HESI RN Fundamentals Exit Exam | 100 Questions & Answers with Rationales
The nurse is called to the waiting room of a pediatric clinic. B, C, D
The frantic mother states, "I think my 4-month-old baby is Rationale: The fingers are placed at the same location on an infant as chest
choking!" What steps will the nurse take? (Select all that compressions for CPR; however, the nurse must deliver five chest thrusts, after the
apply.) five back slaps. Blind sweeps are not used as this action may push the object
A. deeper into the throat. The remaining steps are correct.
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.
Which fluid will the nurse select to administer with the B
prescribed blood transfusion? Rationale: Normal saline solution is the only solution that is compatible with blood.
A.
5% Dextrose and water
B.
Normal saline
C.
Lactated Ringers solution
D.
5% Dextrose and lactated ringers
When assisting a client from the bed to a chair, which B
procedure is best for the nurse to follow? Rationale: Option B describes the correct positioning of the nurse and affords the
A. nurse a wide base of support while stabilizing the client's knees when assisting to a
Place the chair parallel to the bed, with its back toward the standing position. The chair should be placed at a 45-degree angle to the bed, with
head of the bed and assist the client in moving to the chair. the back of the chair toward the head of the bed. Clients should never be lifted
B. under the axillae; this could damage nerves and strain the nurse's back. The client
With the nurse's feet spread apart and knees aligned with should be instructed to use the arms of the chair and should never place his or her
the client's knees, stand and pivot the client into the chair. arms around the nurse's neck; this places undue stress on the nurse's neck and
C. back and increases the risk for a fall.
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.
How many mL will the nurse document on the client's Answer: 2155
intake and output record from the items listed? _____ mL Rationale: 1200 + 240 (8 oz) + 240 (1 cup) + 120 (4 oz) + 355 = 2155
1200 mL water
4 ounce container of gelatin
8 ounces of orange juice
355 mL can of soda1 cup of soup
The nurse observes a UAP taking a client's blood pressure B
in the lower extremity. Which observation of this procedure Rationale: When obtaining the blood pressure in the lower extremities, the popliteal
requires the nurse to intervene with the UAP's approach? pulse is the site for auscultation when the blood pressure cuff is applied around the
A. thigh. The nurse should intervene with the UAP who has applied the cuff on the
The cuff wraps around the girth of the leg. lower leg. Option A ensures an accurate assessment, and option C provides the
B. best access to the artery. Systolic pressure in the popliteal artery is usually 10 to 40
The UAP auscultates the popliteal pulse with the cuff on mm Hg higher than in the brachial artery.
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.
Grade A+ | Updated
, HESI RN Fundamentals Exit Exam | 100 Questions & Answers with Rationales
During a clinic visit, the mother of a 7-year-old reports to D
the nurse that her child is often awake until midnight Rationale: School-age children often resist bedtime. The nurse should begin by
playing and is then very difficult to awaken in the morning assessing the environment of the home to determine factors that may not be
for school. Which assessment data should the nurse conducive to the establishment of bedtime rituals that promote sleep. Option A often
obtain in response to the mother's concern? causes daytime fatigue rather than resistance to going to sleep. Option B is unlikely
A. to provide useful data. The nurse cannot determine option C.
The occurrence of any episodes of sleep apnea
B.
The child's blood pressure, pulse, and respirations
C.
Length of rapid eye movement (REM) sleep that the child
is experiencing
D.
Description of the family's home environment
The nurse identifies a potential for infection in a client with B
partial-thickness (second-degree) and full-thickness (third- Rationale: Careful handwashing technique is the single most effective intervention
degree) burns. What action has the highest priority in for the prevention of contamination to all clients. Option A reverses the hypovolemia
decreasing the client's risk of infection? that initially accompanies burn trauma but is not related to decreasing the
A. proliferation of infective organisms. Options C and D are recommended by various
Administration of plasma expanders burn centers as possible ways to reduce the chance of infection. Option B is a
B. proven technique to prevent infection.
Use of careful handwashing technique
C.
Application of a topical antibacterial cream
D.
