HESI RN FUNDAMENTALS EXAM QUESTIONS WITH
ANSWERS AND EXPLANATIONS UPDATED
• When turning an immobile bedridden client without assistance, which action by the
nurse best ensures client safety?
A Securely grasp the client's arm and leg.
B. Put bed rails up on the side of bed opposite from the nurse.
C. Correctly position and use a turn sheet.
D Lower the head of the client's bed slowly.
.
Rationale:
Because the nurse can only stand on one side of the bed, bed rails should be up on the
opposite side to ensure that the client does not fall out of bed. Option A can cause client injury
to the skinor joint. Options C and D are useful techniques while turning a client but have less
priority in terms of safety than use of the bed rails.
• The nurse identifies a potential for infection in a client with partial-thickness (second-
degree) and full-thickness (third-degree) burns. What intervention has the highest
priorityin decreasing the client's risk of infection?
• Administration of plasma expanders
• Use of careful handwashing technique
• Application of a topical antibacterial cream
• Limiting visitors to the client with burns
Rationale:
Careful handwashing technique is the single most effective intervention for the prevention of
contamination to all clients. Option A reverses the hypovolemia that initially accompanies burn
trauma but is not related to decreasing the proliferation of infective organisms. Options C and D
are recommended by various burn centers as possible ways to reduce the chance of infection.
Option B is a proven technique to prevent infection.
, • The nurse is aware that malnutrition is a common problem among clients served by
a community health clinic for the homeless. Which laboratory value is the most
reliable indicator of chronic protein malnutrition?
• Low serum albumin level
• Low serum transferrin level
• High hemoglobin level
• High cholesterol level
Rationale:
Long-term protein deficiency is required to cause significantly lowered serum albumin levels.
Albumin is made by the liver only when adequate amounts of amino acids (from protein
breakdown) are available. Albumin has a long half-life, so acute protein loss does not
significantly alter serum levels. Option B is a serum protein with a half-life of only 8 to 10
days, so it will drop with an acute protein deficiency. Options C and D are not clinical
measures of protein malnutrition.
• In completing a client's preoperative routine, the nurse finds that the operative permit
is not signed. The client begins to ask more questions about the surgical procedure.
Whichaction should the nurse take next?
• Witness the client's signature to the permit.
• Answer the client's questions about the surgery.
• Inform the surgeon that the operative permit is not signed
and the client has questions about the surgery.
• Reassure the client that the surgeon will answer any
questions before the anesthesia is administered.
Rationale:
The surgeon should be informed immediately that the permit is not signed. It is the surgeon's
responsibility to explain the procedure to the client and obtain the client's signature on the
permit. Although the nurse can witness an operative permit, the procedure must first be
explained by the health care provider or surgeon, including answering the client's questions. The
client's questions should be addressed before the permit is signed.
, • The nurse is assessing several clients prior to surgery. Which factor in a client's
historyposes the greatest threat for complications to occur during surgery?
• Taking birth control pills for the past 2 years
• Taking anticoagulants for the past year
• Recently completing antibiotic therapy
• Having taken laxatives PRN for the last 6 months
Rationale:
Anticoagulants increase the risk for bleeding during surgery, which can pose a threat for the
development of surgical complications. The health care provider should be informed that the
client is taking these drugs. Although clients who take birth control pills may be more
susceptible to the development of thrombi, such problems usually occur postoperatively. A
client with option C or D is at less of a surgical risk than with option B.
• 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.
Rationale:
Option B describes the correct positioning of the nurse and affords the nurse a wide base
ofsupport 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.
• Which step(s) should the nurse take when administering ear drops to an
adult client? (Select all that apply.)
A Place the client in a side-lying position.
B. Pull the auricle upward and outward.
C. Hold the dropper 6 cm above the ear canal.
D Place a cotton ball into the inner canal.
.
E. Pull the auricle down and back.
Rationale:
The correct answers (A and B) are the appropriate administration of ear drops. The dropper
should be held 1 cm (½ inch) above the ear canal (C). A cotton ball should be placed in the
outermost canal (D). The auricle is pulled down and back for a child younger than 3 years of
age, but not an adult (E).
• The nurse is instructing a client in the proper use of a metered-dose inhaler. Which
instructionshould the nurse provide the client to ensure the optimal benefits from the drug?
• "Fill your lungs with air through your mouth and then
compress the inhaler."
• "Compress the inhaler while slowly breathing in through
your mouth."
• "Compress the inhaler while inhaling quickly through your
nose."
• "Exhale completely after compressing the inhaler and then
inhale."
Rationale:
The medication should be inhaled through the mouth simultaneously with compression of the
inhaler. This will facilitate the desired destination of the aerosol medication deep in the lungs
foran optimal bronchodilation effect. Options A, C, and D do not allow for deep lung
penetration
ANSWERS AND EXPLANATIONS UPDATED
• When turning an immobile bedridden client without assistance, which action by the
nurse best ensures client safety?
