HESI RN FUNDAMENTAL EXAM TEST BANK EXAM 2024/2025 QUESTIONS AND ANSWERS
100 % PASS SOLUTIONS A+ GRADED
A nurse is working in an occupational health clinic when an employee walks in and states, "I was walking
outside and I believe I was just struck by lightning." The client is alert but reports feeling faint. Which
assessment will the nurse perform first?
Page | 1 A. Pulse characteristics
B.
Open airway
C.
Entrance and exit woundsD.
Cervical spine injury (ANS- A
Rationale: Lightning is a jolt of electrical current and can produce a "natural" defibrillation, so
assessment of the pulse rate and regularity is a priority. Because the client is talking, he has anopen
airway so that assessment is not necessary.
Assessing for options C and D should occur after assessing for adequate circulation.
The nurse who is preparing to give a 14-year-old client a prescribed antipsychotic medicationnotes
that parental consent has not been obtained. Which action should the nurse take?
A.
Review the chart for a signed consent for hospitalization.B.
Get the health care provider's permission to give the medication.C.
Do not give the medication and document the reason.D.
Complete an incident report and notify the parents. (ANS- C
Rationale: The nurse should not give the medication and should document the reason becausethe client is
a minor and needs a guardian's permission to receive medications. Permission to give medications is not
granted by a signed hospital consent or a health care provider's permission, unless conditions are met to
justify coerced treatment. Option D is not necessary unless the medication had previously been
administered.
A hospitalized client has had difficulty falling asleep for two nights, and is becoming irritable andrestless.
Which action by the nurse is best?
A.
Determine the client's usual bedtime routine and include these rituals in the plan of care assafety
allows.
B.
STUDYGUIDESOLUTIONS
, HESI RN FUNDAMENTAL EXAM TEST BANK EXAM 2024/2025 QUESTIONS AND ANSWERS
100 % PASS SOLUTIONS A+ GRADED
Instruct the UAP not to wake the client under any circumstances during the night.C.
Place a "Do Not Disturb" sign on the door and change assessments from every 4 to 8 hours. D.
Encourage the client to avoid pain medication during the day, which might increase daytime
napping. (ANS- A
Page | 2 Rationale: Including habitual rituals that do not interfere with the client's care or safety mayallow
the client to go to sleep faster and increase the quality of care. Options B, C, and D decrease the
client's standard of care and compromise safety.
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 tofall. 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. (ANS- D
Rationale: Option D is the most prudent intervention and is the priority nursing action to preventinjury
to the client and the nurse. Lowering the client to the floor should be done when the client cannot
support his own weight. The client should be placed in a bed or chair only when sufficient help is
available to prevent injury. Option A is important but should be done after the client is in a safe position.
Because the client is not supporting himself, option B is impractical. Option C is likely to cause chaos
on the unit and might alarm the other clients.
A client is laughing at a television program when the evening nurse enters the room. The client states, "My
foot is hurting. I would like a pain pill." How should the nurse respond?
A.
Ask the client to rate the pain using a 1 to 10 scale.B.
Encourage the client to wait until bedtime for the pill.C.
Attend to an acutely ill client's needs first because this client is laughing.D.
STUDYGUIDESOLUTIONS
, HESI RN FUNDAMENTAL EXAM TEST BANK EXAM 2024/2025 QUESTIONS AND ANSWERS
100 % PASS SOLUTIONS A+ GRADED
Instruct the client in the use of deep breathing exercises for pain control. (ANS- A Rationale: Obtaining
a subjective estimate of the pain experience by asking the client to rate hispain helps the nurse
determine which pain medication should be administered and also provides a baseline for evaluating
the effectiveness of the medication. Medicating for pain should not be delayed so that it can be used as a
Page | 3 sleep medication. Option C is judgmental.
Option D should be used as an adjunct to pain medication, not instead of medication.
During a routine assessment, an obese 50-year-old client states, "I feel so unlovable because ofmy
weight." Which is the best response by the nurse?
A.
Reassure the client that many obese people have concerns about sex.B.
Remind the client that sexual relationships need not be affected by obesity.C.
Determine the frequency of sexual intercourse.
