HESI NCLEX-RN FUNDAMENTALS NEWEST EXAM
2024 -2025 TEST BANK COMPLETE 200+ ACTUAL
EXAM QUESTIONS WITH CORRECT DETAILED
ANSWERS (VERIFIED ANSWERS) AGRADE ASSURED!!
The nurse assesses a 2-year-old who is admitted for dehydration and finds
the peripheral IV rate by gravity has slowed even though the venous
access site is healthy. What should the nurse do next? - Answer –
✓ Check for kinks in the tubing and raise the IV pole.
Rationale:
The nurse should first check the tubing and height of the bag on the IV pole
(B), 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
Which serum laboratory value should the nurse monitor carefully for a client
who has a nasogastric (NG) tube to suction for the past week? - Answer –
✓ Sodium
Rationale:
Monitoring of serum sodium levels (D) for hyponatremia is indicated during
prolonged NG suctioning.
pg. 1
,A client's blood pressure reading is 156/94. What action should the nurse
take first? - Answer –
✓ Compare the current reading with the client's previously documented
blood pressure readings.
Rationale:
Comparing this reading with previous readings (D) will provide information
about what is normal for this client: this action should be taken first.
The healthcare provider has changed a client's prescription from the PO to
IV route of administration. The nurse should anticipate which change in the
pharmacokinetic properties of the medication? - Answer –
✓ The onset of action of the drug will occur more rapidly, resulting in a
more rapid effect.
Rationale:
Because the absorptive process is eliminated when medications are
administered via the IV route, the onset of action is more rapid, resulting in
a more immediate effect
A 65-year-old client who attends an adult daycare program and is
wheelchair-mobile has redness in the sacral area. Which instruction is most
important for the nurse to provide? - Answer –
✓ Change positions in the chair at least every hour.
Rationale:
The most important teaching is to change positions frequently (B), since
pressure is the most significant factor related to the development of
pressure ulcers.
After receiving written and verbal instructions from a clinic nurse about a
newly prescribed medication, a male client asks the nurse what he should
pg. 2
,do if he has questions about the medication when he gets home. How
should the nurse respond? - Answer –
✓ Encourage the client to call the clinic nurse or healthcare provider if
any questions should arise.
Rationale:
To ensure safe medication use, the nurse should encourage the client to
call the nurse or healthcare provider (D) if any questions should arise.
Which nonverbal action should the nurse implement to demonstrate active
listening? - Answer –
✓ Sit facing the client.
Rationale:
Active listening is conveyed using attentive verbal and nonverbal
communication techniques. To facilitate therapeutic communication and
attentiveness, the nurse should sit facing the client (A), which lets the client
know that the nurse is there to listen. Active listening skills include postures
that are open to the client, such as keeping the arms open and relaxed,
The nurse is reviewing a client's lab results from 2 hours ago. The
sodium level is 128 mEq/L. The nurse should be alert for which findings?
(Select all that apply.)
A. Weakness in the hands and feet
B. +1 reflexes to the patella
C. Headache
D. Muscle twitching
E. Nausea
F. Facial redness - Correct Answer - A, B, C, E
pg. 3
, Rationale:
The client is hyponatremic. All are signs of hyponatremia except muscle
twitching and facial redness.
A community hospital is opening a mental health services department.
Which document should the nurse use to develop the unit's nursing
guidelines? - Answer –
✓ The ANA's Scope and Standards of Nursing Practice
Rationale:
The ANA Scope of Standards of Practice for Psychiatric-Mental Health
Nursing (C) serves to direct the philosophy and standards of psychiatric
nursing practice.
When administering an intramuscular injection, which factor is most
important to ensure the best medication absorption? - Answer –
✓ Inject the needle at a 90-degree angle.
Rationale:
Injecting the needle at a 90-degree angle allows the medication to be
injected into the muscle, so that appropriate absorption can occur
Based on the nursing diagnosis of Risk for infection, which intervention is
best for the nurse to implement when providing care for an elderly
incontinent client? - Answer –
✓ Maintain standard precautions.
