HESI RN FUNDAMENTALS EXIT EXAM
2025 | LATET PRACTICE QUESTIONS
VERIFIELD ANSWERS &DETAILED
RATIONALES
During a clinic visit, the mother of a 7-year-old reports to the nurse that her
child is often awake until midnight playing and is then very difficult to
awaken in the morning for school. Which assessment data should the
nurse obtain in response to the mother's concern?
A.
The occurrence of any episodes of sleep apnea
B.
The child's blood pressure, pulse, and respirations
C.
Length of rapid eye movement (REM) sleep that the child is experiencing
D.
Description of the family's home environment - ANS✔✔-D
Rationale: School-age children often resist bedtime. The nurse should
begin by assessing the environment of the home to determine factors that
may not be conducive to the establishment of bedtime rituals that promote
sleep. Option A often causes daytime fatigue rather than resistance to
going to sleep. Option B is unlikely to provide useful data. The nurse
cannot determine option C.
The nurse identifies a potential for infection in a client with partial-thickness
(second-degree) and full-thickness (third-degree) burns. What action has
the highest priority in decreasing the client's risk of infection?
A.
Administration of plasma expanders
B.
Use of careful handwashing technique
, C.
Application of a topical antibacterial cream
D.
Limiting visitors to the client with burns - ANS✔✔-B
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 assesses a 2-year-old who is admitted for dehydration and finds
that the peripheral IV rate by gravity has slowed, even though the venous
access site is healthy. What should the nurse do next?
A.
Apply a warm compress proximal to the site.
B.
Check for kinks in the tubing and raise the IV pole.
C.
Adjust the tape that stabilizes the needle.
D.
Flush with normal saline and recount the drop rate. - ANS✔✔-B
Rationale: The nurse should first check the tubing and height of the bag on
the IV pole, which are common factors that may slow the rate. Gravity
infusion rates are influenced by the height of the bag, tubing clamp closure
or kinks, needle size or position, fluid viscosity, client blood pressure
(crying in the pediatric client), and infiltration. Venospasm can slow the rate
and often responds to warmth over the vessel, but the nurse should first
adjust the IV pole height. The nurse may need to adjust the stabilizing tape
on a positional needle or flush the venous access with normal saline, but
less invasive actions should be implemented first.
The nurse manager of a skilled nursing (chronic care) unit is instructing
UAPs on ways to prevent complications of immobility. Which action should
be included in this instruction?
A.
Perform range-of-motion exercises to prevent contractures.
B.
Decrease the client's fluid intake to prevent diarrhea.
, C.
Massage the client's legs to reduce embolism occurrence.
D.
Turn the client from side to back every shift. - ANS✔✔-A
Rationale: Performing range-of-motion exercises is beneficial in reducing
contractures around joints. Options B, C, and D are all potentially harmful
practices that place the immobile client at risk of complications.
The nurse administered 10 mg of diazepam to the preoperative client. What
steps will the nurse take next? (Select all that apply.)
A.
Place the client in the bed next to the nurse's station.
B.
Instruct the client not to get out of bed.
C.
Place the call bell within the client's reach.
D.
Place the side rails up, according to institutional policy.
E.
Assist the client to the bathroom - ANS✔✔-B, C, D
Rationale: Diazepam is a common preoperative medication. Close
observation by placing the client close to the nurse's station is not
necessary. The medication has a sedative effect and the client should not
get out of bed, even with assistance. The remaining selections are correct.
A terminally ill client tells the nurse, "I am so tired and in so much pain!
Please help me to die." Which is the best response for the nurse to
provide?
A.
Administer the prescribed maximum dose of pain medication.
B.
Talk with the client about thoughts and feelings about death.
C.
Collaborate with the health care provider about initiating antidepressant
therapy.
D.
Refer the client to the ethics committee of her local health care facility. -
ANS✔✔-B
, Rationale: The nurse should first assess the client's feelings about death
and determine the extent to which this statement expresses the client's true
feelings. The client may need additional pain management, but further
assessment is needed before implementing option A. Options C and D are
both premature interventions and should not be implemented until further
assessment is obtained.
A nurse stops at a motor vehicle collision site to render aid until the
emergency personnel arrive and applies pressure to a groin wound that is
bleeding profusely. Later the client has to have the leg amputated and sues
the nurse for malpractice. Which statement reflects the likely outcome for
the nurse?
A.
The Patient's Bill of Rights protects clients from malicious intents, so the
nurse could lose the case.
B.
The lawsuit may be settled out of court, but the nurse's license is likely to
be revoked.
C.
There will be no judgment against the nurse, whose actions are protected
under the Good Samaritan Act.
D.
The client will win because the four elements of negligence (duty, breach,
causation, and damages) can be proved. - ANS✔✔-C
Rationale: The Good Samaritan Act protects health care professionals who
practice in good faith and provide reasonable care from malpractice claims,
regardless of the client outcome. Although the Patient's Bill of Rights
protects clients, this nurse is protected by the Good Samaritan Act. The
state Board of Nursing has no reason to revoke a registered nurse's license
unless there was evidence that actions taken in the emergency were not
done in good faith or that reasonable care was not provided. All four
elements of malpractice were not shown.
An older client who had abdominal surgery 3 days earlier was given a
barbiturate for sleep and is now requesting to go to the bathroom. What is
the priority nursing action for this client?
A.
Assist the client to walk to the bathroom and do not leave the client alone.
B.
