HESI RN FUNDAMENTALS EXIT EXAM
2024–2025 100 PRACTICE QUESTIONS
AND CORRECT ANSWERS WITH DETAILED
RATIONALES NURSING FUNDAMENTALS
STUDY GUIDE A+ EXAM PREPARATION
"We often go and play beach volleyball when it is nice out." - CORRECT
ANSWER-A, D
Rationale: Sexual exploration is not uncommon as a teen. However,
pregnancy can occur with ejaculation on the perineal area. Accidents are
the leading cause of death in the teen years and seatbelt use must be
encouraged at all times. The remaining statements demonstrate normal
growth and development for the teen years.
By rolling contaminated gloves inside-out, the nurse is affecting which step
in the chain of infection?
A.
Mode of transmission
B.
Portal of entry
C.
Reservoir
D.
Portal of exit - CORRECT ANSWER-A
,Rationale: The contaminated gloves serve as the mode of transmission from
the portal of exit of the reservoir to a portal of entry.
The health care provider diagnoses metastatic cancer and recommends a
gastrostomy for an elderly client in stable condition. The client's adult child
is concerned and states to the nurse, "I don't think my parent 'can handle'
the cancer diagnosis." What information will guide the nurse's response?
A.
The family can provide the consent required in this situation because the
older adult is in no condition to make such decisions.
B.
Because the client is mentally incompetent, the adult child has the right to
waive informed consent for the parent.
C.
The court will allow the health care provider to make the decision to
withhold informed consent under therapeutic privilege.
D.
If informed consent is withheld from a client, health care providers could
be found guilty of negligence. - CORRECT ANSWER-D
Rationale: Health care providers may be found guilty of negligence,
specifically assault and battery, if they carry out a treatment without the
client's consent. The client's condition is stable, so option A is not a valid
rationale. Advanced age does not automatically authorize the son to make
all decisions for his mother, and there is no evidence that the client is
mentally incompetent. Although option C may have been upheld in the
past, when paternalistic medical practice was common, today's courts are
unlikely to accept it.
,After a needle stick occurs while removing the cap from a sterile needle,
which action should the nurse take next?
A.
Complete an incident report.
B.
Select another sterile needle.
C.
Disinfect the needle with an alcohol swab.
D.
Notify the supervisor of the department immediately. - CORRECT
ANSWER-B
Rationale: After a needle stick, the needle is considered used, so the nurse
should discard it and select another needle. Because the needle was sterile
when the nurse was stuck and the needle was not in contact with any other
person's body fluids, the nurse does not need to complete an incident
report or notify the occupational health nurse. Disinfecting a needle with an
alcohol swab is not in accordance with standards for safe practice and
infection control.
An 89-year-old client is admitted to the rehabilitation unit after a hip
fracture. When reviewing the client's pre-fracture routine the client states,
"I usually get up around 0800 and have breakfast by 0900; I say my daily
prayers between 1000 and 1030. I like lunch around 1300; then a nap from
1400 to 1600. I generally eat supper around 1900." What is the nurse's best
response to the client's schedule?
A.
"We can try our best to work around your schedule."
B.
, "Your physical therapy is scheduled for 1500 to 1600."
C.
"You will have to get your own supper if you want to eat that late."
D.
"Is there any way you could say your prayers between 1230 and 1300?" -
CORRECT ANSWER-D
Rationale:The elderly have a routine that generally fits around their sleep-
wake cycle, or their circadian rhythm. The flexibility is around prayer time,
since it is during the wake time. If the rehabilitation therapy can be
scheduled in the am, that is generally the time when they have more energy.
Trying the best, does not place the client's sleep-wake schedule as a
priority. While supper on the rehab unit may be before 1900, arrangements
can be made to deliver a tray later, or keep a tray warm
The nurse determines that a postoperative client's respiratory rate has
increased from 18 to 24 breaths/min. Based on this assessment finding,
what is the priority nursing action?
A.
Encourage the client to increase ambulation in the room.
B.
Offer the client a high-carbohydrate snack for energy.
C.
Force fluids to thin the client's pulmonary secretions.
D.
