HESI RN FUNDAMENTALS EXIT ACTUAL EXAM WITH CORRECT ANSWERS &
RATIONALES
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.
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.
Which uid will the nurse select to administer with the prescribed blood transfusion?
A.
5% Dextrose and water
B.
Normal saline
C.
Lactated Ringers solution
,D.
5% Dextrose and lactated ringers
Correct answer: B
Rationale: Normal saline solution is the only solution that is compatible with blood.
When assisting a client from the bed to a chair, which procedure is best for the nurse to
follow?
A.
Place the chair parallel to the bed, with its back toward the head of the bed and assist the
client in moving to the chair.
B.
With the nurse's feet spread apart and knees aligned with the client's knees, stand and
pivot the client into the chair.
C.
Assist the client to a standing position by gently lifting upward, underneath the axillae.
D.
Stand beside the client, place the client's arms around the nurse's neck, and gently move
the client to the chair.
Correct answer: B
Rationale: Option B describes the correct positioning of the nurse and aords the nurse a
wide base of support while stabilizing the client's knees when assisting to a standing
position. The chair should be placed at a 45-degree angle to the bed, with the back of the
chair toward the head of the bed. Clients should never be lifted under the axillae; this could
damage nerves and strain the nurse's back. The client should be instructed to use the arms
of the chair and should never place his or her arms around the nurse's neck; this places
undue stress on the nurse's neck and back and increases the risk for a fall.
The nurse is called to the waiting room of a pediatric clinic. The frantic mother states, "I
think my 4-month-old baby is choking!" What steps will the nurse take? (Select all that
apply.)
,A.
Compress the chest once between the nipples with two ngers.
B.
Note any obstruction or absence of breathing.
C.
Deliver ve backslaps between the shoulder blades.
D.
Place the infant over the nurse's arm.
E.
Perform a blind nger sweep.
Correct answer: B, C, D
Rationale: The ngers are placed at the same location on an infant as chest compressions
for CPR; however, the nurse must deliver ve chest thrusts, after the ve back slaps. Blind
sweeps are not used as this action may push the object deeper into the throat. The
remaining steps are correct.
How many mL will the nurse document on the client's intake and output record from the
items listed? _____ mL
1200 mL water
4 ounce container of gelatin
8 ounces of orange juice
355 mL can of soda1 cup of soup
Correct answer: Answer: 2155
Rationale: 1200 + 240 (8 oz) + 240 (1 cup) + 120 (4 oz) + 355 = 2155
The nurse observes a UAP taking a client's blood pressure in the lower extremity. Which
observation of this procedure requires the nurse to intervene with the UAP's approach?
, A.
The cu wraps around the girth of the leg.
B.
The UAP auscultates the popliteal pulse with the cu on the lower leg.
C.
The client is placed in a prone position.
D.
The systolic reading is 20 mm Hg higher than the blood pressure in the client's arm.
Correct answer: B
Rationale: When obtaining the blood pressure in the lower extremities, the popliteal pulse
is the site for auscultation when the blood pressure cu is applied around the thigh. The
nurse should intervene with the UAP who has applied the cu on the lower leg. Option A
ensures an accurate assessment, and option C provides the best access to the artery.
Systolic pressure in the popliteal artery is usually 10 to 40 mm Hg higher than in the
brachial artery.
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 diicult 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
Correct answer: D
RATIONALES
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.
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.
Which uid will the nurse select to administer with the prescribed blood transfusion?
A.
5% Dextrose and water
B.
Normal saline
C.
Lactated Ringers solution
,D.
5% Dextrose and lactated ringers
Correct answer: B
Rationale: Normal saline solution is the only solution that is compatible with blood.
When assisting a client from the bed to a chair, which procedure is best for the nurse to
follow?
A.
Place the chair parallel to the bed, with its back toward the head of the bed and assist the
client in moving to the chair.
B.
With the nurse's feet spread apart and knees aligned with the client's knees, stand and
pivot the client into the chair.
C.
Assist the client to a standing position by gently lifting upward, underneath the axillae.
D.
Stand beside the client, place the client's arms around the nurse's neck, and gently move
the client to the chair.
Correct answer: B
Rationale: Option B describes the correct positioning of the nurse and aords the nurse a
wide base of support while stabilizing the client's knees when assisting to a standing
position. The chair should be placed at a 45-degree angle to the bed, with the back of the
chair toward the head of the bed. Clients should never be lifted under the axillae; this could
damage nerves and strain the nurse's back. The client should be instructed to use the arms
of the chair and should never place his or her arms around the nurse's neck; this places
undue stress on the nurse's neck and back and increases the risk for a fall.
The nurse is called to the waiting room of a pediatric clinic. The frantic mother states, "I
think my 4-month-old baby is choking!" What steps will the nurse take? (Select all that
apply.)
,A.
Compress the chest once between the nipples with two ngers.
B.
Note any obstruction or absence of breathing.
C.
Deliver ve backslaps between the shoulder blades.
D.
Place the infant over the nurse's arm.
E.
Perform a blind nger sweep.
Correct answer: B, C, D
Rationale: The ngers are placed at the same location on an infant as chest compressions
for CPR; however, the nurse must deliver ve chest thrusts, after the ve back slaps. Blind
sweeps are not used as this action may push the object deeper into the throat. The
remaining steps are correct.
How many mL will the nurse document on the client's intake and output record from the
items listed? _____ mL
1200 mL water
4 ounce container of gelatin
8 ounces of orange juice
355 mL can of soda1 cup of soup
Correct answer: Answer: 2155
Rationale: 1200 + 240 (8 oz) + 240 (1 cup) + 120 (4 oz) + 355 = 2155
The nurse observes a UAP taking a client's blood pressure in the lower extremity. Which
observation of this procedure requires the nurse to intervene with the UAP's approach?
, A.
The cu wraps around the girth of the leg.
B.
The UAP auscultates the popliteal pulse with the cu on the lower leg.
C.
The client is placed in a prone position.
D.
The systolic reading is 20 mm Hg higher than the blood pressure in the client's arm.
Correct answer: B
Rationale: When obtaining the blood pressure in the lower extremities, the popliteal pulse
is the site for auscultation when the blood pressure cu is applied around the thigh. The
nurse should intervene with the UAP who has applied the cu on the lower leg. Option A
ensures an accurate assessment, and option C provides the best access to the artery.
Systolic pressure in the popliteal artery is usually 10 to 40 mm Hg higher than in the
brachial artery.
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 diicult 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
Correct answer: D
