HESI RN FUNDAMENTALS EXIT EXAM LATEST
2024-2025 ACTUAL EXAM 100 QUESTIONS
AND CORRECT ANSWERS WITH RATIOANLES
The nurse is preparing to initiate parenteral nutrition (PN) for a client. What actions will the
nurse consider when administering PN? (Select all that apply.)
A.
Remove the PN from the refrigerator 30 minutes before infusing.
B.
Have a second nurse double check the PN before connecting the solution.
C.
Have a second IV line in place for administering IV medications.
D.
Assure the infusion time for the PN does not exceed 24 hours.
E.
Tell the client a feeling of being full should occur with PN.
F.
Return amber and cloudy solutions of PN to the pharmacy. - ANSWER -A, D, F
Rationale: There are no issues with antibody incompatibility with PN, so there is no need to
double check the PN, or start a second IV line. PN is administered through the venous system
and does not satiate the client. The remaining selections are true about the administration of
PN.
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,The nurse is preparing to insert an IV, and cap off the IV with an intermittent infusion devise for
an 80-year-old who is prescribed IV antibiotics every 8 hours. The client is taking po fluids well.
What supplies will the nurse take into the room for this procedure? (Select all that apply.)
A.
A 16 gauge IV catheter
B.
Normal saline in a 10 mL syringe
C.
Clear plastic sterile bandage
D.
Skin preparation antiseptic swab
E.
1000 mL bag of normal saline - ANSWER -B, C, D
Rationale: Items not needed to insert an IV for intermittent antibiotic therapy for an 80-year-old
are a 16 gauge intracath; the intracath is too large. Large bore intracaths are for rapid infusions.
A small bag of NS, e.g. 250 mL, will be needed to flush the line. The remaining items are needed
to start an IV.
The nurse is instructing a client with cholecystitis regarding diet choices. Which meal best meets
the dietary needs of this client?
A.
Steak, baked beans, and a salad
B.
Broiled fish, green beans, and an apple
C.
Pork chops, macaroni and cheese, and grapes
D.
Avocado salad, milk, and angel food cake - ANSWER -B
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,Rationale: Clients with cholecystitis (inflammation of the gallbladder) should follow a low-fat
diet, such as option B. Option A is a high-protein diet, and options C and D contain high-fat
foods, which are contraindicated for this client.
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?
A.
"Take a vitamin supplement tablet once a day."
B.
"Change positions in the chair frequently"
C.
"Increase daily intake of water or other oral fluids."
D.
"Purchase a newer model wheelchair." - ANSWER -B
Rationale: The most important teaching is to change positions frequently because pressure is
the most significant factor related to the development of pressure ulcers. Increased vitamin and
fluid intake may also be beneficial and promote healing and reduce further risk. Option D is an
intervention of last resort because this will be very expensive for the client.
Which nonverbal action should the nurse implement to demonstrate active listening?
A.
Sit facing the client.
B.
Cross arms and legs.
C.
Avoid eye contact.
D.
Lean back in the chair. - ANSWER -A
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, 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, 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, not
option B, and leaning toward the client, not option D. To communicate involvement and
willingness to listen to the client, eye contact should be established and maintained.
The nurse is assisting a client to the bathroom. When the client is 5 feet from the bathroom
door, he states, "I feel faint." Before the nurse can get the client to a chair, the client starts to
fall. Which is the priority action for the nurse to take?
A.
Check the client's carotid pulse.
B.
Encourage the client to get to the toilet.
C.
In a loud voice, call for help.
D.
Gently lower the client to the floor. - ANSWER -D
Rationale: Option D is the most prudent intervention and is the priority nursing action to
prevent injury to the client and the nurse. Lowering the client to the floor should be done when
the client cannot support his own weight. The client should be placed in a bed or chair only
when sufficient help is available to prevent injury. Option A is important but should be done
after the client is in a safe position. Because the client is not supporting himself, option B is
impractical. Option C is likely to cause chaos on the unit and might alarm the other clients.
