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HESI RN FUNDAMENTALS EXIT EXAM
QUESTIONS AND VERIFIED ANSWERS
WITH RATIONALES
The nurse is preparing to administer 10 mL of liquid potassium chloride through a
feeding tube, followed by 10 mL of liquid acetaminophen. Which action should
the nurse include in this procedure?
A.
Dilute each of the medications with sterile water prior to administration.
B.
Mix the medications in one syringe before opening the feeding tube.
C.
Administer water between the doses of the two liquid medications.
D.
Withdraw any fluid from the tube before instilling each medication. - correct-
answer - C
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Rationale: Water should be instilled into the feeding tube between administering
the two medications to maintain the patency of the feeding tube and ensure that
the total dose of medication enters the stomach and does not remain in the tube.
These liquid medications do not need to be diluted when administered via a
feeding tube and should be administered separately, with water instilled between
each medication.
The nurse is making an initial daily assessment at 0715 and notes 550 mL of LR
running at 75 mL an hour. At what time, in military time, will the nurse hang the
next bag of IV fluid? _____. - correct-answer - 1435
60 min × 0.33333 = 19.99 min = 20 min7 hr 20 min + 0715 = 1435
The nurse is teaching a group of young adults with families about preparing their
underground shelter in the event of a tornado. What instructions will the nurse
include in teaching plan for these families? (Select all that apply.)
A.
Place two electric lights in the shelter.
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B.
Plan for 1 gallon of water per family member for at least 3 days.
C.
Don't forget a can opener with the supply of canned food.
D.
Make sure you include a first aid kit in the shelter.
E.
Pack shoes with sturdy soles and they must completely cover the feet. - correct-
answer - B, C, D, E
Rationale: The lights need to be battery powered and not rely on electricity. The
remaining items are necessary emergency supplies.
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.
Document that the client responds to painful stimulus.
B.
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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. - correct-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.
HESI RN FUNDAMENTALS EXIT EXAM
QUESTIONS AND VERIFIED ANSWERS
WITH RATIONALES
The nurse is preparing to administer 10 mL of liquid potassium chloride through a
feeding tube, followed by 10 mL of liquid acetaminophen. Which action should
the nurse include in this procedure?
A.
Dilute each of the medications with sterile water prior to administration.
B.
Mix the medications in one syringe before opening the feeding tube.
C.
Administer water between the doses of the two liquid medications.
D.
Withdraw any fluid from the tube before instilling each medication. - correct-
answer - C
, 2
Rationale: Water should be instilled into the feeding tube between administering
the two medications to maintain the patency of the feeding tube and ensure that
the total dose of medication enters the stomach and does not remain in the tube.
These liquid medications do not need to be diluted when administered via a
feeding tube and should be administered separately, with water instilled between
each medication.
The nurse is making an initial daily assessment at 0715 and notes 550 mL of LR
running at 75 mL an hour. At what time, in military time, will the nurse hang the
next bag of IV fluid? _____. - correct-answer - 1435
60 min × 0.33333 = 19.99 min = 20 min7 hr 20 min + 0715 = 1435
The nurse is teaching a group of young adults with families about preparing their
underground shelter in the event of a tornado. What instructions will the nurse
include in teaching plan for these families? (Select all that apply.)
A.
Place two electric lights in the shelter.
, 3
B.
Plan for 1 gallon of water per family member for at least 3 days.
C.
Don't forget a can opener with the supply of canned food.
D.
Make sure you include a first aid kit in the shelter.
E.
Pack shoes with sturdy soles and they must completely cover the feet. - correct-
answer - B, C, D, E
Rationale: The lights need to be battery powered and not rely on electricity. The
remaining items are necessary emergency supplies.
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.
Document that the client responds to painful stimulus.
B.
, 4
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. - correct-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.
