HESI RN FUNDAMENTALS EXIT EXAM
LATEST 2024-2025 ACTUAL EXAM 100
QUESTIONS AND ANSWERS
The fnurse fis fcalled fto fthe fwaiting froom fof fa fpediatric fclinic. fThe ffrantic fmother fstates, f"I fthink fmy f4-
month-old fbaby fis fchoking!" fWhat fsteps fwill fthe fnurse ftake? f(Select fall fthat fapply.)
A.
Compress fthe fchest fonce fbetween fthe fnipples fwith ftwo ffingers.
f
B.
Note fany fobstruction for fabsence fof fbreathing.
f
C.
Deliver ffive fbackslaps fbetween fthe fshoulder fblades.
f
D.
Place fthe finfant fover fthe fnurse's farm.
f E.
Perform fa fblind ffinger fsweep. B, fC, fD
Rationale: fThe ffingers fare fplaced fat fthe fsame flocation fon fan finfant fas fchest fcompressions ffor fCPR;
fhowever, fthe fnurse fmust fdeliver ffive fchest fthrusts, fafter fthe ffive fback fslaps. fBlind fsweeps fare fnot fused
fas fthis faction fmay fpush fthe fobject fdeeper finto fthe fthroat. fThe fremaining fsteps fare fcorrect.
Which ffluid fwill fthe fnurse fselect fto fadminister fwith fthe fprescribed fblood ftransfusion?
A.
5% fDextrose fand fwater
f B.
Normal fsaline
f C.
Lactated fRingers fsolution
f D.
,5% fDextrose fand flactated fringers Bf
Rationale: fNormal fsaline fsolution fis fthe fonly fsolution fthat fis fcompatible fwith fblood.
When fassisting fa fclient ffrom fthe fbed fto fa fchair, fwhich fprocedure fis fbest ffor fthe fnurse fto ffollow?
A.
Place fthe fchair fparallel fto fthe fbed, fwith fits fback ftoward fthe fhead fof fthe fbed fand fassist fthe fclient fin
f
moving fto fthe fchair.
f B.
With fthe fnurse's ffeet fspread fapart fand fknees faligned fwith fthe fclient's fknees, fstand fand fpivot fthe fclient
f
into fthe fchair.
f C.
Assist fthe fclient fto fa fstanding fposition fby fgently flifting fupward, funderneath fthe faxillae.
f D.
Stand fbeside fthe fclient, fplace fthe fclient's farms faround fthe fnurse's fneck, fand fgently fmove fthe fclient fto
fthe fchair. B
Rationale: fOption fB fdescribes fthe fcorrect fpositioning fof fthe fnurse fand faffords fthe fnurse fa fwide fbase fof
fsupport fwhile fstabilizing fthe fclient's fknees fwhen fassisting fto fa fstanding fposition. fThe fchair fshould fbe
fplaced fat fa f45-degree fangle fto fthe fbed, fwith fthe fback fof fthe fchair ftoward fthe fhead fof fthe fbed. fClients
fshould fnever fbe flifted funder fthe faxillae; fthis fcould fdamage fnerves fand fstrain fthe fnurse's fback. fThe
fclient fshould fbe finstructed fto fuse fthe farms fof fthe fchair fand fshould fnever fplace fhis for fher farms faround
fthe fnurse's fneck; fthis fplaces fundue fstress fon fthe fnurse's fneck fand fback fand fincreases fthe frisk ffor fa ffall.
How fmany fmL fwill fthe fnurse fdocument fon fthe fclient's fintake fand foutput frecord ffrom fthe fitems flisted?
f
_____ fmL
1200 fmL fwater
4 founce fcontainer fof fgelatin
8 founces fof forange fjuice
355 fmL fcan fof fsoda1 fcup fof fsoup Answer: f2155
Rationale: f1200 f+ f240 f(8 foz) f+ f240 f(1 fcup) f+ f120 f(4 foz) f+ f355 f= f2155
The fnurse fobserves fa fUAP ftaking fa fclient's fblood fpressure fin fthe flower fextremity. fWhich fobservation fof
fthis fprocedure frequires fthe fnurse fto fintervene fwith fthe fUAP's fapproach?
A.
The fcuff fwraps faround fthe fgirth fof fthe fleg.
f B.
,The fUAP fauscultates fthe fpopliteal fpulse fwith fthe fcuff fon fthe flower fleg.
f C.
The fclient fis fplaced fin fa fprone fposition.
f D.