Determine if pain is causing the client's tachypnea. - CORRECT ANSWER-
D
2024–2025 100 PRACTICE QUESTIONS
AND CORRECT ANSWERS WITH DETAILED
RATIONALES NURSING FUNDAMENTALS
STUDY GUIDE A+ EXAM PREPARATION
"We often go and play beach volleyball when it is nice out." - CORRECT
ANSWER-A, D
Rationale: Sexual exploration is not uncommon as a teen. However,
pregnancy can occur with ejaculation on the perineal area. Accidents are
the leading cause of death in the teen years and seatbelt use must be
encouraged at all times. The remaining statements demonstrate normal
growth and development for the teen years.
By rolling contaminated gloves inside-out, the nurse is affecting which step
in the chain of infection?
A.
Mode of transmission
B.
Portal of entry
C.
Reservoir
D.
Portal of exit - CORRECT ANSWER-A
,Rationale: The contaminated gloves serve as the mode of transmission from
the portal of exit of the reservoir to a portal of entry.
The health care provider diagnoses metastatic cancer and recommends a
gastrostomy for an elderly client in stable condition. The client's adult child
is concerned and states to the nurse, "I don't think my parent 'can handle'
the cancer diagnosis." What information will guide the nurse's response?
A.
The family can provide the consent required in this situation because the
older adult is in no condition to make such decisions.
B.
Because the client is mentally incompetent, the adult child has the right to
waive informed consent for the parent.
C.
The court will allow the health care provider to make the decision to
withhold informed consent under therapeutic privilege.
D.
If informed consent is withheld from a client, health care providers could
be found guilty of negligence. - CORRECT ANSWER-D
Rationale: Health care providers may be found guilty of negligence,
specifically assault and battery, if they carry out a treatment without the
client's consent. The client's condition is stable, so option A is not a valid
rationale. Advanced age does not automatically authorize the son to make
all decisions for his mother, and there is no evidence that the client is
mentally incompetent. Although option C may have been upheld in the
past, when paternalistic medical practice was common, today's courts are
unlikely to accept it.
,After a needle stick occurs while removing the cap from a sterile needle,
which action should the nurse take next?
A.
Complete an incident report.
B.
Select another sterile needle.
C.
Disinfect the needle with an alcohol swab.
D.
Notify the supervisor of the department immediately. - CORRECT
ANSWER-B
Rationale: After a needle stick, the needle is considered used, so the nurse
should discard it and select another needle. Because the needle was sterile
when the nurse was stuck and the needle was not in contact with any other
person's body fluids, the nurse does not need to complete an incident
report or notify the occupational health nurse. Disinfecting a needle with an
alcohol swab is not in accordance with standards for safe practice and
infection control.
An 89-year-old client is admitted to the rehabilitation unit after a hip
fracture. When reviewing the client's pre-fracture routine the client states,
"I usually get up around 0800 and have breakfast by 0900; I say my daily
prayers between 1000 and 1030. I like lunch around 1300; then a nap from
1400 to 1600. I generally eat supper around 1900." What is the nurse's best
response to the client's schedule?
A.
"We can try our best to work around your schedule."
B.
, "Your physical therapy is scheduled for 1500 to 1600."
C.
"You will have to get your own supper if you want to eat that late."
D.
"Is there any way you could say your prayers between 1230 and 1300?" -
CORRECT ANSWER-D
Rationale:The elderly have a routine that generally fits around their sleep-
wake cycle, or their circadian rhythm. The flexibility is around prayer time,
since it is during the wake time. If the rehabilitation therapy can be
scheduled in the am, that is generally the time when they have more energy.
Trying the best, does not place the client's sleep-wake schedule as a
priority. While supper on the rehab unit may be before 1900, arrangements
can be made to deliver a tray later, or keep a tray warm
The nurse determines that a postoperative client's respiratory rate has
increased from 18 to 24 breaths/min. Based on this assessment finding,
what is the priority nursing action?
A.
Encourage the client to increase ambulation in the room.
B.
Offer the client a high-carbohydrate snack for energy.
C.
Force fluids to thin the client's pulmonary secretions.
D.
Determine if pain is causing the client's tachypnea. - CORRECT ANSWER-
D
