HESI RN FUNDAMENTALS EXIT EXAM
LATEST 2024-2025 ACTUAL EXAM 100
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. - Answer-✅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 - Answer-✅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. - Answer-✅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-✅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. -
Answer-✅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 - Answer-✅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 - Answer-✅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. - Answer-✅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. - Answer-✅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 - Answer-✅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.
LATEST 2024-2025 ACTUAL EXAM 100
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. - Answer-✅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 - Answer-✅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. - Answer-✅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-✅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. -
Answer-✅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 - Answer-✅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 - Answer-✅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. - Answer-✅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. - Answer-✅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 - Answer-✅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.