D.Ask the client to talk about specific concerns. (ANS- D
Rationale: Option D provides an opportunity for the client to verbalize concerns and provides the nurse
with more assessment data. Options A and B may not be related to the current concern, assume that
obesity is the problem, and are communication blocks. Option C may be appropriate after discussing the
stated concerns.
The nurse determines that a postoperative client's respiratory rate has increased from 18 to 24
breaths/min. Based on this assessment finding, what is the priority nursing action?
A.
Encourage the client to increase ambulation in the room.B.
Offer the client a high-carbohydrate snack for energy.C.
Force fluids to thin the client's pulmonary secretions.D.
Determine if pain is causing the client's tachypnea. (ANS- D
Rationale: Pain, anxiety, and increasing fluid accumulation in the lungs can cause tachypnea (increased
respiratory rate). Encouraging the client to increase ambulation when the respiratoryrate is rising above
normal limits puts the client at risk for further oxygen desaturation. Option Bcan increase the client's
carbon metabolism, so an alternative source of energy, such as Pulmocare liquid supplement, should be
offered instead. Option C could increase respiratory congestion in a client with a poorly functioning
cardiopulmonary system, placing the client at risk of fluid overload.
STUDYGUIDESOLUTIONS
, HESI RN FUNDAMENTAL EXAM TEST BANK EXAM 2024/2025 QUESTIONS AND ANSWERS
100 % PASS SOLUTIONS A+ GRADED
A nurse is assigned to care for a close friend in the hospital setting. Which action should thenurse
take first when given the assignment?
A.
Page | 4 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. (ANS- B
Rationale: Caring for a close friend can violate boundaries for nurses and should be avoided when
possible (B). If the assignment is unavoidable (there are no other nurses to care for theclient) then C,
A, and D should be addressed.
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 (ANS- 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 is preparing an older client for discharge. Which method is best for the nurse to use when
evaluating the client's ability to perform a dressing change at home?
A.
Determine how the client feels about changing the dressing.B.
Ask the client to describe the procedure in writing.
C.Seek a family member's evaluation of the client's ability to change the dressing.
.
d.Observe the client change the dressing unassisted (ANS- D
STUDYGUIDESOLUTIONS
100 % PASS SOLUTIONS A+ GRADED
A nurse is working in an occupational health clinic when an employee walks in and states, "I was walking
outside and I believe I was just struck by lightning." The client is alert but reports feeling faint. Which
assessment will the nurse perform first?
Page | 1 A. Pulse characteristics
B.
Open airway
C.
Entrance and exit woundsD.
Cervical spine injury (ANS- A
Rationale: Lightning is a jolt of electrical current and can produce a "natural" defibrillation, so
assessment of the pulse rate and regularity is a priority. Because the client is talking, he has anopen
airway so that assessment is not necessary.
Assessing for options C and D should occur after assessing for adequate circulation.
The nurse who is preparing to give a 14-year-old client a prescribed antipsychotic medicationnotes
that parental consent has not been obtained. Which action should the nurse take?
A.
Review the chart for a signed consent for hospitalization.B.
Get the health care provider's permission to give the medication.C.
Do not give the medication and document the reason.D.
Complete an incident report and notify the parents. (ANS- C
Rationale: The nurse should not give the medication and should document the reason becausethe client is
a minor and needs a guardian's permission to receive medications. Permission to give medications is not
granted by a signed hospital consent or a health care provider's permission, unless conditions are met to
justify coerced treatment. Option D is not necessary unless the medication had previously been
administered.
A hospitalized client has had difficulty falling asleep for two nights, and is becoming irritable andrestless.
Which action by the nurse is best?
A.
Determine the client's usual bedtime routine and include these rituals in the plan of care assafety
allows.
B.
STUDYGUIDESOLUTIONS
, HESI RN FUNDAMENTAL EXAM TEST BANK EXAM 2024/2025 QUESTIONS AND ANSWERS
100 % PASS SOLUTIONS A+ GRADED
Instruct the UAP not to wake the client under any circumstances during the night.C.
Place a "Do Not Disturb" sign on the door and change assessments from every 4 to 8 hours. D.
