HESI RN FUNDAMENTALS EXIT EXAM
LATEST 2024-2025 ACTUAL EXAM 125
QUESTIONS AND CORRECT ANSWERS
WITH RATIOANLES (VERIFIED
ANSWERS)
The nurse is called to the waiting room of a pediatric clinic. The frantic mother states, "I think
my 4-month-old baby is choking!" What steps will the nurse take? (Select all that apply.)
A.
Compress the chest once between the nipples with two fingers.
B.
Note any obstruction or absence of breathing.
C.
Deliver five backslaps between the shoulder blades.
D.
Place the infant over the nurse's arm.
E.
Perform a blind finger sweep.
B, C, D
Rationale: The fingers are placed at the same location on an infant as chest compressions for
CPR; however, the nurse must deliver five chest thrusts, after the five back slaps. Blind sweeps
are not used as this action may push the object deeper into the throat. The remaining steps are
correct.
Which fluid will the nurse select to administer with the prescribed blood transfusion?
A.
5% Dextrose and water
B.
Normal saline
C.
Lactated Ringers solution
D.
5% Dextrose and lactated ringers
,B
Rationale: Normal saline solution is the only solution that is compatible with blood.
When assisting a client from the bed to a chair, which procedure is best for the nurse to follow?
A.
Place the chair parallel to the bed, with its back toward the head of the bed and assist the client
in moving to the chair.
B.
With the nurse's feet spread apart and knees aligned with the client's knees, stand and pivot
the client into the chair.
C.
Assist the client to a standing position by gently lifting upward, underneath the axillae.
D.
Stand beside the client, place the client's arms around the nurse's neck, and gently move the
client to the chair.
B
Rationale: Option B describes the correct positioning of the nurse and affords the nurse a wide
base of support while stabilizing the client's knees when assisting to a standing position. The
chair should be placed at a 45-degree angle to the bed, with the back of the chair toward the
head of the bed. Clients should never be lifted under the axillae; this could damage nerves and
strain the nurse's back. The client should be instructed to use the arms of the chair and should
never place his or her arms around the nurse's neck; this places undue stress on the nurse's
neck and back and increases the risk for a fall.
How many mL will the nurse document on the client's intake and output record from the items
listed? _____ mL
1200 mL water
4 ounce container of gelatin
8 ounces of orange juice
355 mL can of soda1 cup of soup
Answer: 2155
Rationale: 1200 + 240 (8 oz) + 240 (1 cup) + 120 (4 oz) + 355 = 2155
The nurse observes a UAP taking a client's blood pressure in the lower extremity. Which
observation of this procedure requires the nurse to intervene with the UAP's approach?
A.
The cuff wraps around the girth of the leg.
B.
The UAP auscultates the popliteal pulse with the cuff on the lower leg.
,C.
The client is placed in a prone position.
D.
The systolic reading is 20 mm Hg higher than the blood pressure in the client's arm.
B
Rationale: When obtaining the blood pressure in the lower extremities, the popliteal pulse is
the site for auscultation when the blood pressure cuff is applied around the thigh. The nurse
should intervene with the UAP who has applied the cuff on the lower leg. Option A ensures an
accurate assessment, and option C provides the best access to the artery. Systolic pressure in
the popliteal artery is usually 10 to 40 mm Hg higher than in the brachial artery.
During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often awake
until midnight playing and is then very difficult to awaken in the morning for school. Which
assessment data should the nurse obtain in response to the mother's concern?
A.
The occurrence of any episodes of sleep apnea
B.
The child's blood pressure, pulse, and respirations
C.
Length of rapid eye movement (REM) sleep that the child is experiencing
D.
Description of the family's home environment
D
Rationale: School-age children often resist bedtime. The nurse should begin by assessing the
environment of the home to determine factors that may not be conducive to the establishment
of bedtime rituals that promote sleep. Option A often causes daytime fatigue rather than
resistance to going to sleep. Option B is unlikely to provide useful data. The nurse cannot
determine option C.
