RN Fundamentals HESI Latest Exam 4 Prep Test Bank Review - 250 Most Recently Tested Questions and Correct Answers with Rationales/ Fundamentals of Nursing Hesi Exam Prep (Newest!)

RN Fundamentals HESI Latest Exam
RN Fundamentals HESI Latest Exam 4 Prep
Test Bank Review - 250 Most Recently Tested
Questions and Correct Answers with
Rationales/ Fundamentals of Nursing Hesi
Exam Prep (Newest!)




The nurse identifies a potential for infection in a client with partial-thickness (second-degree) and full-
thickness (third-degree) burns. What action has the highest priority in decreasing the client's risk of
infection?
A.
Administration of plasma expanders
B.
Use of careful handwashing technique
C.
Application of a topical antibacterial cream
D.
Limiting visitors to the client with burns


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B
Rationale: Careful handwashing technique is the single most effective intervention for the prevention
of contamination to all clients. Option A reverses the hypovolemia that initially accompanies burn
trauma but is not related to decreasing the proliferation of infective organisms. Options C and D are
recommended by various burn centers as possible ways to reduce the chance of infection. Option B is
a proven technique to prevent infection.




The nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate
by gravity has slowed, even though the venous access site is healthy. What should the nurse do next?
A.
Apply a warm compress proximal to the site.
B.
Check for kinks in the tubing and raise the IV pole.
C.
Adjust the tape that stabilizes the needle.
D.
Flush with normal saline and recount the drop rate.




B
Rationale: The nurse should first check the tubing and height of the bag on the IV pole, 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, but the nurse should first adjust the IV pole height. The nurse may need to adjust the
stabilizing tape on a positional needle or flush the venous access with normal saline, but less invasive
actions should be implemented first.

.

Ten minutes after signing an operative permit for a fractured hip, an older client states, "The aliens will
be coming to get me soon!" and falls asleep. Which action should the nurse take next?
A.
Make the client comfortable and allow the client to sleep.
B.
Assess the client's neurologic status.
C.
Notify the surgeon about the comment.
D.
Ask the client's family to co-sign the operative permit.


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B
Rationale: This statement may indicate that the client is confused. Informed consent must be
provided by a mentally competent individual, so the nurse should further assess the client's neurologic
status to be sure that the client understands and can legally provide consent for surgery. Option A
does not provide sufficient follow-up. If the nurse determines that the client is confused, the surgeon
must be notified and permission obtained from the next of kin.




When turning an immobile bedridden client without assistance, which action by the nurse best
ensures client safety?
A.
Securely grasp the client's arm and leg.
B.
Put bed rails up on the side of bed opposite from the nurse.
C.
Correctly position and use a turn sheet.
D.
Lower the head of the client's bed slowly.




B
Rationale: Because the nurse can only stand on one side of the bed, bed rails should be up on the
opposite side to ensure that the client does not fall out of bed. Option A can cause client injury to the
skin or joint. Options C and D are useful techniques while turning a client but have less priority in terms
of safety than use of the bed rails.




A community hospital is opening a mental health services department. Which document should the
nurse use to develop the unit's nursing guidelines?
A.
Americans with Disabilities Act of 1990
B.
ANA Code of Ethics with Interpretative Statements
C.
ANA's Scope and Standards of Nursing Practice
D.
Patient's Bill of Rights of 1990



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C
Rationale: The ANA Scope of Standards of Practice for Psychiatric-Mental Health Nursing serves to
direct the philosophy and standards of psychiatric nursing practice. Options A and D define the client's
rights. Option B provides ethical guidelines for nursing.




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.




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.




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.
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