HESI RN FUNDAMENTALS EXIT EXAM LATEST
2024-2025 ACTUAL EXAM 100 QUESTIONS AND
CORRECT ANSWERS WITH RATIOANLES (VERIFIED
ANSWERS
Question and answer
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. - CORRECT ANSWERB
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. - CORRECT ANSWERA
,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 - CORRECT ANSWERB, 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. - CORRECT
ANSWERB
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.
2024-2025 ACTUAL EXAM 100 QUESTIONS AND
CORRECT ANSWERS WITH RATIOANLES (VERIFIED
ANSWERS
Question and answer
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. - CORRECT ANSWERB
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. - CORRECT ANSWERA
,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 - CORRECT ANSWERB, 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. - CORRECT
ANSWERB
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.