A Securely grasp the client's arm and leg.
B. Put bed rails up on the side of bed opposite from the nurse.
C. Correctly position and use a turn sheet.
D Lower the head of the client's bed slowly.
.
Rationale:
Because the nurse can only stand on one side of the bed, bed rails should be up on the
opposite side to ensure that the client does not fall out of bed. Option A can cause client injury
to the skinor joint. Options C and D are useful techniques while turning a client but have less
priority in terms of safety than use of the bed rails.
• The nurse identifies a potential for infection in a client with partial-thickness (second-
degree) and full-thickness (third-degree) burns. What intervention has the highest
priorityin decreasing the client's risk of infection?
• Administration of plasma expanders
• Use of careful handwashing technique
• Application of a topical antibacterial cream
• Limiting visitors to the client with burns
Rationale:
Careful handwashing technique is the single most effective intervention for the prevention of
contamination to all clients. Option A reverses the hypovolemia that initially accompanies burn
trauma but is not related to decreasing the proliferation of infective organisms. Options C and D
are recommended by various burn centers as possible ways to reduce the chance of infection.
Option B is a proven technique to prevent infection.
, • The nurse is aware that malnutrition is a common problem among clients served by
a community health clinic for the homeless. Which laboratory value is the most
reliable indicator of chronic protein malnutrition?
• Low serum albumin level
• Low serum transferrin level
• High hemoglobin level
• High cholesterol level
Rationale:
Long-term protein deficiency is required to cause significantly lowered serum albumin levels.
Albumin is made by the liver only when adequate amounts of amino acids (from protein
breakdown) are available. Albumin has a long half-life, so acute protein loss does not
significantly alter serum levels. Option B is a serum protein with a half-life of only 8 to 10
days, so it will drop with an acute protein deficiency. Options C and D are not clinical
measures of protein malnutrition.
• In completing a client's preoperative routine, the nurse finds that the operative permit
is not signed. The client begins to ask more questions about the surgical procedure.
Whichaction should the nurse take next?
• Witness the client's signature to the permit.
• Answer the client's questions about the surgery.
• Inform the surgeon that the operative permit is not signed
and the client has questions about the surgery.
• Reassure the client that the surgeon will answer any
questions before the anesthesia is administered.
Rationale:
The surgeon should be informed immediately that the permit is not signed. It is the surgeon's
responsibility to explain the procedure to the client and obtain the client's signature on the
permit. Although the nurse can witness an operative permit, the procedure must first be
explained by the health care provider or surgeon, including answering the client's questions. The
client's questions should be addressed before the permit is signed.
, • The nurse is assessing several clients prior to surgery. Which factor in a client's
historyposes the greatest threat for complications to occur during surgery?
• Taking birth control pills for the past 2 years
• Taking anticoagulants for the past year
• Recently completing antibiotic therapy
• Having taken laxatives PRN for the last 6 months
Rationale:
Anticoagulants increase the risk for bleeding during surgery, which can pose a threat for the
development of surgical complications. The health care provider should be informed that the
client is taking these drugs. Although clients who take birth control pills may be more
susceptible to the development of thrombi, such problems usually occur postoperatively. A
client with option C or D is at less of a surgical risk than with option B.
• 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.
Rationale:
Option B describes the correct positioning of the nurse and affords the nurse a wide base
ofsupport 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.
• Which step(s) should the nurse take when administering ear drops to an
adult client? (Select all that apply.)
A Place the client in a side-lying position.
B. Pull the auricle upward and outward.
C. Hold the dropper 6 cm above the ear canal.
D Place a cotton ball into the inner canal.
.
E. Pull the auricle down and back.
Rationale:
The correct answers (A and B) are the appropriate administration of ear drops. The dropper
should be held 1 cm (½ inch) above the ear canal (C). A cotton ball should be placed in the
outermost canal (D). The auricle is pulled down and back for a child younger than 3 years of
age, but not an adult (E).
• The nurse is instructing a client in the proper use of a metered-dose inhaler. Which
instructionshould the nurse provide the client to ensure the optimal benefits from the drug?
• "Fill your lungs with air through your mouth and then
compress the inhaler."
• "Compress the inhaler while slowly breathing in through
your mouth."
• "Compress the inhaler while inhaling quickly through your
nose."
• "Exhale completely after compressing the inhaler and then
inhale."
Rationale:
The medication should be inhaled through the mouth simultaneously with compression of the
inhaler. This will facilitate the desired destination of the aerosol medication deep in the lungs
foran optimal bronchodilation effect. Options A, C, and D do not allow for deep lung
penetration