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.
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2024-2025 ACTUAL EXAM 100 QUESTIONS
AND CORRECT ANSWERS WITH RATIOANLES
The nurse is preparing to initiate parenteral nutrition (PN) for a client. What actions will the
nurse consider when administering PN? (Select all that apply.)
A.
Remove the PN from the refrigerator 30 minutes before infusing.
B.
Have a second nurse double check the PN before connecting the solution.
C.
Have a second IV line in place for administering IV medications.
D.
Assure the infusion time for the PN does not exceed 24 hours.
E.
Tell the client a feeling of being full should occur with PN.
F.
Return amber and cloudy solutions of PN to the pharmacy. - ANSWER -A, D, F
Rationale: There are no issues with antibody incompatibility with PN, so there is no need to
double check the PN, or start a second IV line. PN is administered through the venous system
and does not satiate the client. The remaining selections are true about the administration of
PN.
1|Page
,The nurse is preparing to insert an IV, and cap off the IV with an intermittent infusion devise for
an 80-year-old who is prescribed IV antibiotics every 8 hours. The client is taking po fluids well.
What supplies will the nurse take into the room for this procedure? (Select all that apply.)
A.
A 16 gauge IV catheter
B.
Normal saline in a 10 mL syringe
C.
Clear plastic sterile bandage
D.
Skin preparation antiseptic swab
E.
1000 mL bag of normal saline - ANSWER -B, C, D
Rationale: Items not needed to insert an IV for intermittent antibiotic therapy for an 80-year-old
are a 16 gauge intracath; the intracath is too large. Large bore intracaths are for rapid infusions.
A small bag of NS, e.g. 250 mL, will be needed to flush the line. The remaining items are needed
to start an IV.
The nurse is instructing a client with cholecystitis regarding diet choices. Which meal best meets
the dietary needs of this client?
A.
Steak, baked beans, and a salad
B.
Broiled fish, green beans, and an apple
C.
Pork chops, macaroni and cheese, and grapes
D.
Avocado salad, milk, and angel food cake - ANSWER -B
2|Page
,Rationale: Clients with cholecystitis (inflammation of the gallbladder) should follow a low-fat
diet, such as option B. Option A is a high-protein diet, and options C and D contain high-fat
foods, which are contraindicated for this client.
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?
A.
"Take a vitamin supplement tablet once a day."
B.
"Change positions in the chair frequently"
C.
"Increase daily intake of water or other oral fluids."
D.
"Purchase a newer model wheelchair." - ANSWER -B
Rationale: The most important teaching is to change positions frequently because pressure is
the most significant factor related to the development of pressure ulcers. Increased vitamin and
fluid intake may also be beneficial and promote healing and reduce further risk. Option D is an
intervention of last resort because this will be very expensive for the client.
Which nonverbal action should the nurse implement to demonstrate active listening?
A.
Sit facing the client.
B.
Cross arms and legs.
C.
Avoid eye contact.
D.
Lean back in the chair. - ANSWER -A
3|Page
, 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, 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, not
option B, and leaning toward the client, not option D. To communicate involvement and
willingness to listen to the client, eye contact should be established and maintained.
The nurse is assisting a client to the bathroom. When the client is 5 feet from the bathroom
door, he states, "I feel faint." Before the nurse can get the client to a chair, the client starts to
fall. Which is the priority action for the nurse to take?
A.
Check the client's carotid pulse.
B.
Encourage the client to get to the toilet.
C.
In a loud voice, call for help.
D.
Gently lower the client to the floor. - ANSWER -D
Rationale: Option D is the most prudent intervention and is the priority nursing action to
prevent injury to the client and the nurse. Lowering the client to the floor should be done when
the client cannot support his own weight. The client should be placed in a bed or chair only
when sufficient help is available to prevent injury. Option A is important but should be done
after the client is in a safe position. Because the client is not supporting himself, option B is
impractical. Option C is likely to cause chaos on the unit and might alarm the other clients.
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.
4|Page
