HESI RN FUNDAMENTALS EXIT EXAM
LATEST 2024-2025 ACTUAL EXAM 100
QUESTIONS AND CORRECT ANSWERS
WITH RATIOANLES (VERIFIED
ANSWERS)
Thexcnursexcisxccalledxctoxcthexcwaitingxcroomxcofxcaxcpediatricxcclinic.xcThexcfranticxcmother
xcstates,xc"Ixcthinkxcmyxc4-month-
oldxcbabyxcisxcchoking!"xcWhatxcstepsxcwillxcthexcnursexctake?xc(Selectxcallxcthatxcapply.)
A.
Compressxcthexcchestxconcexcbetweenxcthexcnipplesxcwithxctwoxcfingers.
xcB.
Notexcanyxcobstructionxcorxcabsencexcofxcbreathing.
xcC.
Deliverxcfivexcbackslapsxcbetweenxcthexcshoulderxcblades.
xcD.
Placexcthexcinfantxcoverxcthexcnurse'sxcarm.
xcE.
Performxcaxcblindxcfingerxcsweep.xc-xcanswer--B,xcC,xcD
Rationale:xcThexcfingersxcarexcplacedxcatxcthexcsamexclocationxconxcanxcinfantxcasxcchestxcc
ompressionsxcforxcCPR;xchowever,xcthexcnursexcmustxcdeliverxcfivexcchestxcthrusts,xcafterxc
thexcfivexcbackxcslaps.xcBlindxcsweepsxcarexcnotxcusedxcasxcthisxcactionxcmayxcpushxcthexco
bjectxcdeeperxcintoxcthexcthroat.xcThexcremainingxcstepsxcarexccorrect.
Whichxcfluidxcwillxcthexcnursexcselectxctoxcadministerxcwithxcthexcprescribedxcbloodxctransfu
sion?
A.
5%xcDextrosexcandxcwater
xcB.
Normalxcsaline
xcC.
LactatedxcRingersxcsolution
xcD.
5%xcDextrosexcandxclactatedxcringersxc-xcanswer--Bxc
Rationale:xcNormalxcsalinexcsolutionxcisxcthexconlyxcsolutionxcthatxcisxccompatiblexcwithxcblo
od.
Whenxcassistingxcaxcclientxcfromxcthexcbedxctoxcaxcchair,xcwhichxcprocedurexcisxcbestxcforxcth
excnursexctoxcfollow?
A.
Placexcthexcchairxcparallelxctoxcthexcbed,xcwithxcitsxcbackxctowardxcthexcheadxcofxcthexcbedxca
ndxcassistxcthexcclientxcinxcmovingxctoxcthexcchair.
,xcB.
Withxcthexcnurse'sxcfeetxcspreadxcapartxcandxckneesxcalignedxcwithxcthexcclient'sxcknees,xcst
andxcandxcpivotxcthexcclientxcintoxcthexcchair.
xcC.
Assistxcthexcclientxctoxcaxcstandingxcpositionxcbyxcgentlyxcliftingxcupward,xcunderneathxcthexc
axillae.
xcD.
Standxcbesidexcthexcclient,xcplacexcthexcclient'sxcarmsxcaroundxcthexcnurse'sxcneck,xcandxcg
entlyxcmovexcthexcclientxctoxcthexcchair.xc-xcanswer--B
Rationale:xcOptionxcBxcdescribesxcthexccorrectxcpositioningxcofxcthexcnursexcandxcaffordsxct
hexcnursexcaxcwidexcbasexcofxcsupportxcwhilexcstabilizingxcthexcclient'sxckneesxcwhenxcassis
tingxctoxcaxcstandingxcposition.xcThexcchairxcshouldxcbexcplacedxcatxcaxc45-
degreexcanglexctoxcthexcbed,xcwithxcthexcbackxcofxcthexcchairxctowardxcthexcheadxcofxcthexcbe
d.xcClientsxcshouldxcneverxcbexcliftedxcunderxcthexcaxillae;xcthisxccouldxcdamagexcnervesxca
ndxcstrainxcthexcnurse'sxcback.xcThexcclientxcshouldxcbexcinstructedxctoxcusexcthexcarmsxcofxc
thexcchairxcandxcshouldxcneverxcplacexchisxcorxcherxcarmsxcaroundxcthexcnurse'sxcneck;xcthis
xcplacesxcunduexcstressxconxcthexcnurse'sxcneckxcandxcbackxcandxcincreasesxcthexcriskxcforxc
axcfall.
