HESI RN
FUNDAMENTALS
EXIT EXAM LATEST
ACTUAL EXAM 100
QUESTIONS AND
CORRECT ANSWERS
WITH RATIOANLES
(VERIFIED
ANSWERS)
,The nurse is called to the waiting room of a pediatric clinic. The frantic mother
states, "I think my 4-month-old baby is choking!" What steps will the nurse
take? (Select all that apply.)
A.
Compress the chest once between the nipples with two
fingers. B.
Note any obstruction or absence of
breathing. C.
Deliver five backslaps between the shoulder
blades. D.
Place the infant over the nurse's
arm. E.
Perform a blind finger sweep.
B, C, D
Rationale: The fingers are placed at the same location on an infant as chest
compressions for CPR; however, the nurse must deliver five chest thrusts, after
the five back slaps. Blind sweeps are not used as this action may push the
object deeper into the throat. The
remaining steps are correct.
Which fluid will the nurse select to administer with the prescribed blood
transfusion? A.
5% Dextrose and
water B.
Normal
saline C.
Lactated Ringers
solution D.
5% Dextrose and lactated ringers
B
Rationale: Normal saline solution is the only solution that is compatible with blood.
,When assisting a client from the bed to a chair, which procedure is best for
the nurse to follow?
A.
Place the chair parallel to the bed, with its back toward the head of the bed
and assist the client in moving to the chair.
B.
With the nurse's feet spread apart and knees aligned with the client's knees,
stand and pivot the client into the chair.
C.
Assist the client to a standing position by gently lifting upward,
underneath the axillae. D.
Stand beside the client, place the client's arms around the nurse's neck, and
gently move the client to the chair.
B
Rationale: Option B describes the correct positioning of the nurse and affords
the nurse a wide base of support while stabilizing the client's knees when
assisting to a standing position. The chair should be placed at a 45-degree
angle to the bed, with the back of the chair toward the head of the bed.
Clients should never be lifted under the axillae; this
could damage nerves and strain the nurse's back. The client should be
instructed to use the arms of the chair and should never place his or her arms
around the nurse's neck; this places undue stress on the nurse's neck and
back and increases the risk for a fall.
, How many mL will the nurse document on the client's intake and output
record from the items listed? mL
1200 mL water
4 ounce container of
gelatin 8 ounces of
orange juice
355 mL can of soda1 cup of soup
Answer: 2155
Rationale: 1200 + 240 (8 oz) + 240 (1 cup) + 120 (4 oz) + 355 = 2155
The nurse observes a UAP taking a client's blood pressure in the lower
extremity. Which observation of this procedure requires the nurse to
intervene with the UAP's approach? A.
The cuff wraps around the girth of
the leg. B.
The UAP auscultates the popliteal pulse with the cuff on the
lower leg. C.
The client is placed in a prone
position. D.
The systolic reading is 20 mm Hg higher than the blood pressure in the client's
arm.
B
Rationale: When obtaining the blood pressure in the lower extremities, the
popliteal pulse is the site for auscultation when the blood pressure cuff is
applied around the thigh. The
nurse should intervene with the UAP who has applied the cuff on the lower leg.
Option A ensures an accurate assessment, and option C provides the best access
to the artery.
Systolic pressure in the popliteal artery is usually 10 to 40 mm Hg higher
than in the brachial artery.