HESI RN FUNDAMENTALS EXIT EXAM 100
QUESTIONS AND CORRECT ANSWERS WITH
RATIOANLES (VERIFIED ANSWERS)
,The nurse is called to the waiting room of a B, C, D
pediatric
Rationale: The fingers are placed at the same location on an infant as chest
clinic. The frantic mother states, "I think my 4-
compressions for CPR; however, the nurse must deliver five chest thrusts,
month-old baby is choking!" What steps will the
after the five back slaps. Blind sweeps are not used as this action may
nurse take? (Select all that apply.)
push the object
A.
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 B
with the 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
,When assisting a client from the bed to a chair, B
which procedure is best for the nurse to follow? Rationale: Option B describes the correct positioning of the nurse and
A. affords the nurse a wide base of support while stabilizing the client's
Place the chair parallel to the bed, with its back knees when assisting to a standing position. The chair should be placed
toward the head of the bed and assist the client at a 45-degree angle to the bed, with the back of the chair toward the
in moving to the chair. head of the bed. Clients should never be
B. lifted under the axillae; this could damage nerves and strain the
With the nurse's feet spread apart and knees nurse's back. The client should be instructed to use the arms of the
aligned with the client's knees, stand and pivot the chair and should never place his or her arms around the nurse's neck;
client into the chair. C. this places undue stress on the nurse's neck
Assist the client to a standing position by gently and back and increases the risk for a fall.
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 Answer: 2155
client's
Rationale: 1200 + 240 (8 oz) + 240 (1 cup) + 120 (4 oz) + 355 = 2155
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
, The nurse observes a UAP taking a client's blood B
pressure in the lower extremity. Which Rationale: When obtaining the blood pressure in the lower extremities, the
observation of this popliteal pulse is the site for auscultation when the blood pressure cuff
procedure requires the nurse to intervene with is applied around the thigh. The nurse should intervene with the UAP
the UAP's approach? who has applied the cuff on the lower leg. Option A ensures an
A. accurate assessment, and option C
The cuff wraps around the girth of provides the best access to the artery. Systolic pressure in the
the leg. B. popliteal artery is usually 10 to 40 mm Hg higher than in the brachial
The UAP auscultates the popliteal pulse with the artery.
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.