HowxcmanyxcmLxcwillxcthexcnursexcdocumentxconxcthexcclient'sxcintakexcandxcoutputxcrecord
xcfromxcthexcitemsxclisted?xc_____xcmL
1200xcmLxcwater
4xcouncexccontainerxcofxcgelatin
8xcouncesxcofxcorangexcjuice
355xcmLxccanxcofxcsoda1xccupxcofxcsoupxc-xcanswer--Answer:xc2155
Rationale:xc1200xc+xc240xc(8xcoz)xc+xc240xc(1xccup)xc+xc120xc(4xcoz)xc+xc355xc=xc2155
ThexcnursexcobservesxcaxcUAPxctakingxcaxcclient'sxcbloodxcpressurexcinxcthexclowerxcextre
mity.xcWhichxcobservationxcofxcthisxcprocedurexcrequiresxcthexcnursexctoxcintervenexcwithxct
hexcUAP'sxcapproach?
A.
Thexccuffxcwrapsxcaroundxcthexcgirthxcofxcthexcleg.
xcB.
ThexcUAPxcauscultatesxcthexcpoplitealxcpulsexcwithxcthexccuffxconxcthexclowerxcleg.
xcC.
Thexcclientxcisxcplacedxcinxcaxcpronexcposition.
xcD.
Thexcsystolicxcreadingxcisxc20xcmmxcHgxchigherxcthanxcthexcbloodxcpressurexcinxcthexcclient'
sxcarm.xc-xcanswer--B
Rationale:xcWhenxcobtainingxcthexcbloodxcpressurexcinxcthexclowerxcextremities,xcthexcpopli
tealxcpulsexcisxcthexcsitexcforxcauscultationxcwhenxcthexcbloodxcpressurexccuffxcisxcappliedxca
roundxcthexcthigh.xcThexcnursexcshouldxcintervenexcwithxcthexcUAPxcwhoxchasxcappliedxcthe
xccuffxconxcthexclowerxcleg.xcOptionxcAxcensuresxcanxcaccuratexcassessment,xcandxcoptionxc
Cxcprovidesxcthexcbestxcaccessxctoxcthexcartery.xcSystolicxcpressurexcinxcthexcpoplitealxcarte
ryxcisxcusuallyxc10xctoxc40xcmmxcHgxchigherxcthanxcinxcthexcbrachialxcartery.
Duringxcaxcclinicxcvisit,xcthexcmotherxcofxcaxc7-year-
oldxcreportsxctoxcthexcnursexcthatxcherxcchildxcisxcoftenxcawakexcuntilxcmidnightxcplayingxcan
dxcisxcthenxcveryxcdifficultxctoxcawakenxcinxcthexcmorningxcforxcschool.xcWhichxcassessmentx
cdataxcshouldxcthexcnursexcobtainxcinxcresponsexctoxcthexcmother'sxcconcern?
,A.
Thexcoccurrencexcofxcanyxcepisodesxcofxcsleepxcapnea
xcB.
Thexcchild'sxcbloodxcpressure,xcpulse,xcandxcrespirations
xcC.
Lengthxcofxcrapidxceyexcmovementxc(REM)xcsleepxcthatxcthexcchildxcisxcexperiencing
xcD.
Descriptionxcofxcthexcfamily'sxchomexcenvironmentxc-xcanswer--D
Rationale:xcSchool-
agexcchildrenxcoftenxcresistxcbedtime.xcThexcnursexcshouldxcbeginxcbyxcassessingxcthexcen
vironmentxcofxcthexchomexctoxcdeterminexcfactorsxcthatxcmayxcnotxcbexcconducivexctoxcthexc
establishmentxcofxcbedtimexcritualsxcthatxcpromotexcsleep.xcOptionxcAxcoftenxccausesxcday
timexcfatiguexcratherxcthanxcresistancexctoxcgoingxctoxcsleep.xcOptionxcBxcisxcunlikelyxctoxcpr
ovidexcusefulxcdata.xcThexcnursexccannotxcdeterminexcoptionxcC.
Thexcnursexcidentifiesxcaxcpotentialxcforxcinfectionxcinxcaxcclientxcwithxcpartial-
thicknessxc(second-degree)xcandxcfull-thicknessxc(third-
degree)xcburns.xcWhatxcactionxchasxcthexchighestxcpriorityxcinxcdecreasingxcthexcclient'sxcris
kxcofxcinfection?
