RN HESI Fundamentals Test | Questions with
Verified Answers
The nurse identifies a potential for infection in a client with partial-thickness (second-degree)
and full-thickness (third-degree) burns. What action 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
D.
Limiting visitors to the client with burns - ✔✔B
Rationale: Careful handwashing technique is the single most effective intervention for the
prevention of contamination to all clients. Option A reverses the hypovolemia that initially
accompanies burn trauma but is not related to decreasing the proliferation of infective
organisms. Options C and D are recommended by various burn centers as possible ways to
reduce the chance of infection. Option B is a proven technique to prevent infection.
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. - ✔✔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. - ✔✔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 - ✔✔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. - ✔✔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. - ✔✔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. - ✔✔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
Verified Answers
The nurse identifies a potential for infection in a client with partial-thickness (second-degree)
and full-thickness (third-degree) burns. What action 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
D.
Limiting visitors to the client with burns - ✔✔B
Rationale: Careful handwashing technique is the single most effective intervention for the
prevention of contamination to all clients. Option A reverses the hypovolemia that initially
accompanies burn trauma but is not related to decreasing the proliferation of infective
organisms. Options C and D are recommended by various burn centers as possible ways to
reduce the chance of infection. Option B is a proven technique to prevent infection.
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. - ✔✔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. - ✔✔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 - ✔✔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. - ✔✔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. - ✔✔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. - ✔✔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
