HESI RN Fundamentals Real Exam Insight
2024-25 Graded A + Complete 3 Version
Exam Each 100 Multiple Choice
QUESTIONS WITH ANSWERS
The nurse is obtaining a lie-sit-stand blood pressure reading on a client. Which
action is most important for the nurse to implement?
A. Stay with the client while the client is standing.
B. Record the findings on the graphic sheet in the chart.
C. Keep the blood pressure cuff on the same arm.
D. Record changes in the client's pulse rate.
A
Rationale: Although all these measures are important, option A is most important
because it helps ensure client safety. Option B is necessary but does not have the
priority of option A. Options C and D are important measures to ensure accuracy
of the recording but are of less importance than providing client safety.
A client becomes angry while waiting for a supervised break to smoke a cigarette
outside and states, "I want to go outside now and smoke. It takes forever to get
anything done here!" Which intervention is best for the nurse to implement?
A. Encourage the client to use a nicotine patch.
,B. Reassure the client that it is almost time for another break.
C. Have the client leave the unit with another staff member.
D. Review the schedule of outdoor breaks with the client.
D
Rationale: The best nursing action is to review the schedule of outdoor breaks and
provide concrete information about the schedule. Option A is contraindicated if
the client wants to continue smoking. Option B is insufficient to encourage a
trusting relationship with the client. Option C is preferential for this client only
and is inconsistent with unit rules.
Which serum laboratory value should the nurse monitor carefully for a client who
has a nasogastric (NG) tube to suction for the past week?
A. White blood cell count
B. Albumin
C. Calcium
D. Sodium
D
Rationale: Monitoring serum sodium levels for hyponatremia is indicated during
prolonged NG suctioning because of loss of fluids. Changes in levels of option A, B,
or C are not typically associated with prolonged NG suctioning.
,A female client with frequent urinary tract infections (UTIs) asks the nurse to
explain her friend's advice about drinking a glass of juice daily to prevent future
UTIs. Which response is best for the nurse to provide?
A. Orange juice has vitamin C that deters bacterial growth.
B. Apple juice is the most useful in acidifying the urine.
C. Cranberry juice stops pathogens' adherence to the bladder.
D. Grapefruit juice increases absorption of most antibiotics.
C
Rationale: Cranberry juice maintains urinary tract health by reducing the
adherence of Escherichia coli bacteria to cells within the bladder. Options A, B,
and D have not been shown to be as effective as cranberry juice in preventing
UTIs.
The nurse is counting a client's respiratory rate. During a 30-second interval, the
nurse counts six respirations and the client coughs three times. In repeating the
count for a second 30-second interval, the nurse counts eight respirations. Which
respiratory rate should the nurse document?
A. 14
B. 16
C. 17
D. 28
B
, Rationale: The most accurate respiratory rate is the second count obtained by the
nurse, which was not interrupted by coughing. Because it was counted for 30
seconds, the rate should be doubled. Options A, C, and D are inaccurate
recordings.
The nurse is teaching an obese client, newly diagnosed with arteriosclerosis,
about reducing the risk of a heart attack or stroke. Which health promotion
brochure is most important for the nurse to provide to this client?
A. "Monitoring Your Blood Pressure at Home"
B. "Smoking Cessation as a Lifelong Commitment"
C. "Decreasing Cholesterol Levels Through Diet"
D. "Stress Management for a Healthier You"
C
Rationale: A health promotion brochure about decreasing cholesterol is most
important to provide this client, because the most significant risk factor
contributing to development of arteriosclerosis is excess dietary fat, particularly
saturated fat and cholesterol. Option A does not address the underlying causes of
arteriosclerosis. Options B and D are also important factors for reversing
arteriosclerosis but are not as important as lowering cholesterol.
The nurse finds a client crying behind a locked bathroom door. The client will not
open the door. Which action should the nurse implement first?
2024-25 Graded A + Complete 3 Version
Exam Each 100 Multiple Choice
QUESTIONS WITH ANSWERS
The nurse is obtaining a lie-sit-stand blood pressure reading on a client. Which
action is most important for the nurse to implement?
A. Stay with the client while the client is standing.
B. Record the findings on the graphic sheet in the chart.
C. Keep the blood pressure cuff on the same arm.
D. Record changes in the client's pulse rate.
A
Rationale: Although all these measures are important, option A is most important
because it helps ensure client safety. Option B is necessary but does not have the
priority of option A. Options C and D are important measures to ensure accuracy
of the recording but are of less importance than providing client safety.
A client becomes angry while waiting for a supervised break to smoke a cigarette
outside and states, "I want to go outside now and smoke. It takes forever to get
anything done here!" Which intervention is best for the nurse to implement?
A. Encourage the client to use a nicotine patch.
,B. Reassure the client that it is almost time for another break.
C. Have the client leave the unit with another staff member.
D. Review the schedule of outdoor breaks with the client.
D
Rationale: The best nursing action is to review the schedule of outdoor breaks and
provide concrete information about the schedule. Option A is contraindicated if
the client wants to continue smoking. Option B is insufficient to encourage a
trusting relationship with the client. Option C is preferential for this client only
and is inconsistent with unit rules.
Which serum laboratory value should the nurse monitor carefully for a client who
has a nasogastric (NG) tube to suction for the past week?
A. White blood cell count
B. Albumin
C. Calcium
D. Sodium
D
Rationale: Monitoring serum sodium levels for hyponatremia is indicated during
prolonged NG suctioning because of loss of fluids. Changes in levels of option A, B,
or C are not typically associated with prolonged NG suctioning.
,A female client with frequent urinary tract infections (UTIs) asks the nurse to
explain her friend's advice about drinking a glass of juice daily to prevent future
UTIs. Which response is best for the nurse to provide?
A. Orange juice has vitamin C that deters bacterial growth.
B. Apple juice is the most useful in acidifying the urine.
C. Cranberry juice stops pathogens' adherence to the bladder.
D. Grapefruit juice increases absorption of most antibiotics.
C
Rationale: Cranberry juice maintains urinary tract health by reducing the
adherence of Escherichia coli bacteria to cells within the bladder. Options A, B,
and D have not been shown to be as effective as cranberry juice in preventing
UTIs.
The nurse is counting a client's respiratory rate. During a 30-second interval, the
nurse counts six respirations and the client coughs three times. In repeating the
count for a second 30-second interval, the nurse counts eight respirations. Which
respiratory rate should the nurse document?
A. 14
B. 16
C. 17
D. 28
B
, Rationale: The most accurate respiratory rate is the second count obtained by the
nurse, which was not interrupted by coughing. Because it was counted for 30
seconds, the rate should be doubled. Options A, C, and D are inaccurate
recordings.
The nurse is teaching an obese client, newly diagnosed with arteriosclerosis,
about reducing the risk of a heart attack or stroke. Which health promotion
brochure is most important for the nurse to provide to this client?
A. "Monitoring Your Blood Pressure at Home"
B. "Smoking Cessation as a Lifelong Commitment"
C. "Decreasing Cholesterol Levels Through Diet"
D. "Stress Management for a Healthier You"
C
Rationale: A health promotion brochure about decreasing cholesterol is most
important to provide this client, because the most significant risk factor
contributing to development of arteriosclerosis is excess dietary fat, particularly
saturated fat and cholesterol. Option A does not address the underlying causes of
arteriosclerosis. Options B and D are also important factors for reversing
arteriosclerosis but are not as important as lowering cholesterol.
The nurse finds a client crying behind a locked bathroom door. The client will not
open the door. Which action should the nurse implement first?