A.
Administrationxcofxcplasmaxcexpanders
xcB.
Usexcofxccarefulxchandwashingxctechnique
xcC.
Applicationxcofxcaxctopicalxcantibacterialxccream
xcD.
Limitingxcvisitorsxctoxcthexcclientxcwithxcburnsxc-xcanswer--B
Rationale:xcCarefulxchandwashingxctechniquexcisxcthexcsinglexcmostxceffectivexcinterventi
onxcforxcthexcpreventionxcofxccontaminationxctoxcallxcclients.xcOptionxcAxcreversesxcthexchyp
ovolemiaxcthatxcinitiallyxcaccompaniesxcburnxctraumaxcbutxcisxcnotxcrelatedxctoxcdecreasing
xcthexcproliferationxcofxcinfectivexcorganisms.xcOptionsxcCxcandxcDxcarexcrecommendedxcby
xcvariousxcburnxccentersxcasxcpossiblexcwaysxctoxcreducexcthexcchancexcofxcinfection.xcOpti
onxcBxcisxcaxcprovenxctechniquexctoxcpreventxcinfection.
Thexcnursexcassessesxcaxc2-year-
oldxcwhoxcisxcadmittedxcforxcdehydrationxcandxcfindsxcthatxcthexcperipheralxcIVxcratexcbyxcgra
vityxchasxcslowed,xcevenxcthoughxcthexcvenousxcaccessxcsitexcisxchealthy.xcWhatxcshouldxct
hexcnursexcdoxcnext?
A.
Applyxcaxcwarmxccompressxcproximalxctoxcthexcsite.
xcB.
CheckxcforxckinksxcinxcthexctubingxcandxcraisexcthexcIVxcpole.
xcC.
Adjustxcthexctapexcthatxcstabilizesxcthexcneedle.
xcD.
Flushxcwithxcnormalxcsalinexcandxcrecountxcthexcdropxcrate.xc-xcanswer--B
Rationale:xcThexcnursexcshouldxcfirstxccheckxcthexctubingxcandxcheightxcofxcthexcbagxconxcth
excIVxcpole,xcwhichxcarexccommonxcfactorsxcthatxcmayxcslowxcthexcrate.xcGravityxcinfusionxcr
atesxcarexcinfluencedxcbyxcthexcheightxcofxcthexcbag,xctubingxcclampxcclosurexcorxckinks,xcne
edlexcsizexcorxcposition,xcfluidxcviscosity,xcclientxcbloodxcpressurexc(cryingxcinxcthexcpediatri
, cxcclient),xcandxcinfiltration.xcVenospasmxccanxcslowxcthexcratexcandxcoftenxcrespondsxctoxc
warmthxcoverxcthexcvessel,xcbutxcthexcnursexcshouldxcfirstxcadjustxcthexcIVxcpolexcheight.xcT
hexcnursexcmayxcneedxctoxcadjustxcthexcstabilizingxctapexconxcaxcpositionalxcneedlexcorxcflus
hxcthexcvenousxcaccessxcwithxcnormalxcsaline,xcbutxclessxcinvasivexcactionsxcshouldxcbexcim
plementedxcfirst.
Thexcnursexcmanagerxcofxcaxcskilledxcnursingxc(chronicxccare)xcunitxcisxcinstructingxcUAPsxc
onxcwaysxctoxcpreventxccomplicationsxcofxcimmobility.xcWhichxcactionxcshouldxcbexcinclude
dxcinxcthisxcinstruction?
A.
Performxcrange-of-motionxcexercisesxctoxcpreventxccontractures.
xcB.
Decreasexcthexcclient'sxcfluidxcintakexctoxcpreventxcdiarrhea.
xcC.
Massagexcthexcclient'sxclegsxctoxcreducexcembolismxcoccurrence.
xcD.
Turnxcthexcclientxcfromxcsidexctoxcbackxceveryxcshift.xc-xcanswer--A
Rationale:xcPerformingxcrange-of-
motionxcexercisesxcisxcbeneficialxcinxcreducingxccontracturesxcaroundxcjoints.xcOptionsxcB,
xcC,xcandxcDxcarexcallxcpotentiallyxcharmfulxcpracticesxcthatxcplacexcthexcimmobilexcclientxcatx
criskxcofxccomplications.
