HESI RN Fundamentals Exit Exam Latest
Updates Actual Exam 100 Questions And
Correct Answers With Ratioanles (Verified
Answers)
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. - ANSWER -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.
The nurse manager of a skilled nursing (chronic care) unit is instructing UAPs on
ways to prevent complications of immobility. Which action should be included in
this instruction?
A.
Perform range-of-motion exercises to prevent contractures.
B.
Decrease the client's fluid intake to prevent diarrhea.
C.
Massage the client's legs to reduce embolism occurrence.
D.
Turn the client from side to back every shift. - ANSWER -A
,Rationale: Performing range-of-motion exercises is beneficial in reducing
contractures around joints. Options B, C, and D are all potentially harmful
practices that place the immobile client at risk of complications.
The nurse administered 10 mg of diazepam to the preoperative client. What steps
will the nurse take next? (Select all that apply.)
A.
Place the client in the bed next to the nurse's station.
B.
Instruct the client not to get out of bed.
C.
Place the call bell within the client's reach.
D.
Place the side rails up, according to institutional policy.
E.
Assist the client to the bathroom - ANSWER -B, C, D
Rationale: Diazepam is a common preoperative medication. Close observation by
placing the client close to the nurse's station is not necessary. The medication has a
sedative effect and the client should not get out of bed, even with assistance. The
remaining selections are correct.
A terminally ill client tells the nurse, "I am so tired and in so much pain! Please
help me to die." Which is the best response for the nurse to provide?
A.
Administer the prescribed maximum dose of pain medication.
B.
Talk with the client about thoughts and feelings about death.
C.
Collaborate with the health care provider about initiating antidepressant therapy.
D.
Refer the client to the ethics committee of her local health care facility. -
ANSWER -B
Rationale: The nurse should first assess the client's feelings about death and
determine the extent to which this statement expresses the client's true feelings.
The client may need additional pain management, but further assessment is needed
before implementing option A. Options C and D are both premature interventions
and should not be implemented until further assessment is obtained.
A nurse stops at a motor vehicle collision site to render aid until the emergency
personnel arrive and applies pressure to a groin wound that is bleeding profusely.
,Later the client has to have the leg amputated and sues the nurse for malpractice.
Which statement reflects the likely outcome for the nurse?
A.
The Patient's Bill of Rights protects clients from malicious intents, so the nurse
could lose the case.
B.
The lawsuit may be settled out of court, but the nurse's license is likely to be
revoked.
C.
There will be no judgment against the nurse, whose actions are protected under the
Good Samaritan Act.
D.
The client will win because the four elements of negligence (duty, breach,
causation, and damages) can be proved. - ANSWER -C
Rationale: The Good Samaritan Act protects health care professionals who practice
in good faith and provide reasonable care from malpractice claims, regardless of
the client outcome. Although the Patient's Bill of Rights protects clients, this nurse
is protected by the Good Samaritan Act. The state Board of Nursing has no reason
to revoke a registered nurse's license unless there was evidence that actions taken
in the emergency were not done in good faith or that reasonable care was not
provided. All four elements of malpractice were not shown.
An older client who had abdominal surgery 3 days earlier was given a barbiturate
for sleep and is now requesting to go to the bathroom. What is the priority nursing
action for this client?
A.
Assist the client to walk to the bathroom and do not leave the client alone.
B.
Request that the UAP assist the client onto a bedpan.
C.
Ask if the client needs to have a bowel movement or void.
D.
Assess the client's bladder to determine if the client needs to urinate. - ANSWER -
A
Rationale: Barbiturates cause central nervous system (CNS) depression, and
individuals taking these medications are at greater risk for falls. The nurse should
assist the client to the bathroom. A bedpan is not necessary as long as safety is
ensured. Whether the client needs to void or have a bowel movement, option C is
irrelevant in terms of meeting this client's safety needs. There is no indication that
, this client cannot voice her or his needs, so assessment of the bladder is not
needed.
The nurse is planning care for a client with an indwelling urinary catheter. Which
nursing action has the highest priority?
A.
Assist the client with daily cleansing.
B.
Tell the client that incontinence happens with aging.
C.
Offer 200 mL of fluid every 2 hours while awake.
D.
Take the client's temperature every 4 hours. - ANSWER -D
Rationale: Indwelling urinary catheters are a major source of infection. Option A is
a problem that may develop from having an indwelling catheter. Option B may or
may not be true for the client. Option C is not affected by an indwelling catheter.
When bathing an uncircumcised boy older than 3 years, which action should the
nurse take?
A.
Remind the child to clean his genital area.
B.
Defer perineal care because of the child's age.
C.
Retract the foreskin gently to cleanse the penis.
D.
Ask the parents why the child is not circumcised. - ANSWER -C
Rationale: The foreskin (prepuce) of the penis should be gently retracted to cleanse
all areas that could harbor bacteria. The child's cognitive development may not be
at the level at which option A would be effective. Perineal care needs to be
provided daily regardless of the client's age. Option D is not indicated and may be
perceived as intrusive.
A nurse is assigned to care for a close friend in the hospital setting. Which action
should the nurse take first when given the assignment?
A.
Notify the friend that all medical information will be kept confidential.
B.
Explain the relationship to the charge nurse and ask for reassignment.
