 = 2155 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. - B Rationale:
When obtaining the blood pressure in the lower extremities, the popliteal