Thexcnursexcadministeredxc10xcmgxcofxcdiazepamxctoxcthexcpreoperativexcclient.xcWhatxcst
epsxcwillxcthexcnursexctakexcnext?xc(Selectxcallxcthatxcapply.)
A.
Placexcthexcclientxcinxcthexcbedxcnextxctoxcthexcnurse'sxcstation.
xcB.
Instructxcthexcclientxcnotxctoxcgetxcoutxcofxcbed.
xcC.
Placexcthexccallxcbellxcwithinxcthexcclient'sxcreach.
xcD.
Placexcthexcsidexcrailsxcup,xcaccordingxctoxcinstitutionalxcpolicy.
xcE.
Assistxcthexcclientxctoxcthexcbathroomxc-xcanswer--B,xcC,xcD
Rationale:xcDiazepamxcisxcaxccommonxcpreoperativexcmedication.xcClosexcobservationxcb
yxcplacingxcthexcclientxcclosexctoxcthexcnurse'sxcstationxcisxcnotxcnecessary.xcThexcmedicatio
nxchasxcaxcsedativexceffectxcandxcthexcclientxcshouldxcnotxcgetxcoutxcofxcbed,xcevenxcwithxcas
sistance.xcThexcremainingxcselectionsxcarexccorrect.
Axcterminallyxcillxcclientxctellsxcthexcnurse,xc"Ixcamxcsoxctiredxcandxcinxcsoxcmuchxcpain!
xcPleasexchelpxcmexctoxcdie."xcWhichxcisxcthexcbestxcresponsexcforxcthexcnursexctoxcprovide?
A.
Administerxcthexcprescribedxcmaximumxcdosexcofxcpainxcmedication.
xcB.
Talkxcwithxcthexcclientxcaboutxcthoughtsxcandxcfeelingsxcaboutxcdeath.
xcC.
Collaboratexcwithxcthexchealthxccarexcproviderxcaboutxcinitiatingxcantidepressantxctherapy.
xcD.
Referxcthexcclientxctoxcthexcethicsxccommitteexcofxcherxclocalxchealthxccarexcfacility.xc-
xcanswer--B
LATEST 2024-2025 ACTUAL EXAM 100
QUESTIONS AND CORRECT ANSWERS
WITH RATIOANLES (VERIFIED
ANSWERS)
Thexcnursexcisxccalledxctoxcthexcwaitingxcroomxcofxcaxcpediatricxcclinic.xcThexcfranticxcmother
xcstates,xc"Ixcthinkxcmyxc4-month-
oldxcbabyxcisxcchoking!"xcWhatxcstepsxcwillxcthexcnursexctake?xc(Selectxcallxcthatxcapply.)
A.
Compressxcthexcchestxconcexcbetweenxcthexcnipplesxcwithxctwoxcfingers.
xcB.
Notexcanyxcobstructionxcorxcabsencexcofxcbreathing.
xcC.
Deliverxcfivexcbackslapsxcbetweenxcthexcshoulderxcblades.
xcD.
Placexcthexcinfantxcoverxcthexcnurse'sxcarm.
xcE.
Performxcaxcblindxcfingerxcsweep.xc-xcanswer--B,xcC,xcD
Rationale:xcThexcfingersxcarexcplacedxcatxcthexcsamexclocationxconxcanxcinfantxcasxcchestxcc
ompressionsxcforxcCPR;xchowever,xcthexcnursexcmustxcdeliverxcfivexcchestxcthrusts,xcafterxc
thexcfivexcbackxcslaps.xcBlindxcsweepsxcarexcnotxcusedxcasxcthisxcactionxcmayxcpushxcthexco
bjectxcdeeperxcintoxcthexcthroat.xcThexcremainingxcstepsxcarexccorrect.
Whichxcfluidxcwillxcthexcnursexcselectxctoxcadministerxcwithxcthexcprescribedxcbloodxctransfu
sion?
A.
5%xcDextrosexcandxcwater
xcB.
Normalxcsaline
xcC.
LactatedxcRingersxcsolution
xcD.
5%xcDextrosexcandxclactatedxcringersxc-xcanswer--Bxc
Rationale:xcNormalxcsalinexcsolutionxcisxcthexconlyxcsolutionxcthatxcisxccompatiblexcwithxcblo
od.
