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HESI RN FUNDAMENTALS NEWEST 2024-2025
ACTUAL EXAM VERSION 4 COMPLETE 160
QUESTIONS AND CORRECT DETAILED
ANSWERS (VERIFIED ANSWERS) |ALREADY
GRADED A+
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- Check for kinks in the tubing and raise the IV pole.
The nurse determines that a postoperative client's respiratory
rate has increased from 18 to 24 breaths/min. Based on this
assessment finding, which intervention is most important for the
nurse to implement?
A.Encourage the client to increase ambulation in the room.
B.Offer the client a high-carbohydrate snack for energy.
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C.Force fluids to thin the client's pulmonary secretions.
D.Determine if pain is causing the client's tachypnea. -
ANSWER- Determine if pain is causing the client's tachypnea.
The nurse finds a client crying behind a locked bathroom door.
The client will not open the door. Which action should the nurse
implement first?A.Instruct an unlicensed assistive personnel
(UAP) to stay and keep talking to the client.
B.Sit quietly in the client's room until the client leaves the
bathroom.
C.Allow the client to cry alone and leave the client in the
bathroom.
D.Talk to the client and attempt to find out why the client is
crying. - ANSWER- Talk to the client and attempt to find out
why the client is crying.
The nurse identifies a potential for infection in a client with
partial-thickness (second- degree) and full-thickness (third-
degree) burns. What intervention 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
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D.Limiting visitors to the client with burns - ANSWER- Use of
careful handwashing technique
The nurse is administering the 0900 medications to a client who
was admitted during the night. Which client statement indicates
that the nurse should further assess the medication order?
A."At home I take my pills at 8:00 am."
B."It costs a lot of money to buy all of these pills."
C."I get so tired of taking pills every day."
D."This is a new pill I have never taken before." - ANSWER-
"This is a new pill I have never taken before."
The nurse is assessing several clients prior to surgery. Which
factor in a client's history poses the greatest threat for
complications to occur during surgery?
A.Taking birth control pills for the past 2 years
B.Taking anticoagulants for the past year
C.Recently completing antibiotic therapy
D.Having taken laxatives PRN for the last 6 months -
ANSWER- Taking anticoagulants for the past year
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?
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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.Approach the client and ask if the assignment is
uncomfortable.
D.Accept the assignment but protect the client's confidentiality.
- ANSWER- Explain the relationship to the charge nurse and
ask for reassignment.
The nurse is assisting a client to the bathroom. When the client
is 5 feet from the bathroom door, he states, "I feel faint." Before
the nurse can get the client to a chair, the client starts to fall.
Which is the priority action for the nurse to take?
A.Check the client's carotid pulse.
B.Encourage the client to get to the toilet.
C.In a loud voice, call for help.
D.Gently lower the client to the floor. - ANSWER- Gently lower
the client to the floor.
The nurse is aware that malnutrition is a common problem
among clients served by a community health clinic for the
homeless. Which laboratory value is the most reliable indicator
of chronic protein malnutrition?
HESI RN FUNDAMENTALS NEWEST 2024-2025
ACTUAL EXAM VERSION 4 COMPLETE 160
QUESTIONS AND CORRECT DETAILED
ANSWERS (VERIFIED ANSWERS) |ALREADY
GRADED A+
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- Check for kinks in the tubing and raise the IV pole.
The nurse determines that a postoperative client's respiratory
rate has increased from 18 to 24 breaths/min. Based on this
assessment finding, which intervention is most important for the
nurse to implement?
A.Encourage the client to increase ambulation in the room.
B.Offer the client a high-carbohydrate snack for energy.
,2|Page
C.Force fluids to thin the client's pulmonary secretions.
D.Determine if pain is causing the client's tachypnea. -
ANSWER- Determine if pain is causing the client's tachypnea.
The nurse finds a client crying behind a locked bathroom door.
The client will not open the door. Which action should the nurse
implement first?A.Instruct an unlicensed assistive personnel
(UAP) to stay and keep talking to the client.
B.Sit quietly in the client's room until the client leaves the
bathroom.
C.Allow the client to cry alone and leave the client in the
bathroom.
D.Talk to the client and attempt to find out why the client is
crying. - ANSWER- Talk to the client and attempt to find out
why the client is crying.
The nurse identifies a potential for infection in a client with
partial-thickness (second- degree) and full-thickness (third-
degree) burns. What intervention 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
,3|Page
D.Limiting visitors to the client with burns - ANSWER- Use of
careful handwashing technique
The nurse is administering the 0900 medications to a client who
was admitted during the night. Which client statement indicates
that the nurse should further assess the medication order?
A."At home I take my pills at 8:00 am."
B."It costs a lot of money to buy all of these pills."
C."I get so tired of taking pills every day."
D."This is a new pill I have never taken before." - ANSWER-
"This is a new pill I have never taken before."
The nurse is assessing several clients prior to surgery. Which
factor in a client's history poses the greatest threat for
complications to occur during surgery?
A.Taking birth control pills for the past 2 years
B.Taking anticoagulants for the past year
C.Recently completing antibiotic therapy
D.Having taken laxatives PRN for the last 6 months -
ANSWER- Taking anticoagulants for the past year
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?
, 4|Page
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.Approach the client and ask if the assignment is
uncomfortable.
D.Accept the assignment but protect the client's confidentiality.
- ANSWER- Explain the relationship to the charge nurse and
ask for reassignment.
The nurse is assisting a client to the bathroom. When the client
is 5 feet from the bathroom door, he states, "I feel faint." Before
the nurse can get the client to a chair, the client starts to fall.
Which is the priority action for the nurse to take?
A.Check the client's carotid pulse.
B.Encourage the client to get to the toilet.
C.In a loud voice, call for help.
D.Gently lower the client to the floor. - ANSWER- Gently lower
the client to the floor.
The nurse is aware that malnutrition is a common problem
among clients served by a community health clinic for the
homeless. Which laboratory value is the most reliable indicator
of chronic protein malnutrition?
