HESI RN FUNDAMENTALS EXIT EXAM LATEST ACTUAL EXAM 100 QUESTIONS AND CORRECT
ANSWERS WITH RATIOANLES (VERIFIEDANSWERS)
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C
Terms in this set (125)
The nurse is called to the waiting room of a pediatric B, C, D
clinic. The frantic mother states, "I think my 4-month-old Rationale: The fingers are placed at the same location on an infant as chest
baby is choking!" What steps will the nurse take? (Select compressions for CPR; however, the nurse must deliver five chest thrusts, after
all that apply.) the five back slaps. Blind sweeps are not used as this action may push the
A. object deeper into the throat. The remaining steps are correct.
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.
Which fluid will the nurse select to administer with the B
prescribed blood transfusion? Rationale: Normal saline solution is the only solution that is compatible with
A. blood.
5% Dextrose and water
B.
Normal saline
C.
Lactated Ringers solution
D.
5% Dextrose and lactated ringers
1/31
, HESI RN FUNDAMENTALS EXIT EXAM LATEST ACTUAL EXAM 100 QUESTIONS AND CORRECT
ANSWERS WITH RATIOANLES (VERIFIEDANSWERS)
When assisting a client from the bed to a chair, which B
procedure is best for the nurse to follow? Rationale: Option B describes the correct positioning of the nurse and affords
A. the nurse a wide base of support while stabilizing the client's knees when
Place the chair parallel to the bed, with its back toward assisting to a standing position. The chair should be placed at a 45-degree
the head of the bed and assist the client in moving to angle to the bed, with the back of the chair toward the head of the bed. Clients
the chair. should never be lifted under the axillae; this could damage nerves and strain
B. the nurse's back. The client should be instructed to use the arms of the chair
With the nurse's feet spread apart and knees aligned and should never place his or her arms around the nurse's neck; this places
with the client's knees, stand and pivot the client into undue stress on the nurse's neck and back and increases the risk for a fall.
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.
How many mL will the nurse document on the client's Answer: 2155
intake and output record from the items listed? _____ mL Rationale: 1200 + 240 (8 oz) + 240 (1 cup) + 120 (4 oz) + 355 = 2155
1200 mL water
4 ounce container of gelatin
8 ounces of orange juice
355 mL can of soda1 cup of soup
The nurse observes a UAP taking a client's blood B
pressure in the lower extremity. Which observation of Rationale: When obtaining the blood pressure in the lower extremities, the
this procedure requires the nurse to intervene with the popliteal pulse is the site for auscultation when the blood pressure cuff is
UAP's approach? applied around the thigh. The nurse should intervene with the UAP who has
A. applied the cuff on the lower leg. Option A ensures an accurate assessment,
The cuff wraps around the girth of the leg. and option C provides the best access to the artery. Systolic pressure in the
B. popliteal artery is usually 10 to 40 mm Hg higher than in the brachial artery.
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.
2/31
, HESI RN FUNDAMENTALS EXIT EXAM LATEST ACTUAL EXAM 100 QUESTIONS AND CORRECT
ANSWERS WITH RATIOANLES (VERIFIEDANSWERS)
During a clinic visit, the mother of a 7-year-old reports D
to the nurse that her child is often awake until midnight Rationale: School-age children often resist bedtime. The nurse should begin by
playing and is then very difficult to awaken in the assessing the environment of the home to determine factors that may not be
morning for school. Which assessment data should the conducive to the establishment of bedtime rituals that promote sleep. Option A
nurse obtain in response to the mother's concern? often causes daytime fatigue rather than resistance to going to sleep. Option B
A. is unlikely to provide useful data. The nurse cannot determine option C.
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
3/31
, HESI RN FUNDAMENTALS EXIT EXAM LATEST ACTUAL EXAM 100 QUESTIONS AND CORRECT
ANSWERS WITH RATIOANLES (VERIFIEDANSWERS)
The nurse identifies a potential for infection in a client B
with partial-thickness (second-degree) and full- Rationale: Careful handwashing technique is the single most effective
thickness (third-degree) burns. What action has the intervention for the prevention of contamination to all clients. Option A
highest priority in decreasing the client's risk of reverses the hypovolemia that initially accompanies burn trauma but is not
infection? related to decreasing the proliferation of infective organisms. Options C and D
A. are recommended by various burn centers as possible ways to reduce the
Administration of plasma expanders chance of infection. Option B is a proven technique to prevent infection.
B.