Limiting visitors to the client with burns
The nurse assesses a 2-year-old who is admitted for B
dehydration and finds that the peripheral IV rate by gravity Rationale: The nurse should first check the tubing and height of the bag on the IV
has slowed, even though the venous access site is pole, which are common factors that may slow the rate. Gravity infusion rates are
healthy. What should the nurse do next? influenced by the height of the bag, tubing clamp closure or kinks, needle size or
A. position, fluid viscosity, client blood pressure (crying in the pediatric client), and
Apply a warm compress proximal to the site. infiltration. Venospasm can slow the rate and often responds to warmth over the
B. vessel, but the nurse should first adjust the IV pole height. The nurse may need to
Check for kinks in the tubing and raise the IV pole. adjust the stabilizing tape on a positional needle or flush the venous access with
C. normal saline, but less invasive actions should be implemented first.
Adjust the tape that stabilizes the needle.
D.
Flush with normal saline and recount the drop rate.
The nurse manager of a skilled nursing (chronic care) unit A
is instructing UAPs on ways to prevent complications of Rationale: Performing range-of-motion exercises is beneficial in reducing
immobility. Which action should be included in this contractures around joints. Options B, C, and D are all potentially harmful practices
instruction? that place the immobile client at risk of complications.
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.
The nurse administered 10 mg of diazepam to the B, C, D
preoperative client. What steps will the nurse take next? Rationale: Diazepam is a common preoperative medication. Close observation by
(Select all that apply.) placing the client close to the nurse's station is not necessary. The medication has a
A. sedative effect and the client should not get out of bed, even with assistance. The
Place the client in the bed next to the nurse's station. remaining selections are correct.
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
Grade A+ | Updated
, HESI RN Fundamentals Exit Exam | 100 Questions & Answers with Rationales
A terminally ill client tells the nurse, "I am so tired and in so B
much pain! Please help me to die." Which is the best Rationale: The nurse should first assess the client's feelings about death and
response for the nurse to provide? determine the extent to which this statement expresses the client's true feelings.
A. The client may need additional pain management, but further assessment is
Administer the prescribed maximum dose of pain needed before implementing option A. Options C and D are both premature
medication. interventions and should not be implemented until further assessment is obtained.
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.
A nurse stops at a motor vehicle collision site to render aid C
until the emergency personnel arrive and applies pressure Rationale: The Good Samaritan Act protects health care professionals who practice
to a groin wound that is bleeding profusely. Later the client in good faith and provide reasonable care from malpractice claims, regardless of the
has to have the leg amputated and sues the nurse for client outcome. Although the Patient's Bill of Rights protects clients, this nurse is
malpractice. Which statement reflects the likely outcome protected by the Good Samaritan Act. The state Board of Nursing has no reason to
for the nurse? revoke a registered nurse's license unless there was evidence that actions taken in
A. the emergency were not done in good faith or that reasonable care was not
The Patient's Bill of Rights protects clients from malicious provided. All four elements of malpractice were not shown.
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.
An older client who had abdominal surgery 3 days earlier A
was given a barbiturate for sleep and is now requesting to Rationale: Barbiturates cause central nervous system (CNS) depression, and
go to the bathroom. What is the priority nursing action for individuals taking these medications are at greater risk for falls. The nurse should
this client? assist the client to the bathroom. A bedpan is not necessary as long as safety is
A. ensured. Whether the client needs to void or have a bowel movement, option C is
Assist the client to walk to the bathroom and do not leave irrelevant in terms of meeting this client's safety needs. There is no indication that
the client alone. this client cannot voice her or his needs, so assessment of the bladder is not
B. needed.
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.
The nurse is planning care for a client with an indwelling D
urinary catheter. Which nursing action has the highest Rationale: Indwelling urinary catheters are a major source of infection. Option A is a
priority? problem that may develop from having an indwelling catheter. Option B may or may
A. not be true for the client. Option C is not affected by an indwelling catheter.
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.
When bathing an uncircumcised boy older than 3 years, C
which action should the nurse take? Rationale: The foreskin (prepuce) of the penis should be gently retracted to cleanse
A. all areas that could harbor bacteria. The child's cognitive development may not be
Remind the child to clean his genital area. at the level at which option A would be effective. Perineal care needs to be provided
B. daily regardless of the client's age. Option D is not indicated and may be perceived
Defer perineal care because of the child's age. as intrusive.
C.
Retract the foreskin gently to cleanse the penis.
D.
Ask the parents why the child is not circumcised.
