HESI RN FUNDAMENTAL EXIT EXAM LATEST
2024-2025 ACTUAL EXAM 100 QUESTIONS AND
VERIFIED ANSWERS 100% (GRADED A+)
An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse
is at greatest risk for a malpractice judgement?
A. A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes.
B. The nurse assigned to care for the client who was at lunch at the time of the fall.
C. The nurse who transferred the client to the chair when the fall occurred.
D. The charge nurse who completed rounds 30 minutes before the fall occurred. - ANS-
C. The nurse who transferred the client to the chair when the fall occurred.
(The four elements of malpractice are: breach of duty owed, failure to adhere to the
recognized standard of care, direct causation of injury, and evidence of actual injury.
The hip fracture is the actual injury and the standard of care was "frequent monitoring."
(C) implies the duty was owed and the injury occurred while the nurse was in charge of
the client's care. There is no evidence of negligence in (A, B, and D). )
When assessing a client with wrist restraints, the nurse observes that the fingers on the
right hand are blue. What action should the nurse implement first?
A. Loosen the right wrist restraint.
B. Apply a pulse oximeter to the right hand.
C. Compare hand color bilaterally.
D. Palpate the right radial pulse. - ANS-A. Loosen the right wrist restraint.
(The priority nursing action is to restore circulation by loosening the restraint (A),
because blue fingers (cyanosis) indicates decreased circulation. (C and D) are also
important nursing interventions, but do not have the priority of (A). Pulse oximetry (B)
measures saturation of hemoglobin with oxygen and is not indicated in situations where
the cyanosis is related to mechanical compression-- the restraints.)
The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood
pressure with a cuff that is too small, but the blood pressure reading obtained is within
the client's usual range. What action is most important for the nurse to implement?
A. Tell the UAP to use a larger cuff at the next scheduled assessment.
B. Reassess the client's blood pressure using a larger cuff.
C. Have the unit educator review this procedure with the UAPs.
D. Teach the UAP the correct technique for assessing blood pressure. - ANS-B.
Reassess the client's blood pressure using a larger cuff.
(The most important action is to ensure that an accurate BP reading is obtained. The
nurse should reassess the BP with the correct size cuff (B). Reassessment should not
be postponed (A). Though (C and D) are likely indicated, these actions do not have the
priority of (B).)
2024-2025 ACTUAL EXAM 100 QUESTIONS AND
VERIFIED ANSWERS 100% (GRADED A+)
An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse
is at greatest risk for a malpractice judgement?
A. A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes.
B. The nurse assigned to care for the client who was at lunch at the time of the fall.
C. The nurse who transferred the client to the chair when the fall occurred.
D. The charge nurse who completed rounds 30 minutes before the fall occurred. - ANS-
C. The nurse who transferred the client to the chair when the fall occurred.
(The four elements of malpractice are: breach of duty owed, failure to adhere to the
recognized standard of care, direct causation of injury, and evidence of actual injury.
The hip fracture is the actual injury and the standard of care was "frequent monitoring."
(C) implies the duty was owed and the injury occurred while the nurse was in charge of
the client's care. There is no evidence of negligence in (A, B, and D). )
When assessing a client with wrist restraints, the nurse observes that the fingers on the
right hand are blue. What action should the nurse implement first?
A. Loosen the right wrist restraint.
B. Apply a pulse oximeter to the right hand.
C. Compare hand color bilaterally.
D. Palpate the right radial pulse. - ANS-A. Loosen the right wrist restraint.
(The priority nursing action is to restore circulation by loosening the restraint (A),
because blue fingers (cyanosis) indicates decreased circulation. (C and D) are also
important nursing interventions, but do not have the priority of (A). Pulse oximetry (B)
measures saturation of hemoglobin with oxygen and is not indicated in situations where
the cyanosis is related to mechanical compression-- the restraints.)
The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood
pressure with a cuff that is too small, but the blood pressure reading obtained is within
the client's usual range. What action is most important for the nurse to implement?
A. Tell the UAP to use a larger cuff at the next scheduled assessment.
B. Reassess the client's blood pressure using a larger cuff.
C. Have the unit educator review this procedure with the UAPs.
D. Teach the UAP the correct technique for assessing blood pressure. - ANS-B.
Reassess the client's blood pressure using a larger cuff.
(The most important action is to ensure that an accurate BP reading is obtained. The
nurse should reassess the BP with the correct size cuff (B). Reassessment should not
be postponed (A). Though (C and D) are likely indicated, these actions do not have the
priority of (B).)