Whenxcassistingxcaxcclientxcfromxcthexcbedxctoxcaxcchair,xcwhichxcprocedurexcisxcbestxcforxcth
excnursexctoxcfollow?
A.
Placexcthexcchairxcparallelxctoxcthexcbed,xcwithxcitsxcbackxctowardxcthexcheadxcofxcthexcbedxca
ndxcassistxcthexcclientxcinxcmovingxctoxcthexcchair.
,xcB.
Withxcthexcnurse'sxcfeetxcspreadxcapartxcandxckneesxcalignedxcwithxcthexcclient'sxcknees,xcst
andxcandxcpivotxcthexcclientxcintoxcthexcchair.
xcC.
Assistxcthexcclientxctoxcaxcstandingxcpositionxcbyxcgentlyxcliftingxcupward,xcunderneathxcthexc
axillae.
xcD.
Standxcbesidexcthexcclient,xcplacexcthexcclient'sxcarmsxcaroundxcthexcnurse'sxcneck,xcandxcg
entlyxcmovexcthexcclientxctoxcthexcchair.xc-xcanswer--B
Rationale:xcOptionxcBxcdescribesxcthexccorrectxcpositioningxcofxcthexcnursexcandxcaffordsxct
hexcnursexcaxcwidexcbasexcofxcsupportxcwhilexcstabilizingxcthexcclient'sxckneesxcwhenxcassis
tingxctoxcaxcstandingxcposition.xcThexcchairxcshouldxcbexcplacedxcatxcaxc45-
degreexcanglexctoxcthexcbed,xcwithxcthexcbackxcofxcthexcchairxctowardxcthexcheadxcofxcthexcbe
d.xcClientsxcshouldxcneverxcbexcliftedxcunderxcthexcaxillae;xcthisxccouldxcdamagexcnervesxca
ndxcstrainxcthexcnurse'sxcback.xcThexcclientxcshouldxcbexcinstructedxctoxcusexcthexcarmsxcofxc
thexcchairxcandxcshouldxcneverxcplacexchisxcorxcherxcarmsxcaroundxcthexcnurse'sxcneck;xcthis
xcplacesxcunduexcstressxconxcthexcnurse'sxcneckxcandxcbackxcandxcincreasesxcthexcriskxcforxc
axcfall.
HowxcmanyxcmLxcwillxcthexcnursexcdocumentxconxcthexcclient'sxcintakexcandxcoutputxcrecord
xcfromxcthexcitemsxclisted?xc_____xcmL
1200xcmLxcwater
4xcouncexccontainerxcofxcgelatin
8xcouncesxcofxcorangexcjuice
355xcmLxccanxcofxcsoda1xccupxcofxcsoupxc-xcanswer--Answer:xc2155
Rationale:xc1200xc+xc240xc(8xcoz)xc+xc240xc(1xccup)xc+xc120xc(4xcoz)xc+xc355xc=xc2155
ThexcnursexcobservesxcaxcUAPxctakingxcaxcclient'sxcbloodxcpressurexcinxcthexclowerxcextre
mity.xcWhichxcobservationxcofxcthisxcprocedurexcrequiresxcthexcnursexctoxcintervenexcwithxct
hexcUAP'sxcapproach?
A.
Thexccuffxcwrapsxcaroundxcthexcgirthxcofxcthexcleg.
xcB.
ThexcUAPxcauscultatesxcthexcpoplitealxcpulsexcwithxcthexccuffxconxcthexclowerxcleg.
xcC.
Thexcclientxcisxcplacedxcinxcaxcpronexcposition.
xcD.
Thexcsystolicxcreadingxcisxc20xcmmxcHgxchigherxcthanxcthexcbloodxcpressurexcinxcthexcclient'
sxcarm.xc-xcanswer--B
Rationale:xcWhenxcobtainingxcthexcbloodxcpressurexcinxcthexclowerxcextremities,xcthexcpopli
tealxcpulsexcisxcthexcsitexcforxcauscultationxcwhenxcthexcbloodxcpressurexccuffxcisxcappliedxca
roundxcthexcthigh.xcThexcnursexcshouldxcintervenexcwithxcthexcUAPxcwhoxchasxcappliedxcthe
xccuffxconxcthexclowerxcleg.xcOptionxcAxcensuresxcanxcaccuratexcassessment,xcandxcoptionxc
Cxcprovidesxcthexcbestxcaccessxctoxcthexcartery.xcSystolicxcpressurexcinxcthexcpoplitealxcarte
ryxcisxcusuallyxc10xctoxc40xcmmxcHgxchigherxcthanxcinxcthexcbrachialxcartery.
