QUESTIONS AND CORRECT ANSWERS WITH RATIOANLES (VERIFIED AN-
SWERS)
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1. The nurse is called to the waiting room of a pedi- B, C, D
atric clinic. The frantic mother states, "I think my Rationale: The fingers are
4-month-old baby is choking!" What steps will the placed at the same location
nurse take? (Select all that apply.) on an infant as chest com-
A. pressions for CPR; however,
Compress the chest once between the nipples with the nurse must deliver five
two fingers. chest thrusts, after the five back
B. slaps. Blind sweeps are not
Note any obstruction or absence of breathing. used as this action may push
C. the object deeper into the
Deliver five backslaps between the shoulder throat. The remaining steps
blades. are correct.
D.
Place the infant over the nurse's arm.
E.
Perform a blind finger sweep.
2. Which fluid will the nurse select to administer with B
the prescribed blood transfusion? Rationale: Normal saline solu-
A. tion is the only solution that is
5% Dextrose and water compatible with blood.
B.
Normal saline
C.
Lactated Ringers solution
D.
5% Dextrose and lactated ringers
3. When assisting a client from the bed to a chair, B
which procedure is best for the nurse to follow? Rationale: Option B describes
, HESI RN FUNDAMENTALS EXIT EXAM LATEST 2024-2025 ACTUAL EXAM 1
QUESTIONS AND CORRECT ANSWERS WITH RATIOANLES (VERIFIED AN-
SWERS)
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A. the correct positioning of the
Place the chair parallel to the bed, with its back nurse and affords the nurse
toward the head of the bed and assist the client in a wide base of support while
moving to the chair. stabilizing the client's knees
B. when assisting to a standing
With the nurse's feet spread apart and knees position. The chair should be
aligned with the client's knees, stand and pivot the placed at a 45-degree angle
client into the chair. to the bed, with the back of
C. the chair toward the head of
Assist the client to a standing position by gently the bed. Clients should nev-
lifting upward, underneath the axillae. er be lifted under the axillae;
D. this could damage nerves and
Stand beside the client, place the client's arms strain the nurse's back. The
around the nurse's neck, and gently move the client client should be instructed to
to the chair. 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 in-
creases the risk for a fall.
4. How many mL will the nurse document on the Answer: 2155
client's intake and output record from the items Rationale: 1200 + 240 (8 oz) +
listed? _____ mL 240 (1 cup) + 120 (4 oz) + 355
1200 mL water = 2155
4 ounce container of gelatin
8 ounces of orange juice
355 mL can of soda1 cup of soup
5.
, HESI RN FUNDAMENTALS EXIT EXAM LATEST 2024-2025 ACTUAL EXAM 1
QUESTIONS AND CORRECT ANSWERS WITH RATIOANLES (VERIFIED AN-
SWERS)
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The nurse observes a UAP taking a client's blood B
pressure in the lower extremity. Which observation Rationale: When obtaining the
of this procedure requires the nurse to intervene blood pressure in the low-
with the UAP's approach? er extremities, the popliteal
A. pulse is the site for auscul-
The cuff wraps around the girth of the leg. tation when the blood pres-
B. sure cuff is applied around the
The UAP auscultates the popliteal pulse with the thigh. The nurse should inter-
cuff on the lower leg. vene with the UAP who has ap-
C. plied the cuff on the lower leg.
The client is placed in a prone position. Option A ensures an accurate
D. assessment, and option C pro-
The systolic reading is 20 mm Hg higher than the vides the best access to the
blood pressure in the client's arm. artery. Systolic pressure in the
popliteal artery is usually 10 to
40 mm Hg higher than in the
brachial artery.
6. During a clinic visit, the mother of a 7-year-old D
reports to the nurse that her child is often awake Rationale: School-age children
until midnight playing and is then very difficult to often resist bedtime. The nurse
awaken in the morning for school. Which assess- should begin by assessing the
ment data should the nurse obtain in response to environment of the home to
the mother's concern? determine factors that may not
A. be conducive to the establish-
The occurrence of any episodes of sleep apnea ment of bedtime rituals that
B. promote sleep. Option A often
The child's blood pressure, pulse, and respirations causes daytime fatigue rather
C. than resistance to going to
Length of rapid eye movement (REM) sleep that the sleep. Option B is unlikely to
, HESI RN FUNDAMENTALS EXIT EXAM LATEST 2024-2025 ACTUAL EXAM 1
QUESTIONS AND CORRECT ANSWERS WITH RATIOANLES (VERIFIED AN-
SWERS)
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child is experiencing provide useful data. The nurse
D. cannot determine option C.
Description of the family's home environment
7. The nurse identifies a potential for infection in a B
client with partial-thickness (second-degree) and Rationale: Careful handwash-
full-thickness (third-degree) burns. What action has ing technique is the single
the highest priority in decreasing the client's risk of most effective intervention for
infection? the prevention of contami-
A. nation to all clients. Option
Administration of plasma expanders A reverses the hypovolemia
B. that initially accompanies burn
Use of careful handwashing technique trauma but is not related to
C. decreasing the proliferation of
Application of a topical antibacterial cream infective organisms. Options C
D. and D are recommended by
Limiting visitors to the client with burns various burn centers as possi-
ble ways to reduce the chance
of infection. Option B is a
proven technique to prevent
infection.
8. 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
gravity has slowed, even though the venous access first check the tubing and
site is healthy. What should the nurse do next? height of the bag on the IV
A. pole, which are common fac-
Apply a warm compress proximal to the site. tors that may slow the rate.
B. Gravity infusion rates are in-
Check for kinks in the tubing and raise the IV pole. fluenced by the height of the