C.
Updates Actual Exam 100 Questions And
Correct Answers With Ratioanles (Verified
Answers)
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. - ANSWER -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.
The nurse manager of a skilled nursing (chronic care) unit is instructing UAPs on
ways to prevent complications of immobility. Which action should be included in
this instruction?
A.
Perform range-of-motion exercises to prevent contractures.
B.
Decrease the client's fluid intake to prevent diarrhea.
C.
Massage the client's legs to reduce embolism occurrence.
D.
Turn the client from side to back every shift. - ANSWER -A
,Rationale: Performing range-of-motion exercises is beneficial in reducing
contractures around joints. Options B, C, and D are all potentially harmful
practices that place the immobile client at risk of complications.
The nurse administered 10 mg of diazepam to the preoperative client. What steps
will the nurse take next? (Select all that apply.)
A.
Place the client in the bed next to the nurse's station.
B.
Instruct the client not to get out of bed.
C.
Place the call bell within the client's reach.
D.
Place the side rails up, according to institutional policy.
E.
Assist the client to the bathroom - ANSWER -B, C, D
Rationale: Diazepam is a common preoperative medication. Close observation by
placing the client close to the nurse's station is not necessary. The medication has a
sedative effect and the client should not get out of bed, even with assistance. The
remaining selections are correct.
A terminally ill client tells the nurse, "I am so tired and in so much pain! Please
help me to die." Which is the best response for the nurse to provide?
A.
Administer the prescribed maximum dose of pain medication.
B.
Talk with the client about thoughts and feelings about death.
C.
Collaborate with the health care provider about initiating antidepressant therapy.
D.
Refer the client to the ethics committee of her local health care facility. -
ANSWER -B
Rationale: The nurse should first assess the client's feelings about death and
determine the extent to which this statement expresses the client's true feelings.
The client may need additional pain management, but further assessment is needed
before implementing option A. Options C and D are both premature interventions
and should not be implemented until further assessment is obtained.
A nurse stops at a motor vehicle collision site to render aid until the emergency
personnel arrive and applies pressure to a groin wound that is bleeding profusely.
,Later the client has to have the leg amputated and sues the nurse for malpractice.
Which statement reflects the likely outcome for the nurse?
A.
The Patient's Bill of Rights protects clients from malicious intents, so the nurse
could lose the case.
B.
The lawsuit may be settled out of court, but the nurse's license is likely to be
revoked.
C.
There will be no judgment against the nurse, whose actions are protected under the
Good Samaritan Act.
D.
The client will win because the four elements of negligence (duty, breach,
causation, and damages) can be proved. - ANSWER -C
Rationale: The Good Samaritan Act protects health care professionals who practice
in good faith and provide reasonable care from malpractice claims, regardless of
the client outcome. Although the Patient's Bill of Rights protects clients, this nurse
is protected by the Good Samaritan Act. The state Board of Nursing has no reason
to revoke a registered nurse's license unless there was evidence that actions taken
in the emergency were not done in good faith or that reasonable care was not
provided. All four elements of malpractice were not shown.
An older client who had abdominal surgery 3 days earlier was given a barbiturate
for sleep and is now requesting to go to the bathroom. What is the priority nursing
action for this client?
A.
Assist the client to walk to the bathroom and do not leave the client alone.
B.
Request that the UAP assist the client onto a bedpan.
C.
Ask if the client needs to have a bowel movement or void.
D.
Assess the client's bladder to determine if the client needs to urinate. - ANSWER -
A
Rationale: Barbiturates cause central nervous system (CNS) depression, and
individuals taking these medications are at greater risk for falls. The nurse should
assist the client to the bathroom. A bedpan is not necessary as long as safety is
ensured. Whether the client needs to void or have a bowel movement, option C is
irrelevant in terms of meeting this client's safety needs. There is no indication that
, this client cannot voice her or his needs, so assessment of the bladder is not
needed.
The nurse is planning care for a client with an indwelling urinary catheter. Which
nursing action has the highest priority?
A.
Assist the client with daily cleansing.
B.
Tell the client that incontinence happens with aging.
C.
Offer 200 mL of fluid every 2 hours while awake.
D.
Take the client's temperature every 4 hours. - ANSWER -D
Rationale: Indwelling urinary catheters are a major source of infection. Option A is
a problem that may develop from having an indwelling catheter. Option B may or
may not be true for the client. Option C is not affected by an indwelling catheter.
When bathing an uncircumcised boy older than 3 years, which action should the
nurse take?
A.
Remind the child to clean his genital area.
B.
Defer perineal care because of the child's age.
C.
Retract the foreskin gently to cleanse the penis.
D.
Ask the parents why the child is not circumcised. - ANSWER -C
Rationale: The foreskin (prepuce) of the penis should be gently retracted to cleanse
all areas that could harbor bacteria. The child's cognitive development may not be
at the level at which option A would be effective. Perineal care needs to be
provided daily regardless of the client's age. Option D is not indicated and may be
perceived as intrusive.
A nurse is assigned to care for a close friend in the hospital setting. Which action
should the nurse take first when given the assignment?
A.
Notify the friend that all medical information will be kept confidential.
B.
Explain the relationship to the charge nurse and ask for reassignment.
C.
