FUNDAMENTALS RN HESI EXIT 2024-2025 ACTUAL EXAM
HESI RN FUNDAMENTALS EXIT EXAM
2024-2025 / FUNDAMENTALS RN HESI
EXIT 2024-2025 ACTUAL EXAM ALL
QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES
GRADED A+
The nurse is using the Glasgow Coma Scale to perform a
neurologic assessment. A comatose client winces and pulls
away from a painful stimulus. Which action should the nurse
take next?
A.
,FUNDAMENTALS RN HESI EXIT 2024-2025 ACTUAL EXAM
Document that the client responds to painful stimulus.
B.
Observe the client's response to verbal stimulation.
C.
Place the client on seizure precautions for 24 hours.
D.
Report decorticate posturing to the health care provider. -
ANSWER-A
Rationale: The client has demonstrated a purposeful response
to pain, which should be documented as such. Response to
painful stimulus is assessed after response to verbal stimulus,
not before. There is no indication for placing the client on
seizure precautions. Reporting decorticate posturing to the
health care provider is a nonpurposeful movement.
While conducting an intake assessment of an adult client at a
community mental health clinic, the nurse notes that the
client's affect is flat, responds to questions with short answers,
and reports problems with sleeping. At the end of the intake
assessment, the client reveals the loss of a life partner 1 month
ago. What is the nurse's best action for this client?
A.
Encourage the client to see the clinic's grief counselor.
,FUNDAMENTALS RN HESI EXIT 2024-2025 ACTUAL EXAM
B.
Determine if the client has a family history of suicide attempts.
C.
Inquire about whether the life partner was suffering from AIDS.
D.
Consult with the health care provider about the client's need
for antidepressant medications. - ANSWER-A
Rationale: The client is exhibiting normal grieving behaviors, so
referral to a grief counselor is the most important intervention
for the nurse to implement. Option B is indicated but is not a
high-priority intervention. Option C is irrelevant at this time but
might be important when determining the client's risk for
contracting the illness. An antidepressant may be indicated,
depending on further assessment, but grief counseling is a
better action at this time because grief is an expected reaction
to the loss of a loved one.
The nurse who is preparing to give a 14-year-old client a
prescribed antipsychotic medication notes that parental
consent has not been obtained. Which action should the nurse
take?
A.
Review the chart for a signed consent for hospitalization.
, FUNDAMENTALS RN HESI EXIT 2024-2025 ACTUAL EXAM
B.
Get the health care provider's permission to give the
medication.
C.
Do not give the medication and document the reason.
D.
Complete an incident report and notify the parents. - ANSWER-
C
Rationale: The nurse should not give the medication and should
document the reason because the client is a minor and needs a
guardian's permission to receive medications. Permission to
give medications is not granted by a signed hospital consent or
a health care provider's permission, unless conditions are met
to justify coerced treatment. Option D is not necessary unless
the medication had previously been administered.
The nurse is preparing to administer a bolus tube feeding. What
steps must the nurse include prior to administering the
feeding? (Select all that apply.)
A.
Aspirate the stomach contents.
B.
Assess bowel sounds.
HESI RN FUNDAMENTALS EXIT EXAM
2024-2025 / FUNDAMENTALS RN HESI
EXIT 2024-2025 ACTUAL EXAM ALL
QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES
GRADED A+
The nurse is using the Glasgow Coma Scale to perform a
neurologic assessment. A comatose client winces and pulls
away from a painful stimulus. Which action should the nurse
take next?
A.
,FUNDAMENTALS RN HESI EXIT 2024-2025 ACTUAL EXAM
Document that the client responds to painful stimulus.
B.
Observe the client's response to verbal stimulation.
C.
Place the client on seizure precautions for 24 hours.
D.
Report decorticate posturing to the health care provider. -
ANSWER-A
Rationale: The client has demonstrated a purposeful response
to pain, which should be documented as such. Response to
painful stimulus is assessed after response to verbal stimulus,
not before. There is no indication for placing the client on
seizure precautions. Reporting decorticate posturing to the
health care provider is a nonpurposeful movement.
While conducting an intake assessment of an adult client at a
community mental health clinic, the nurse notes that the
client's affect is flat, responds to questions with short answers,
and reports problems with sleeping. At the end of the intake
assessment, the client reveals the loss of a life partner 1 month
ago. What is the nurse's best action for this client?
A.
Encourage the client to see the clinic's grief counselor.
,FUNDAMENTALS RN HESI EXIT 2024-2025 ACTUAL EXAM
B.
Determine if the client has a family history of suicide attempts.
C.
Inquire about whether the life partner was suffering from AIDS.
D.
Consult with the health care provider about the client's need
for antidepressant medications. - ANSWER-A
Rationale: The client is exhibiting normal grieving behaviors, so
referral to a grief counselor is the most important intervention
for the nurse to implement. Option B is indicated but is not a
high-priority intervention. Option C is irrelevant at this time but
might be important when determining the client's risk for
contracting the illness. An antidepressant may be indicated,
depending on further assessment, but grief counseling is a
better action at this time because grief is an expected reaction
to the loss of a loved one.
The nurse who is preparing to give a 14-year-old client a
prescribed antipsychotic medication notes that parental
consent has not been obtained. Which action should the nurse
take?
A.
Review the chart for a signed consent for hospitalization.
, FUNDAMENTALS RN HESI EXIT 2024-2025 ACTUAL EXAM
B.
Get the health care provider's permission to give the
medication.
C.
Do not give the medication and document the reason.
D.
Complete an incident report and notify the parents. - ANSWER-
C
Rationale: The nurse should not give the medication and should
document the reason because the client is a minor and needs a
guardian's permission to receive medications. Permission to
give medications is not granted by a signed hospital consent or
a health care provider's permission, unless conditions are met
to justify coerced treatment. Option D is not necessary unless
the medication had previously been administered.
The nurse is preparing to administer a bolus tube feeding. What
steps must the nurse include prior to administering the
feeding? (Select all that apply.)
A.
Aspirate the stomach contents.
B.
Assess bowel sounds.