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.
LATEST 2024-2025 ACTUAL EXAM 125
QUESTIONS AND CORRECT ANSWERS
WITH RATIOANLES (VERIFIED
ANSWERS)
The nurse is called to the waiting room of a pediatric clinic. The frantic mother states, "I think
my 4-month-old baby is choking!" What steps will the nurse take? (Select all that apply.)
A.
Compress the chest once between the nipples with two fingers.
B.
Note any obstruction or absence of breathing.
C.
Deliver five backslaps between the shoulder blades.
D.
Place the infant over the nurse's arm.
E.
Perform a blind finger sweep.
B, C, D
Rationale: The fingers are placed at the same location on an infant as chest compressions for
CPR; however, the nurse must deliver five chest thrusts, after the five back slaps. Blind sweeps
are not used as this action may push the object deeper into the throat. The remaining steps are
correct.
Which fluid will the nurse select to administer with the prescribed blood transfusion?
A.
5% Dextrose and water
B.
Normal saline
C.
Lactated Ringers solution
D.
5% Dextrose and lactated ringers
,B
Rationale: Normal saline solution is the only solution that is compatible with blood.
When assisting a client from the bed to a chair, which procedure is best for the nurse to follow?
A.
Place the chair parallel to the bed, with its back toward the head of the bed and assist the client
in moving to the chair.
B.
With the nurse's feet spread apart and knees aligned with the client's knees, stand and pivot
the client into the chair.
C.
Assist the client to a standing position by gently lifting upward, underneath the axillae.
D.
Stand beside the client, place the client's arms around the nurse's neck, and gently move the
client to the chair.
B
Rationale: Option B describes the correct positioning of the nurse and affords the nurse a wide
base of support while stabilizing the client's knees when assisting to a standing position. The
chair should be placed at a 45-degree angle to the bed, with the back of the chair toward the
head of the bed. Clients should never be lifted under the axillae; this could damage nerves and
strain the nurse's back. The client should be instructed to use the arms of the chair and should
never place his or her arms around the nurse's neck; this places undue stress on the nurse's
neck and back and increases the risk for a fall.
How many mL will the nurse document on the client's intake and output record from the items
listed? _____ mL
1200 mL water
4 ounce container of gelatin
8 ounces of orange juice
355 mL can of soda1 cup of soup
Answer: 2155
Rationale: 1200 + 240 (8 oz) + 240 (1 cup) + 120 (4 oz) + 355 = 2155
The nurse observes a UAP taking a client's blood pressure in the lower extremity. Which
observation of this procedure requires the nurse to intervene with the UAP's approach?
A.
The cuff wraps around the girth of the leg.
B.
The UAP auscultates the popliteal pulse with the cuff on the lower leg.
,C.
The client is placed in a prone position.
D.
The systolic reading is 20 mm Hg higher than the blood pressure in the client's arm.
B
Rationale: When obtaining the blood pressure in the lower extremities, the popliteal pulse is
the site for auscultation when the blood pressure cuff is applied around the thigh. The nurse
should intervene with the UAP who has applied the cuff on the lower leg. Option A ensures an
accurate assessment, and option C provides the best access to the artery. Systolic pressure in
the popliteal artery is usually 10 to 40 mm Hg higher than in the brachial artery.
During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often awake
until midnight playing and is then very difficult to awaken in the morning for school. Which
assessment data should the nurse obtain in response to the mother's concern?
A.
The occurrence of any episodes of sleep apnea
B.
The child's blood pressure, pulse, and respirations
C.
Length of rapid eye movement (REM) sleep that the child is experiencing
D.
Description of the family's home environment
D
Rationale: School-age children often resist bedtime. The nurse should begin by assessing the
environment of the home to determine factors that may not be conducive to the establishment
of bedtime rituals that promote sleep. Option A often causes daytime fatigue rather than
resistance to going to sleep. Option B is unlikely to provide useful data. The nurse cannot
determine option C.
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.