The fsystolic freading fis f20 fmm fHg fhigher fthan fthe fblood fpressure fin fthe fclient's farm. B
Rationale: fWhen fobtaining fthe fblood fpressure fin fthe flower fextremities, fthe fpopliteal fpulse fis fthe fsite ffor
fauscultation fwhen fthe fblood fpressure fcuff fis fapplied faround fthe fthigh. fThe fnurse fshould fintervene fwith
f
the fUAP fwho fhas fapplied fthe fcuff fon fthe flower fleg. fOption fA fensures fan faccurate fassessment, fand
f
option fC fprovides fthe fbest faccess fto fthe fartery. fSystolic fpressure fin fthe fpopliteal fartery fis fusually f10 fto
f40 fmm fHg fhigher fthan fin fthe fbrachial fartery.
During fa fclinic fvisit, fthe fmother fof fa f7-year-old freports fto fthe fnurse fthat fher fchild fis foften fawake funtil
fmidnight fplaying fand fis fthen fvery fdifficult fto fawaken fin fthe fmorning ffor fschool. fWhich fassessment fdata
fshould fthe fnurse fobtain fin fresponse fto fthe fmother's fconcern?
A.
The foccurrence fof fany fepisodes fof fsleep fapnea
f B.
The fchild's fblood fpressure, fpulse, fand frespirations
f
C.
Length fof frapid feye fmovement f(REM) fsleep fthat fthe fchild fis fexperiencing
f
D.
Description fof fthe ffamily's fhome fenvironment D
Rationale: fSchool-age fchildren foften fresist fbedtime. fThe fnurse fshould fbegin fby fassessing fthe
fenvironment fof fthe fhome fto fdetermine ffactors fthat fmay fnot fbe fconducive fto fthe festablishment fof
fbedtime frituals fthat fpromote fsleep. fOption fA foften fcauses fdaytime ffatigue frather fthan fresistance fto
fgoing fto fsleep. fOption fB fis funlikely fto fprovide fuseful fdata. fThe fnurse fcannot fdetermine foption fC.
The fnurse fidentifies fa fpotential ffor finfection fin fa fclient fwith fpartial-thickness f(second-degree) fand ffull-
thickness f(third-degree) fburns. fWhat faction fhas fthe fhighest fpriority fin fdecreasing fthe fclient's frisk fof
finfection?
A.
Administration fof fplasma fexpanders
f B.
Use fof fcareful fhandwashing ftechnique
f C.
, Application fof fa ftopical fantibacterial fcream
f D.
Limiting fvisitors fto fthe fclient fwith fburns B
Rationale: fCareful fhandwashing ftechnique fis fthe fsingle fmost feffective fintervention ffor fthe fprevention fof
fcontamination fto fall fclients. fOption fA freverses fthe fhypovolemia fthat finitially faccompanies fburn ftrauma
f
but fis fnot frelated fto fdecreasing fthe fproliferation fof finfective forganisms. fOptions fC fand fD fare
frecommended fby fvarious fburn fcenters fas fpossible fways fto freduce fthe fchance fof finfection. fOption fB fis fa
f
proven ftechnique fto fprevent finfection.
The fnurse fassesses fa f2-year-old fwho fis fadmitted ffor fdehydration fand ffinds fthat fthe fperipheral fIV frate fby
fgravity fhas fslowed, feven fthough fthe fvenous faccess fsite fis fhealthy. fWhat fshould fthe fnurse fdo fnext?
A.
Apply fa fwarm fcompress fproximal fto fthe fsite.
f B.
Check ffor fkinks fin fthe ftubing fand fraise fthe fIV fpole.
f C.
Adjust fthe ftape fthat fstabilizes fthe fneedle.
f
D.
Flush fwith fnormal fsaline fand frecount fthe fdrop frate. B
Rationale: fThe fnurse fshould ffirst fcheck fthe ftubing fand fheight fof fthe fbag fon fthe fIV fpole, fwhich fare
fcommon ffactors fthat fmay fslow fthe frate. fGravity finfusion frates fare finfluenced fby fthe fheight fof fthe fbag,
ftubing fclamp fclosure for fkinks, fneedle fsize for fposition, ffluid fviscosity, fclient fblood fpressure f(crying fin fthe
f
pediatric fclient), fand finfiltration. fVenospasm fcan fslow fthe frate fand foften fresponds fto fwarmth fover fthe
f
vessel, fbut fthe fnurse fshould ffirst fadjust fthe fIV fpole fheight. fThe fnurse fmay fneed fto fadjust fthe fstabilizing
ftape fon fa fpositional fneedle for fflush fthe fvenous faccess fwith fnormal fsaline, fbut fless finvasive factions
fshould fbe fimplemented ffirst.
The fnurse fmanager fof fa fskilled fnursing f(chronic fcare) funit fis finstructing fUAPs fon fways fto fprevent
fcomplications fof fimmobility. fWhich faction fshould fbe fincluded fin fthis finstruction?
A.
Perform frange-of-motion fexercises fto fprevent fcontractures.
f B.
Decrease fthe fclient's ffluid fintake fto fprevent fdiarrhea.
f C.
Massage fthe fclient's flegs fto freduce fembolism foccurrence.