Duringxcaxcclinicxcvisit,xcthexcmotherxcofxcaxc7-year-
oldxcreportsxctoxcthexcnursexcthatxcherxcchildxcisxcoftenxcawakexcuntilxcmidnightxcplayingxcan
dxcisxcthenxcveryxcdifficultxctoxcawakenxcinxcthexcmorningxcforxcschool.xcWhichxcassessmentx
cdataxcshouldxcthexcnursexcobtainxcinxcresponsexctoxcthexcmother'sxcconcern?
,A.
Thexcoccurrencexcofxcanyxcepisodesxcofxcsleepxcapnea
xcB.
Thexcchild'sxcbloodxcpressure,xcpulse,xcandxcrespirations
xcC.
Lengthxcofxcrapidxceyexcmovementxc(REM)xcsleepxcthatxcthexcchildxcisxcexperiencing
xcD.
Descriptionxcofxcthexcfamily'sxchomexcenvironmentxc-xcanswer--D
Rationale:xcSchool-
agexcchildrenxcoftenxcresistxcbedtime.xcThexcnursexcshouldxcbeginxcbyxcassessingxcthexcen
vironmentxcofxcthexchomexctoxcdeterminexcfactorsxcthatxcmayxcnotxcbexcconducivexctoxcthexc
establishmentxcofxcbedtimexcritualsxcthatxcpromotexcsleep.xcOptionxcAxcoftenxccausesxcday
timexcfatiguexcratherxcthanxcresistancexctoxcgoingxctoxcsleep.xcOptionxcBxcisxcunlikelyxctoxcpr
ovidexcusefulxcdata.xcThexcnursexccannotxcdeterminexcoptionxcC.
Thexcnursexcidentifiesxcaxcpotentialxcforxcinfectionxcinxcaxcclientxcwithxcpartial-
thicknessxc(second-degree)xcandxcfull-thicknessxc(third-
degree)xcburns.xcWhatxcactionxchasxcthexchighestxcpriorityxcinxcdecreasingxcthexcclient'sxcris
kxcofxcinfection?
A.
Administrationxcofxcplasmaxcexpanders
xcB.
Usexcofxccarefulxchandwashingxctechnique
xcC.
Applicationxcofxcaxctopicalxcantibacterialxccream
xcD.
Limitingxcvisitorsxctoxcthexcclientxcwithxcburnsxc-xcanswer--B
Rationale:xcCarefulxchandwashingxctechniquexcisxcthexcsinglexcmostxceffectivexcinterventi
onxcforxcthexcpreventionxcofxccontaminationxctoxcallxcclients.xcOptionxcAxcreversesxcthexchyp
ovolemiaxcthatxcinitiallyxcaccompaniesxcburnxctraumaxcbutxcisxcnotxcrelatedxctoxcdecreasing
xcthexcproliferationxcofxcinfectivexcorganisms.xcOptionsxcCxcandxcDxcarexcrecommendedxcby
xcvariousxcburnxccentersxcasxcpossiblexcwaysxctoxcreducexcthexcchancexcofxcinfection.xcOpti
onxcBxcisxcaxcprovenxctechniquexctoxcpreventxcinfection.
Thexcnursexcassessesxcaxc2-year-
oldxcwhoxcisxcadmittedxcforxcdehydrationxcandxcfindsxcthatxcthexcperipheralxcIVxcratexcbyxcgra
vityxchasxcslowed,xcevenxcthoughxcthexcvenousxcaccessxcsitexcisxchealthy.xcWhatxcshouldxct
hexcnursexcdoxcnext?
A.
Applyxcaxcwarmxccompressxcproximalxctoxcthexcsite.
xcB.
CheckxcforxckinksxcinxcthexctubingxcandxcraisexcthexcIVxcpole.
xcC.
Adjustxcthexctapexcthatxcstabilizesxcthexcneedle.
xcD.
