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HESI RN FUNDAMENTALS EXIT EXAM |LATEST
ACTUAL EXAM QUESTIONS AND CORRECT
ANSWERS
The nurse is planning care for a client with an indwelling urinary catheter. Which
nursing action has the highest priority?
A.
Assist the client with daily cleansing.
B.Tell the client that incontinence happens with aging.
C.
Offer 200 mL of fluid every 2 hours while awake.
D.
Take the client's temperature every 4 hours. - correct-answer -D
Rationale: Indwelling urinary catheters are a major source of infection. Option A is
a problem that may develop from having an indwelling catheter. Option B may or
may not be true for the client. Option C is not affected by an indwelling catheter.
When bathing an uncircumcised boy older than 3 years, which action should the
nurse take?
A.
Remind the child to clean his genital area.
B.
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Defer perineal care because of the child's age.
C.
Retract the foreskin gently to cleanse the penis.
D.
Ask the parents why the child is not circumcised. - correct-answer -C
Rationale: The foreskin (prepuce) of the penis should be gently retracted to
cleanse all areas that could harbor bacteria. The child's cognitive development
may not be at the level at which option A would be effective. Perineal care needs
to be provided daily regardless of the client's age. Option D is not indicated and
may be perceived as intrusive.
A nurse is assigned to care for a close friend in the hospital setting. Which action
should the nurse take first when given the assignment?
A.
Notify the friend that all medical information will be kept confidential.
B.
Explain the relationship to the charge nurse and ask for reassignment.
C.
Approach the client and ask if the assignment is uncomfortable.
D.
Accept the assignment but protect the client's confidentiality. - correct-answer -B
Rationale: Caring for a close friend can violate boundaries for nurses and should
be avoided when possible (B). If the assignment is unavoidable (there are no other
nurses to care for the client) then C, A, and D should be addressed.
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The nurse selects the best site for insertion of an IV catheter in the client's right
arm. Which documentation should the nurse use to identify placement of the IV
access?
A.
Left brachial vein
B.
Right cephalic vein
C.
Dorsal side of the right wrist
D.
Right upper extremity - correct-answer -B
Rationale: The cephalic vein is large and superficial and identifies the anatomic
name of the vein that is accessed, which should be included in the
documentation. The basilic vein of the arm is used for IV access, not the brachial
vein, which is too deep to be accessed for IV infusion. Although veins on the
dorsal side of the right wrist are visible, they are fragile and using them would be
painful, so they are not recommended for IV access. Option D is not specific
enough for documenting the location of the IV access.
The nurse transcribes the postoperative prescriptions for a client who returns to
the unit following surgery and notes that an antihypertensive medication that was
prescribed preoperatively is not listed. Which action should the nurse take?
A.
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Consult with the pharmacist about the need to continue the medication.
B.
Administer the antihypertensive medication as prescribed preoperatively.
C.
Withhold the medication until the client is fully alert and vital signs are stable.
D.
Contact the health care provider to renew the prescription for the medication. -
correct-answer -D
Rationale: Medications prescribed preoperatively must be renewed
postoperatively, so the nurse should contact the health care provider if the
antihypertensive medication is not included in the postoperative prescriptions.
The pharmacist does not prescribe medications or renew prescriptions. The nurse
must have a current prescription before administering any medications.
When emptying 350 mL of pale yellow urine from a client's urinal, the nurse notes
that this is the first time the client has voided in 4 hours. Which action should the
nurse take next?
A.
Record the amount on the client's fluid output record.
B.
Encourage the client to increase oral fluid intake.
C.
Notify the health care provider of the findings.
D.
HESI RN FUNDAMENTALS EXIT EXAM |LATEST
ACTUAL EXAM QUESTIONS AND CORRECT
ANSWERS
The nurse is planning care for a client with an indwelling urinary catheter. Which
nursing action has the highest priority?
A.
Assist the client with daily cleansing.
B.Tell the client that incontinence happens with aging.
C.
Offer 200 mL of fluid every 2 hours while awake.
D.
Take the client's temperature every 4 hours. - correct-answer -D
Rationale: Indwelling urinary catheters are a major source of infection. Option A is
a problem that may develop from having an indwelling catheter. Option B may or
may not be true for the client. Option C is not affected by an indwelling catheter.
When bathing an uncircumcised boy older than 3 years, which action should the
nurse take?
A.
Remind the child to clean his genital area.
B.
,2|Page
Defer perineal care because of the child's age.
C.
Retract the foreskin gently to cleanse the penis.
D.
Ask the parents why the child is not circumcised. - correct-answer -C
Rationale: The foreskin (prepuce) of the penis should be gently retracted to
cleanse all areas that could harbor bacteria. The child's cognitive development
may not be at the level at which option A would be effective. Perineal care needs
to be provided daily regardless of the client's age. Option D is not indicated and
may be perceived as intrusive.
A nurse is assigned to care for a close friend in the hospital setting. Which action
should the nurse take first when given the assignment?
A.
Notify the friend that all medical information will be kept confidential.
B.
Explain the relationship to the charge nurse and ask for reassignment.
C.
Approach the client and ask if the assignment is uncomfortable.
D.
Accept the assignment but protect the client's confidentiality. - correct-answer -B
Rationale: Caring for a close friend can violate boundaries for nurses and should
be avoided when possible (B). If the assignment is unavoidable (there are no other
nurses to care for the client) then C, A, and D should be addressed.
,3|Page
The nurse selects the best site for insertion of an IV catheter in the client's right
arm. Which documentation should the nurse use to identify placement of the IV
access?
A.
Left brachial vein
B.
Right cephalic vein
C.
Dorsal side of the right wrist
D.
Right upper extremity - correct-answer -B
Rationale: The cephalic vein is large and superficial and identifies the anatomic
name of the vein that is accessed, which should be included in the
documentation. The basilic vein of the arm is used for IV access, not the brachial
vein, which is too deep to be accessed for IV infusion. Although veins on the
dorsal side of the right wrist are visible, they are fragile and using them would be
painful, so they are not recommended for IV access. Option D is not specific
enough for documenting the location of the IV access.
The nurse transcribes the postoperative prescriptions for a client who returns to
the unit following surgery and notes that an antihypertensive medication that was
prescribed preoperatively is not listed. Which action should the nurse take?
A.
, 4|Page
Consult with the pharmacist about the need to continue the medication.
B.
Administer the antihypertensive medication as prescribed preoperatively.
C.
Withhold the medication until the client is fully alert and vital signs are stable.
D.
Contact the health care provider to renew the prescription for the medication. -
correct-answer -D
Rationale: Medications prescribed preoperatively must be renewed
postoperatively, so the nurse should contact the health care provider if the
antihypertensive medication is not included in the postoperative prescriptions.
The pharmacist does not prescribe medications or renew prescriptions. The nurse
must have a current prescription before administering any medications.
When emptying 350 mL of pale yellow urine from a client's urinal, the nurse notes
that this is the first time the client has voided in 4 hours. Which action should the
nurse take next?
A.
Record the amount on the client's fluid output record.
B.
Encourage the client to increase oral fluid intake.
C.
Notify the health care provider of the findings.
D.