LATEST 2024-2025 ACTUAL EXAM 100
QUESTIONS AND ANSWERS
The fnurse fis fcalled fto fthe fwaiting froom fof fa fpediatric fclinic. fThe ffrantic fmother fstates, f"I fthink fmy f4-
month-old fbaby fis fchoking!" fWhat fsteps fwill fthe fnurse ftake? f(Select fall fthat fapply.)
A.
Compress fthe fchest fonce fbetween fthe fnipples fwith ftwo ffingers.
f
B.
Note fany fobstruction for fabsence fof fbreathing.
f
C.
Deliver ffive fbackslaps fbetween fthe fshoulder fblades.
f
D.
Place fthe finfant fover fthe fnurse's farm.
f E.
Perform fa fblind ffinger fsweep. B, fC, fD
Rationale: fThe ffingers fare fplaced fat fthe fsame flocation fon fan finfant fas fchest fcompressions ffor fCPR;
fhowever, fthe fnurse fmust fdeliver ffive fchest fthrusts, fafter fthe ffive fback fslaps. fBlind fsweeps fare fnot fused
fas fthis faction fmay fpush fthe fobject fdeeper finto fthe fthroat. fThe fremaining fsteps fare fcorrect.
Which ffluid fwill fthe fnurse fselect fto fadminister fwith fthe fprescribed fblood ftransfusion?
A.
5% fDextrose fand fwater
f B.
Normal fsaline
f C.
Lactated fRingers fsolution
f D.
,5% fDextrose fand flactated fringers Bf
Rationale: fNormal fsaline fsolution fis fthe fonly fsolution fthat fis fcompatible fwith fblood.
When fassisting fa fclient ffrom fthe fbed fto fa fchair, fwhich fprocedure fis fbest ffor fthe fnurse fto ffollow?
A.
Place fthe fchair fparallel fto fthe fbed, fwith fits fback ftoward fthe fhead fof fthe fbed fand fassist fthe fclient fin
f
moving fto fthe fchair.
f B.
With fthe fnurse's ffeet fspread fapart fand fknees faligned fwith fthe fclient's fknees, fstand fand fpivot fthe fclient
f
into fthe fchair.
f C.
Assist fthe fclient fto fa fstanding fposition fby fgently flifting fupward, funderneath fthe faxillae.
f D.
Stand fbeside fthe fclient, fplace fthe fclient's farms faround fthe fnurse's fneck, fand fgently fmove fthe fclient fto
fthe fchair. B
Rationale: fOption fB fdescribes fthe fcorrect fpositioning fof fthe fnurse fand faffords fthe fnurse fa fwide fbase fof
fsupport fwhile fstabilizing fthe fclient's fknees fwhen fassisting fto fa fstanding fposition. fThe fchair fshould fbe
fplaced fat fa f45-degree fangle fto fthe fbed, fwith fthe fback fof fthe fchair ftoward fthe fhead fof fthe fbed. fClients
fshould fnever fbe flifted funder fthe faxillae; fthis fcould fdamage fnerves fand fstrain fthe fnurse's fback. fThe
fclient fshould fbe finstructed fto fuse fthe farms fof fthe fchair fand fshould fnever fplace fhis for fher farms faround
fthe fnurse's fneck; fthis fplaces fundue fstress fon fthe fnurse's fneck fand fback fand fincreases fthe frisk ffor fa ffall.
How fmany fmL fwill fthe fnurse fdocument fon fthe fclient's fintake fand foutput frecord ffrom fthe fitems flisted?
f
_____ fmL
1200 fmL fwater
4 founce fcontainer fof fgelatin
8 founces fof forange fjuice
355 fmL fcan fof fsoda1 fcup fof fsoup Answer: f2155
Rationale: f1200 f+ f240 f(8 foz) f+ f240 f(1 fcup) f+ f120 f(4 foz) f+ f355 f= f2155
The fnurse fobserves fa fUAP ftaking fa fclient's fblood fpressure fin fthe flower fextremity. fWhich fobservation fof
fthis fprocedure frequires fthe fnurse fto fintervene fwith fthe fUAP's fapproach?
A.
The fcuff fwraps faround fthe fgirth fof fthe fleg.
f B.
,The fUAP fauscultates fthe fpopliteal fpulse fwith fthe fcuff fon fthe flower fleg.
f C.
The fclient fis fplaced fin fa fprone fposition.
f D.
The fsystolic freading fis f20 fmm fHg fhigher fthan fthe fblood fpressure fin fthe fclient's farm. B
Rationale: fWhen fobtaining fthe fblood fpressure fin fthe flower fextremities, fthe fpopliteal fpulse fis fthe fsite ffor
fauscultation fwhen fthe fblood fpressure fcuff fis fapplied faround fthe fthigh. fThe fnurse fshould fintervene fwith
f
the fUAP fwho fhas fapplied fthe fcuff fon fthe flower fleg. fOption fA fensures fan faccurate fassessment, fand
f
option fC fprovides fthe fbest faccess fto fthe fartery. fSystolic fpressure fin fthe fpopliteal fartery fis fusually f10 fto
f40 fmm fHg fhigher fthan fin fthe fbrachial fartery.