Use of careful handwashing technique
C.
Application of a topical antibacterial cream
D.
Limiting visitors to the client with burns
The nurse assesses a 2-year-old who is admitted for B
dehydration and finds that the peripheral IV rate by Rationale: The nurse should first check the tubing and height of the bag on the
gravity has slowed, even though the venous access site IV pole, which are common factors that may slow the rate. Gravity infusion rates
is healthy. What should the nurse do next? are influenced by the height of the bag, tubing clamp closure or kinks, needle
A. size or position, fluid viscosity, client blood pressure (crying in the pediatric
Apply a warm compress proximal to the site. client), and infiltration. Venospasm can slow the rate and often responds to
B. warmth over the vessel, but the nurse should first adjust the IV pole height. The
Check for kinks in the tubing and raise the IV pole. nurse may need to adjust the stabilizing tape on a positional needle or flush the
C. venous access with normal saline, but less invasive actions should be
Adjust the tape that stabilizes the needle. implemented first.
D.
Flush with normal saline and recount the drop rate.
The nurse manager of a skilled nursing (chronic care) A
unit is instructing UAPs on ways to prevent Rationale: Performing range-of-motion exercises is beneficial in reducing
complications of immobility. Which action should be contractures around joints. Options B, C, and D are all potentially harmful
included in this instruction? practices that place the immobile client at risk of complications.
A.
Perform range-of-motion exercises to prevent
contractures.
B.
Decrease the client's fluid intake to prevent diarrhea.
C.
Massage the client's legs to reduce embolism
occurrence.
D.
Turn the client from side to back every shift.
The nurse administered 10 mg of diazepam to the B, C, D
preoperative client. What steps will the nurse take next? Rationale: Diazepam is a common preoperative medication. Close observation
(Select all that apply.) by placing the client close to the nurse's station is not necessary. The
A. medication has a sedative effect and the client should not get out of bed, even
Place the client in the bed next to the nurse's station. with assistance. The remaining selections are correct.
B.
Instruct the client not to get out of bed.
C.
Place the call bell within the client's reach.
D.
Place the side rails up, according to institutional policy.
E.
Assist the client to the bathroom
4/31
ANSWERS WITH RATIOANLES (VERIFIEDANSWERS)
133 studiers today 4.9 (73 reviews)
Save Groups
Students also studied
Flashcard sets Study guides
HESI FUNDAMENTALS 2026 HESI FUNDAMENTALS PRACTICE E... Fu
Teacher terms 80 terms terms 34
TutorDk Preview Christy_Wofford Preview Preview
C
Terms in this set (125)
The nurse is called to the waiting room of a pediatric B, C, D
clinic. The frantic mother states, "I think my 4-month-old Rationale: The fingers are placed at the same location on an infant as chest
baby is choking!" What steps will the nurse take? (Select compressions for CPR; however, the nurse must deliver five chest thrusts, after
all that apply.) the five back slaps. Blind sweeps are not used as this action may push the
A. object deeper into the throat. The remaining steps are correct.
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.
Which fluid will the nurse select to administer with the B
prescribed blood transfusion? Rationale: Normal saline solution is the only solution that is compatible with
A. blood.
5% Dextrose and water
B.
Normal saline
C.
Lactated Ringers solution
D.
5% Dextrose and lactated ringers
1/31
, HESI RN FUNDAMENTALS EXIT EXAM LATEST ACTUAL EXAM 100 QUESTIONS AND CORRECT
ANSWERS WITH RATIOANLES (VERIFIEDANSWERS)
When assisting a client from the bed to a chair, which B
procedure is best for the nurse to follow? Rationale: Option B describes the correct positioning of the nurse and affords
A. the nurse a wide base of support while stabilizing the client's knees when
Place the chair parallel to the bed, with its back toward assisting to a standing position. The chair should be placed at a 45-degree
the head of the bed and assist the client in moving to angle to the bed, with the back of the chair toward the head of the bed. Clients
the chair. should never be lifted under the axillae; this could damage nerves and strain
B. the nurse's back. The client should be instructed to use the arms of the chair
With the nurse's feet spread apart and knees aligned and should never place his or her arms around the nurse's neck; this places
with the client's knees, stand and pivot the client into undue stress on the nurse's neck and back and increases the risk for a fall.
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.