Rationale:
The best action to decrease the risk of infection in vulnerable clients is
handwashing
pg. 4
2024 -2025 TEST BANK COMPLETE 200+ ACTUAL
EXAM QUESTIONS WITH CORRECT DETAILED
ANSWERS (VERIFIED ANSWERS) AGRADE ASSURED!!
The nurse assesses a 2-year-old who is admitted for dehydration and finds
the peripheral IV rate by gravity has slowed even though the venous
access site is healthy. What should the nurse do next? - Answer –
✓ Check for kinks in the tubing and raise the IV pole.
Rationale:
The nurse should first check the tubing and height of the bag on the IV pole
(B), 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
Which serum laboratory value should the nurse monitor carefully for a client
who has a nasogastric (NG) tube to suction for the past week? - Answer –
✓ Sodium
Rationale:
Monitoring of serum sodium levels (D) for hyponatremia is indicated during
prolonged NG suctioning.
pg. 1
,A client's blood pressure reading is 156/94. What action should the nurse
take first? - Answer –
✓ Compare the current reading with the client's previously documented
blood pressure readings.
Rationale:
Comparing this reading with previous readings (D) will provide information
about what is normal for this client: this action should be taken first.
The healthcare provider has changed a client's prescription from the PO to
IV route of administration. The nurse should anticipate which change in the
pharmacokinetic properties of the medication? - Answer –
✓ The onset of action of the drug will occur more rapidly, resulting in a
more rapid effect.
Rationale:
Because the absorptive process is eliminated when medications are
administered via the IV route, the onset of action is more rapid, resulting in
a more immediate effect
A 65-year-old client who attends an adult daycare program and is
wheelchair-mobile has redness in the sacral area. Which instruction is most
important for the nurse to provide? - Answer –
✓ Change positions in the chair at least every hour.
Rationale:
The most important teaching is to change positions frequently (B), since
pressure is the most significant factor related to the development of
pressure ulcers.
After receiving written and verbal instructions from a clinic nurse about a
newly prescribed medication, a male client asks the nurse what he should
pg. 2
,do if he has questions about the medication when he gets home. How
should the nurse respond? - Answer –
✓ Encourage the client to call the clinic nurse or healthcare provider if
any questions should arise.
Rationale:
To ensure safe medication use, the nurse should encourage the client to
call the nurse or healthcare provider (D) if any questions should arise.
Which nonverbal action should the nurse implement to demonstrate active
listening? - Answer –
✓ Sit facing the client.
Rationale:
Active listening is conveyed using attentive verbal and nonverbal
communication techniques. To facilitate therapeutic communication and
attentiveness, the nurse should sit facing the client (A), which lets the client
know that the nurse is there to listen. Active listening skills include postures
that are open to the client, such as keeping the arms open and relaxed,
The nurse is reviewing a client's lab results from 2 hours ago. The
sodium level is 128 mEq/L. The nurse should be alert for which findings?
(Select all that apply.)
A. Weakness in the hands and feet
B. +1 reflexes to the patella
C. Headache
D. Muscle twitching
E. Nausea
F. Facial redness - Correct Answer - A, B, C, E
pg. 3
, Rationale:
The client is hyponatremic. All are signs of hyponatremia except muscle
twitching and facial redness.
A community hospital is opening a mental health services department.
Which document should the nurse use to develop the unit's nursing
guidelines? - Answer –
✓ The ANA's Scope and Standards of Nursing Practice
Rationale:
The ANA Scope of Standards of Practice for Psychiatric-Mental Health
Nursing (C) serves to direct the philosophy and standards of psychiatric
nursing practice.
When administering an intramuscular injection, which factor is most
important to ensure the best medication absorption? - Answer –
✓ Inject the needle at a 90-degree angle.
Rationale:
Injecting the needle at a 90-degree angle allows the medication to be
injected into the muscle, so that appropriate absorption can occur
Based on the nursing diagnosis of Risk for infection, which intervention is
best for the nurse to implement when providing care for an elderly
incontinent client? - Answer –
✓ Maintain standard precautions.
Rationale:
The best action to decrease the risk of infection in vulnerable clients is
handwashing
pg. 4