Grade A+ | Updated
The nurse is called to the waiting room of a pediatric clinic. B, C, D
The frantic mother states, "I think my 4-month-old baby is Rationale: The fingers are placed at the same location on an infant as chest
choking!" What steps will the nurse take? (Select all that compressions for CPR; however, the nurse must deliver five chest thrusts, after the
apply.) five back slaps. Blind sweeps are not used as this action may push the object
A. deeper into the throat. The remaining steps are correct.
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.
Which fluid will the nurse select to administer with the B
prescribed blood transfusion? Rationale: Normal saline solution is the only solution that is compatible with blood.
A.
5% Dextrose and water
B.
Normal saline
C.
Lactated Ringers solution
D.
5% Dextrose and lactated ringers
When assisting a client from the bed to a chair, which B
procedure is best for the nurse to follow? Rationale: Option B describes the correct positioning of the nurse and affords the
A. nurse a wide base of support while stabilizing the client's knees when assisting to a
Place the chair parallel to the bed, with its back toward the standing position. The chair should be placed at a 45-degree angle to the bed, with
head of the bed and assist the client in moving to the chair. the back of the chair toward the head of the bed. Clients should never be lifted
B. under the axillae; this could damage nerves and strain the nurse's back. The client
With the nurse's feet spread apart and knees aligned with should be instructed to use the arms of the chair and should never place his or her
the client's knees, stand and pivot the client into the chair. arms around the nurse's neck; this places undue stress on the nurse's neck and
C. back and increases the risk for a fall.
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.
How many mL will the nurse document on the client's Answer: 2155
intake and output record from the items listed? _____ mL Rationale: 1200 + 240 (8 oz) + 240 (1 cup) + 120 (4 oz) + 355 = 2155
1200 mL water
4 ounce container of gelatin
8 ounces of orange juice
355 mL can of soda1 cup of soup
The nurse observes a UAP taking a client's blood pressure B
in the lower extremity. Which observation of this procedure Rationale: When obtaining the blood pressure in the lower extremities, the popliteal
requires the nurse to intervene with the UAP's approach? pulse is the site for auscultation when the blood pressure cuff is applied around the
A. thigh. The nurse should intervene with the UAP who has applied the cuff on the
The cuff wraps around the girth of the leg. lower leg. Option A ensures an accurate assessment, and option C provides the
B. best access to the artery. Systolic pressure in the popliteal artery is usually 10 to 40
The UAP auscultates the popliteal pulse with the cuff on mm Hg higher than in the brachial artery.
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.
Grade A+ | Updated
, HESI RN Fundamentals Exit Exam | 100 Questions & Answers with Rationales
During a clinic visit, the mother of a 7-year-old reports to D
the nurse that her child is often awake until midnight Rationale: School-age children often resist bedtime. The nurse should begin by
playing and is then very difficult to awaken in the morning assessing the environment of the home to determine factors that may not be
for school. Which assessment data should the nurse conducive to the establishment of bedtime rituals that promote sleep. Option A often
obtain in response to the mother's concern? causes daytime fatigue rather than resistance to going to sleep. Option B is unlikely
A. to provide useful data. The nurse cannot determine option C.
The occurrence of any episodes of sleep apnea
B.
The child's blood pressure, pulse, and respirations
C.
Length of rapid eye movement (REM) sleep that the child
is experiencing
D.
Description of the family's home environment
The nurse identifies a potential for infection in a client with B
partial-thickness (second-degree) and full-thickness (third- Rationale: Careful handwashing technique is the single most effective intervention
degree) burns. What action has the highest priority in for the prevention of contamination to all clients. Option A reverses the hypovolemia
decreasing the client's risk of infection? that initially accompanies burn trauma but is not related to decreasing the
A. proliferation of infective organisms. Options C and D are recommended by various
Administration of plasma expanders burn centers as possible ways to reduce the chance of infection. Option B is a
B. proven technique to prevent infection.
Use of careful handwashing technique
C.
Application of a topical antibacterial cream
D.