During fa fclinic fvisit, fthe fmother fof fa f7-year-old freports fto fthe fnurse fthat fher fchild fis foften fawake funtil
fmidnight fplaying fand fis fthen fvery fdifficult fto fawaken fin fthe fmorning ffor fschool. fWhich fassessment fdata
fshould fthe fnurse fobtain fin fresponse fto fthe fmother's fconcern?
A.
The foccurrence fof fany fepisodes fof fsleep fapnea
f B.
The fchild's fblood fpressure, fpulse, fand frespirations
f
C.
Length fof frapid feye fmovement f(REM) fsleep fthat fthe fchild fis fexperiencing
f
D.
Description fof fthe ffamily's fhome fenvironment D
Rationale: fSchool-age fchildren foften fresist fbedtime. fThe fnurse fshould fbegin fby fassessing fthe
fenvironment fof fthe fhome fto fdetermine ffactors fthat fmay fnot fbe fconducive fto fthe festablishment fof
fbedtime frituals fthat fpromote fsleep. fOption fA foften fcauses fdaytime ffatigue frather fthan fresistance fto
fgoing fto fsleep. fOption fB fis funlikely fto fprovide fuseful fdata. fThe fnurse fcannot fdetermine foption fC.
The fnurse fidentifies fa fpotential ffor finfection fin fa fclient fwith fpartial-thickness f(second-degree) fand ffull-
thickness f(third-degree) fburns. fWhat faction fhas fthe fhighest fpriority fin fdecreasing fthe fclient's frisk fof
finfection?
A.
Administration fof fplasma fexpanders
f B.
Use fof fcareful fhandwashing ftechnique
f C.
, Application fof fa ftopical fantibacterial fcream
f D.
Limiting fvisitors fto fthe fclient fwith fburns B
Rationale: fCareful fhandwashing ftechnique fis fthe fsingle fmost feffective fintervention ffor fthe fprevention fof
fcontamination fto fall fclients. fOption fA freverses fthe fhypovolemia fthat finitially faccompanies fburn ftrauma
f
but fis fnot frelated fto fdecreasing fthe fproliferation fof finfective forganisms. fOptions fC fand fD fare
frecommended fby fvarious fburn fcenters fas fpossible fways fto freduce fthe fchance fof finfection. fOption fB fis fa
f
proven ftechnique fto fprevent finfection.
The fnurse fassesses fa f2-year-old fwho fis fadmitted ffor fdehydration fand ffinds fthat fthe fperipheral fIV frate fby
fgravity fhas fslowed, feven fthough fthe fvenous faccess fsite fis fhealthy. fWhat fshould fthe fnurse fdo fnext?
A.
Apply fa fwarm fcompress fproximal fto fthe fsite.
f B.
Check ffor fkinks fin fthe ftubing fand fraise fthe fIV fpole.
f C.
Adjust fthe ftape fthat fstabilizes fthe fneedle.
f
D.
Flush fwith fnormal fsaline fand frecount fthe fdrop frate. B
Rationale: fThe fnurse fshould ffirst fcheck fthe ftubing fand fheight fof fthe fbag fon fthe fIV fpole, fwhich fare
fcommon ffactors fthat fmay fslow fthe frate. fGravity finfusion frates fare finfluenced fby fthe fheight fof fthe fbag,
ftubing fclamp fclosure for fkinks, fneedle fsize for fposition, ffluid fviscosity, fclient fblood fpressure f(crying fin fthe
f
pediatric fclient), fand finfiltration. fVenospasm fcan fslow fthe frate fand foften fresponds fto fwarmth fover fthe
f
vessel, fbut fthe fnurse fshould ffirst fadjust fthe fIV fpole fheight. fThe fnurse fmay fneed fto fadjust fthe fstabilizing
ftape fon fa fpositional fneedle for fflush fthe fvenous faccess fwith fnormal fsaline, fbut fless finvasive factions
fshould fbe fimplemented ffirst.
The fnurse fmanager fof fa fskilled fnursing f(chronic fcare) funit fis finstructing fUAPs fon fways fto fprevent
fcomplications fof fimmobility. fWhich faction fshould fbe fincluded fin fthis finstruction?
A.
Perform frange-of-motion fexercises fto fprevent fcontractures.
f B.
Decrease fthe fclient's ffluid fintake fto fprevent fdiarrhea.
f C.
Massage fthe fclient's flegs fto freduce fembolism foccurrence.