How many mL will the nurse document on the client's Answer: 2155
intake and output record from the items listed? _____ mL Rationale: 1200 + 240 (8 oz) + 240 (1 cup) + 120 (4 oz) + 355 = 2155
1200 mL water
4 ounce container of gelatin
8 ounces of orange juice
355 mL can of soda1 cup of soup
The nurse observes a UAP taking a client's blood B
pressure in the lower extremity. Which observation of Rationale: When obtaining the blood pressure in the lower extremities, the
this procedure requires the nurse to intervene with the popliteal pulse is the site for auscultation when the blood pressure cuff is
UAP's approach? applied around the thigh. The nurse should intervene with the UAP who has
A. applied the cuff on the lower leg. Option A ensures an accurate assessment,
The cuff wraps around the girth of the leg. and option C provides the best access to the artery. Systolic pressure in the
B. popliteal artery is usually 10 to 40 mm Hg higher than in the brachial artery.
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.
2/31
, HESI RN FUNDAMENTALS EXIT EXAM LATEST ACTUAL EXAM 100 QUESTIONS AND CORRECT
ANSWERS WITH RATIOANLES (VERIFIEDANSWERS)
During a clinic visit, the mother of a 7-year-old reports D
to the nurse that her child is often awake until midnight Rationale: School-age children often resist bedtime. The nurse should begin by
playing and is then very difficult to awaken in the assessing the environment of the home to determine factors that may not be
morning for school. Which assessment data should the conducive to the establishment of bedtime rituals that promote sleep. Option A
nurse obtain in response to the mother's concern? often causes daytime fatigue rather than resistance to going to sleep. Option B
A. is unlikely to provide useful data. The nurse cannot determine option C.
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
3/31
, HESI RN FUNDAMENTALS EXIT EXAM LATEST ACTUAL EXAM 100 QUESTIONS AND CORRECT
ANSWERS WITH RATIOANLES (VERIFIEDANSWERS)
The nurse identifies a potential for infection in a client B
with partial-thickness (second-degree) and full- Rationale: Careful handwashing technique is the single most effective
thickness (third-degree) burns. What action has the intervention for the prevention of contamination to all clients. Option A
highest priority in decreasing the client's risk of reverses the hypovolemia that initially accompanies burn trauma but is not
infection? related to decreasing the proliferation of infective organisms. Options C and D
A. are recommended by various burn centers as possible ways to reduce the
Administration of plasma expanders chance of infection. Option B is a proven technique to prevent infection.
B.
Use of careful handwashing technique
C.
Application of a topical antibacterial cream
D.
Limiting visitors to the client with burns
The nurse assesses a 2-year-old who is admitted for B
dehydration and finds that the peripheral IV rate by Rationale: The nurse should first check the tubing and height of the bag on the
gravity has slowed, even though the venous access site IV pole, which are common factors that may slow the rate. Gravity infusion rates
is healthy. What should the nurse do next? are influenced by the height of the bag, tubing clamp closure or kinks, needle
A. size or position, fluid viscosity, client blood pressure (crying in the pediatric
Apply a warm compress proximal to the site. client), and infiltration. Venospasm can slow the rate and often responds to
B. warmth over the vessel, but the nurse should first adjust the IV pole height. The
Check for kinks in the tubing and raise the IV pole. nurse may need to adjust the stabilizing tape on a positional needle or flush the
C. venous access with normal saline, but less invasive actions should be
Adjust the tape that stabilizes the needle. implemented first.
D.
Flush with normal saline and recount the drop rate.
The nurse manager of a skilled nursing (chronic care) A
unit is instructing UAPs on ways to prevent Rationale: Performing range-of-motion exercises is beneficial in reducing
complications of immobility. Which action should be contractures around joints. Options B, C, and D are all potentially harmful
included in this instruction? practices that place the immobile client at risk of complications.
A.
Perform range-of-motion exercises to prevent
contractures.
B.
Decrease the client's fluid intake to prevent diarrhea.
C.
Massage the client's legs to reduce embolism
occurrence.
D.
Turn the client from side to back every shift.
The nurse administered 10 mg of diazepam to the B, C, D
preoperative client. What steps will the nurse take next? Rationale: Diazepam is a common preoperative medication. Close observation
(Select all that apply.) by placing the client close to the nurse's station is not necessary. The
A. medication has a sedative effect and the client should not get out of bed, even
Place the client in the bed next to the nurse's station. with assistance. The remaining selections are correct.
B.
Instruct the client not to get out of bed.
C.
Place the call bell within the client's reach.
D.
Place the side rails up, according to institutional policy.
E.
Assist the client to the bathroom
4/31