Encourage the client to avoid pain medication during the day, which might increase daytime
napping. (ANS- A
Page | 2 Rationale: Including habitual rituals that do not interfere with the client's care or safety mayallow
the client to go to sleep faster and increase the quality of care. Options B, C, and D decrease the
client's standard of care and compromise safety.
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 tofall. 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. (ANS- D
Rationale: Option D is the most prudent intervention and is the priority nursing action to preventinjury
to the client and the nurse. Lowering the client to the floor should be done when the client cannot
support his own weight. The client should be placed in a bed or chair only when sufficient help is
available to prevent injury. Option A is important but should be done after the client is in a safe position.
Because the client is not supporting himself, option B is impractical. Option C is likely to cause chaos
on the unit and might alarm the other clients.
A client is laughing at a television program when the evening nurse enters the room. The client states, "My
foot is hurting. I would like a pain pill." How should the nurse respond?
A.
Ask the client to rate the pain using a 1 to 10 scale.B.
Encourage the client to wait until bedtime for the pill.C.
Attend to an acutely ill client's needs first because this client is laughing.D.
STUDYGUIDESOLUTIONS
, HESI RN FUNDAMENTAL EXAM TEST BANK EXAM 2024/2025 QUESTIONS AND ANSWERS
100 % PASS SOLUTIONS A+ GRADED
Instruct the client in the use of deep breathing exercises for pain control. (ANS- A Rationale: Obtaining
a subjective estimate of the pain experience by asking the client to rate hispain helps the nurse
determine which pain medication should be administered and also provides a baseline for evaluating
the effectiveness of the medication. Medicating for pain should not be delayed so that it can be used as a
Page | 3 sleep medication. Option C is judgmental.
Option D should be used as an adjunct to pain medication, not instead of medication.
During a routine assessment, an obese 50-year-old client states, "I feel so unlovable because ofmy
weight." Which is the best response by the nurse?
A.
Reassure the client that many obese people have concerns about sex.B.
Remind the client that sexual relationships need not be affected by obesity.C.
Determine the frequency of sexual intercourse.
D.Ask the client to talk about specific concerns. (ANS- D
Rationale: Option D provides an opportunity for the client to verbalize concerns and provides the nurse
with more assessment data. Options A and B may not be related to the current concern, assume that
obesity is the problem, and are communication blocks. Option C may be appropriate after discussing the
stated concerns.
The nurse determines that a postoperative client's respiratory rate has increased from 18 to 24
breaths/min. Based on this assessment finding, what is the priority nursing action?
A.
Encourage the client to increase ambulation in the room.B.
Offer the client a high-carbohydrate snack for energy.C.
Force fluids to thin the client's pulmonary secretions.D.
Determine if pain is causing the client's tachypnea. (ANS- D
Rationale: Pain, anxiety, and increasing fluid accumulation in the lungs can cause tachypnea (increased
respiratory rate). Encouraging the client to increase ambulation when the respiratoryrate is rising above
normal limits puts the client at risk for further oxygen desaturation. Option Bcan increase the client's
carbon metabolism, so an alternative source of energy, such as Pulmocare liquid supplement, should be
offered instead. Option C could increase respiratory congestion in a client with a poorly functioning
cardiopulmonary system, placing the client at risk of fluid overload.
STUDYGUIDESOLUTIONS
, HESI RN FUNDAMENTAL EXAM TEST BANK EXAM 2024/2025 QUESTIONS AND ANSWERS
100 % PASS SOLUTIONS A+ GRADED
A nurse is assigned to care for a close friend in the hospital setting. Which action should thenurse
take first when given the assignment?
A.
Page | 4 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. (ANS- B
Rationale: Caring for a close friend can violate boundaries for nurses and should be avoided when
possible (B). If the assignment is unavoidable (there are no other nurses to care for theclient) then C,
A, and D should be addressed.
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 (ANS- 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 is preparing an older client for discharge. Which method is best for the nurse to use when
evaluating the client's ability to perform a dressing change at home?
A.
Determine how the client feels about changing the dressing.B.
Ask the client to describe the procedure in writing.
C.Seek a family member's evaluation of the client's ability to change the dressing.
.
d.Observe the client change the dressing unassisted (ANS- D
STUDYGUIDESOLUTIONS