Limiting visitors to the client with burns
The nurse assesses a 2-year-old who is admitted for B
dehydration and finds that the peripheral IV rate by gravity Rationale: The nurse should first check the tubing and height of the bag on the IV
has slowed, even though the venous access site is pole, which are common factors that may slow the rate. Gravity infusion rates are
healthy. What should the nurse do next? influenced by the height of the bag, tubing clamp closure or kinks, needle size or
A. position, fluid viscosity, client blood pressure (crying in the pediatric client), and
Apply a warm compress proximal to the site. infiltration. Venospasm can slow the rate and often responds to warmth over the
B. vessel, but the nurse should first adjust the IV pole height. The nurse may need to
Check for kinks in the tubing and raise the IV pole. adjust the stabilizing tape on a positional needle or flush the venous access with
C. normal saline, but less invasive actions should be implemented first.
Adjust the tape that stabilizes the needle.
D.
Flush with normal saline and recount the drop rate.
The nurse manager of a skilled nursing (chronic care) unit A
is instructing UAPs on ways to prevent complications of Rationale: Performing range-of-motion exercises is beneficial in reducing
immobility. Which action should be included in this contractures around joints. Options B, C, and D are all potentially harmful practices
instruction? that place the immobile client at risk of complications.
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.
The nurse administered 10 mg of diazepam to the B, C, D
preoperative client. What steps will the nurse take next? Rationale: Diazepam is a common preoperative medication. Close observation by
(Select all that apply.) placing the client close to the nurse's station is not necessary. The medication has a
A. sedative effect and the client should not get out of bed, even with assistance. The
Place the client in the bed next to the nurse's station. remaining selections are correct.
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
Grade A+ | Updated
, HESI RN Fundamentals Exit Exam | 100 Questions & Answers with Rationales
A terminally ill client tells the nurse, "I am so tired and in so B
much pain! Please help me to die." Which is the best Rationale: The nurse should first assess the client's feelings about death and
response for the nurse to provide? determine the extent to which this statement expresses the client's true feelings.
A. The client may need additional pain management, but further assessment is
Administer the prescribed maximum dose of pain needed before implementing option A. Options C and D are both premature
medication. interventions and should not be implemented until further assessment is obtained.
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.
A nurse stops at a motor vehicle collision site to render aid C
until the emergency personnel arrive and applies pressure Rationale: The Good Samaritan Act protects health care professionals who practice
to a groin wound that is bleeding profusely. Later the client in good faith and provide reasonable care from malpractice claims, regardless of the
has to have the leg amputated and sues the nurse for client outcome. Although the Patient's Bill of Rights protects clients, this nurse is
malpractice. Which statement reflects the likely outcome protected by the Good Samaritan Act. The state Board of Nursing has no reason to
for the nurse? revoke a registered nurse's license unless there was evidence that actions taken in
A. the emergency were not done in good faith or that reasonable care was not
The Patient's Bill of Rights protects clients from malicious provided. All four elements of malpractice were not shown.
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.
An older client who had abdominal surgery 3 days earlier A
was given a barbiturate for sleep and is now requesting to Rationale: Barbiturates cause central nervous system (CNS) depression, and
go to the bathroom. What is the priority nursing action for individuals taking these medications are at greater risk for falls. The nurse should
this client? assist the client to the bathroom. A bedpan is not necessary as long as safety is
A. ensured. Whether the client needs to void or have a bowel movement, option C is
Assist the client to walk to the bathroom and do not leave irrelevant in terms of meeting this client's safety needs. There is no indication that
the client alone. this client cannot voice her or his needs, so assessment of the bladder is not
B. needed.
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.
The nurse is planning care for a client with an indwelling D
urinary catheter. Which nursing action has the highest Rationale: Indwelling urinary catheters are a major source of infection. Option A is a
priority? problem that may develop from having an indwelling catheter. Option B may or may
A. not be true for the client. Option C is not affected by an indwelling catheter.
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.
When bathing an uncircumcised boy older than 3 years, C
which action should the nurse take? Rationale: The foreskin (prepuce) of the penis should be gently retracted to cleanse
A. all areas that could harbor bacteria. The child's cognitive development may not be
Remind the child to clean his genital area. at the level at which option A would be effective. Perineal care needs to be provided
B. daily regardless of the client's age. Option D is not indicated and may be perceived
Defer perineal care because of the child's age. as intrusive.
C.
Retract the foreskin gently to cleanse the penis.
D.
Ask the parents why the child is not circumcised.
Grade A+ | Updated