Request that the UAP assist the client onto a bedpan.
2025 | LATET PRACTICE QUESTIONS
VERIFIELD ANSWERS &DETAILED
RATIONALES
During a clinic visit, the mother of a 7-year-old reports to the nurse that her
child is often awake until midnight playing and is then very difficult to
awaken in the morning for school. Which assessment data should the
nurse obtain in response to the mother's concern?
A.
The occurrence of any episodes of sleep apnea
B.
The child's blood pressure, pulse, and respirations
C.
Length of rapid eye movement (REM) sleep that the child is experiencing
D.
Description of the family's home environment - ANS✔✔-D
Rationale: School-age children often resist bedtime. The nurse should
begin by assessing the environment of the home to determine factors that
may not be conducive to the establishment of bedtime rituals that promote
sleep. Option A often causes daytime fatigue rather than resistance to
going to sleep. Option B is unlikely to provide useful data. The nurse
cannot determine option C.
The nurse identifies a potential for infection in a client with partial-thickness
(second-degree) and full-thickness (third-degree) burns. What action has
the highest priority in decreasing the client's risk of infection?
A.
Administration of plasma expanders
B.
Use of careful handwashing technique
, C.
Application of a topical antibacterial cream
D.
Limiting visitors to the client with burns - ANS✔✔-B
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 assesses a 2-year-old who is admitted for dehydration and finds
that the peripheral IV rate by gravity has slowed, even though the venous
access site is healthy. What should the nurse do next?
A.
Apply a warm compress proximal to the site.
B.
Check for kinks in the tubing and raise the IV pole.
C.
Adjust the tape that stabilizes the needle.
D.
Flush with normal saline and recount the drop rate. - ANS✔✔-B
Rationale: The nurse should first check the tubing and height of the bag on
the IV pole, which are common factors that may slow the rate. Gravity
infusion rates are influenced by the height of the bag, tubing clamp closure
or kinks, needle size or position, fluid viscosity, client blood pressure
(crying in the pediatric client), and infiltration. Venospasm can slow the rate
and often responds to warmth over the vessel, but the nurse should first
adjust the IV pole height. The nurse may need to adjust the stabilizing tape
on a positional needle or flush the venous access with normal saline, but
less invasive actions should be implemented first.
The nurse manager of a skilled nursing (chronic care) unit is instructing
UAPs on ways to prevent complications of immobility. Which action should
be included in this instruction?
A.
Perform range-of-motion exercises to prevent contractures.
B.
Decrease the client's fluid intake to prevent diarrhea.
, C.
Massage the client's legs to reduce embolism occurrence.
D.
Turn the client from side to back every shift. - ANS✔✔-A
Rationale: Performing range-of-motion exercises is beneficial in reducing
contractures around joints. Options B, C, and D are all potentially harmful
practices that place the immobile client at risk of complications.
The nurse administered 10 mg of diazepam to the preoperative client. What
steps will the nurse take next? (Select all that apply.)
A.
Place the client in the bed next to the nurse's station.
B.
Instruct the client not to get out of bed.
C.
Place the call bell within the client's reach.
D.
Place the side rails up, according to institutional policy.
E.
Assist the client to the bathroom - ANS✔✔-B, C, D
Rationale: Diazepam is a common preoperative medication. Close
observation by placing the client close to the nurse's station is not
necessary. The medication has a sedative effect and the client should not
get out of bed, even with assistance. The remaining selections are correct.
A terminally ill client tells the nurse, "I am so tired and in so much pain!
Please help me to die." Which is the best response for the nurse to
provide?
A.
Administer the prescribed maximum dose of pain medication.
B.
Talk with the client about thoughts and feelings about death.
C.
Collaborate with the health care provider about initiating antidepressant
therapy.
D.
Refer the client to the ethics committee of her local health care facility. -
ANS✔✔-B
, Rationale: The nurse should first assess the client's feelings about death
and determine the extent to which this statement expresses the client's true
feelings. The client may need additional pain management, but further
assessment is needed before implementing option A. Options C and D are
both premature interventions and should not be implemented until further
assessment is obtained.
A nurse stops at a motor vehicle collision site to render aid until the
emergency personnel arrive and applies pressure to a groin wound that is
bleeding profusely. Later the client has to have the leg amputated and sues
the nurse for malpractice. Which statement reflects the likely outcome for
the nurse?
A.
The Patient's Bill of Rights protects clients from malicious intents, so the
nurse could lose the case.
B.
The lawsuit may be settled out of court, but the nurse's license is likely to
be revoked.
C.
There will be no judgment against the nurse, whose actions are protected
under the Good Samaritan Act.
D.
The client will win because the four elements of negligence (duty, breach,
causation, and damages) can be proved. - ANS✔✔-C
Rationale: The Good Samaritan Act protects health care professionals who
practice in good faith and provide reasonable care from malpractice claims,
regardless of the client outcome. Although the Patient's Bill of Rights
protects clients, this nurse is protected by the Good Samaritan Act. The
state Board of Nursing has no reason to revoke a registered nurse's license
unless there was evidence that actions taken in the emergency were not
done in good faith or that reasonable care was not provided. All four
elements of malpractice were not shown.
An older client who had abdominal surgery 3 days earlier was given a
barbiturate for sleep and is now requesting to go to the bathroom. What is
the priority nursing action for this client?
A.
Assist the client to walk to the bathroom and do not leave the client alone.
B.
Request that the UAP assist the client onto a bedpan.