Flushxcwithxcnormalxcsalinexcandxcrecountxcthexcdropxcrate.xc-xcanswer--B
Rationale:xcThexcnursexcshouldxcfirstxccheckxcthexctubingxcandxcheightxcofxcthexcbagxconxcth
excIVxcpole,xcwhichxcarexccommonxcfactorsxcthatxcmayxcslowxcthexcrate.xcGravityxcinfusionxcr
atesxcarexcinfluencedxcbyxcthexcheightxcofxcthexcbag,xctubingxcclampxcclosurexcorxckinks,xcne
edlexcsizexcorxcposition,xcfluidxcviscosity,xcclientxcbloodxcpressurexc(cryingxcinxcthexcpediatri
, cxcclient),xcandxcinfiltration.xcVenospasmxccanxcslowxcthexcratexcandxcoftenxcrespondsxctoxc
warmthxcoverxcthexcvessel,xcbutxcthexcnursexcshouldxcfirstxcadjustxcthexcIVxcpolexcheight.xcT
hexcnursexcmayxcneedxctoxcadjustxcthexcstabilizingxctapexconxcaxcpositionalxcneedlexcorxcflus
hxcthexcvenousxcaccessxcwithxcnormalxcsaline,xcbutxclessxcinvasivexcactionsxcshouldxcbexcim
plementedxcfirst.
Thexcnursexcmanagerxcofxcaxcskilledxcnursingxc(chronicxccare)xcunitxcisxcinstructingxcUAPsxc
onxcwaysxctoxcpreventxccomplicationsxcofxcimmobility.xcWhichxcactionxcshouldxcbexcinclude
dxcinxcthisxcinstruction?
A.
Performxcrange-of-motionxcexercisesxctoxcpreventxccontractures.
xcB.
Decreasexcthexcclient'sxcfluidxcintakexctoxcpreventxcdiarrhea.
xcC.
Massagexcthexcclient'sxclegsxctoxcreducexcembolismxcoccurrence.
xcD.
Turnxcthexcclientxcfromxcsidexctoxcbackxceveryxcshift.xc-xcanswer--A
Rationale:xcPerformingxcrange-of-
motionxcexercisesxcisxcbeneficialxcinxcreducingxccontracturesxcaroundxcjoints.xcOptionsxcB,
xcC,xcandxcDxcarexcallxcpotentiallyxcharmfulxcpracticesxcthatxcplacexcthexcimmobilexcclientxcatx
criskxcofxccomplications.
Thexcnursexcadministeredxc10xcmgxcofxcdiazepamxctoxcthexcpreoperativexcclient.xcWhatxcst
epsxcwillxcthexcnursexctakexcnext?xc(Selectxcallxcthatxcapply.)
A.
Placexcthexcclientxcinxcthexcbedxcnextxctoxcthexcnurse'sxcstation.
xcB.
Instructxcthexcclientxcnotxctoxcgetxcoutxcofxcbed.
xcC.
Placexcthexccallxcbellxcwithinxcthexcclient'sxcreach.
xcD.
Placexcthexcsidexcrailsxcup,xcaccordingxctoxcinstitutionalxcpolicy.
xcE.
Assistxcthexcclientxctoxcthexcbathroomxc-xcanswer--B,xcC,xcD
Rationale:xcDiazepamxcisxcaxccommonxcpreoperativexcmedication.xcClosexcobservationxcb
yxcplacingxcthexcclientxcclosexctoxcthexcnurse'sxcstationxcisxcnotxcnecessary.xcThexcmedicatio
nxchasxcaxcsedativexceffectxcandxcthexcclientxcshouldxcnotxcgetxcoutxcofxcbed,xcevenxcwithxcas
sistance.xcThexcremainingxcselectionsxcarexccorrect.
Axcterminallyxcillxcclientxctellsxcthexcnurse,xc"Ixcamxcsoxctiredxcandxcinxcsoxcmuchxcpain!
xcPleasexchelpxcmexctoxcdie."xcWhichxcisxcthexcbestxcresponsexcforxcthexcnursexctoxcprovide?
A.
Administerxcthexcprescribedxcmaximumxcdosexcofxcpainxcmedication.
xcB.
Talkxcwithxcthexcclientxcaboutxcthoughtsxcandxcfeelingsxcaboutxcdeath.
xcC.
Collaboratexcwithxcthexchealthxccarexcproviderxcaboutxcinitiatingxcantidepressantxctherapy.
xcD.
Referxcthexcclientxctoxcthexcethicsxccommitteexcofxcherxclocalxchealthxccarexcfacility.xc-
xcanswer--B
