HESI RN FUNDAMENTALS EXIT EXAM LATEST 2024-2025
ACTUAL EXAM 100 QUESTIONS AND CORRECT
ANSWERS WITH RATIOANLES (VERIFIED ANSWERS)
Which steps should the nurse take when administering ear drops to an adult
client? (Select all that apply.)
A.
Place the client in a side-lying position.
B.
Pull the auricle upward and outward.
C.
Hold the dropper 6 cm above the ear canal.
D.
Place a cotton ball into the inner canal.
E.
Pull the auricle down and back. - <<answer>>-A, B
Rationale: The correct answers (A and B) are the appropriate administration of
ear drops. The dropper should be held 1 cm (½ inch) above the ear canal (C). A
cotton ball should be placed in the outermost canal (D). The auricle is pulled down
and back for a child younger than 3 years of age, but not an adult (E).
The nurse is evaluating measures implemented for the non-responsive client.
Which findings indicate the effectiveness of the care delivered? (Select all that
apply.)
A.
,Footboard at the end of the bed
B.
Heals without redness bilaterally
C.
Skin intact on the back
D.
Sheepskin booties in place
E.
Elbow joint fully flexes and extends.
F.
Ankle joint rotates 360 degrees freely. - <<answer>>-B, C, E, F
Rationale: The footboard helps prevent foot drop, but does not measure the
effectiveness of the treatment. The sheepskin booties are in place to protect the
heal, but they do not demonstrate the effectiveness. The remaining are
assessments that demonstrate the interventions are effective.
The nurse is assessing several clients prior to surgery. Which factor in a client's
history poses the greatest threat for complications to occur during surgery?
A.
Taking birth control pills for the past 2 years
B.
Taking anticoagulants for the past year
C.
Recently completing antibiotic therapy
D.
Having taken laxatives PRN for the last 6 months - <<answer>>-B
,Rationale: Anticoagulants increase the risk for bleeding during surgery, which can
pose a threat for the development of surgical complications. The health care
provider should be informed that the client is taking these drugs. Although clients
who take birth control pills may be more susceptible to the development of
thrombi, such problems usually occur postoperatively. A client with option C or D
is at less of a surgical risk than with option B.
The nurse is performing an intake interview for a newly admitted client to the
rehabilitation unit. Which questions will the nurse include in the interview?
(Select all that apply.)
A.
"When do you usually go to bed? And, when do you usually wake up?"
B.
"Do you usually bathe/shower in the morning or in the evening?"
C.
"Do you have any intolerance to food that we need to know about?"
D.
"How long do you think you will be here on the rehabilitation unit?"
E.
"Do you urinate every hour, on the hour, when you are awake?" - <<answer>>-A,
B, C, D
Rationale: The goal of the intake interview is to understand the client's daily
routines so those routines can be observed and upheld while residing on the
rehabilitation unit. Asking about how long the client will be on the rehabilitation
unit helps the nurse to understand the client's expectations of the duration of the
stay. Urinary and bowel patterns are important to understand, but the issue with
this assessment is the frequency of urination. The better question is, "How often
do you urinate when you are awake?"
, The nurse is providing care to a client immediately after a total right mastectomy.
What steps will the nurse include when positioning the client? (Select all that
apply.)
A.
Raise the head of the bed 30 to 45 degrees.
B.
Roll the client to her right side and place a pillow behind her back.
C.
Elevate her right arm under two pillows.
D.
Require the client to stay in bed for 72 hours post procedure.
E.
Place a sandbag on the incision. - <<answer>>-A, C
Rationale: The client must stay on her back or on the unaffected side, not on the
operative side. Mobility as tolerated; there is no need to remain immobile. A
sandbag is used when there is risk of bleeding from the wound. There is no
mention of that risk in the stem. Sitting up and elevating the arm will help lymph
drainage.
The nurse is teaching an obese client, newly diagnosed with arteriosclerosis,
about reducing the risk of a heart attack or stroke. Which health promotion
brochure is most important for the nurse to provide to this client?
A.
"Monitoring Your Blood Pressure at Home"
B.
"Smoking Cessation as a Lifelong Commitment"
C.
ACTUAL EXAM 100 QUESTIONS AND CORRECT
ANSWERS WITH RATIOANLES (VERIFIED ANSWERS)
Which steps should the nurse take when administering ear drops to an adult
client? (Select all that apply.)
A.
Place the client in a side-lying position.
B.
Pull the auricle upward and outward.
C.
Hold the dropper 6 cm above the ear canal.
D.
Place a cotton ball into the inner canal.
E.
Pull the auricle down and back. - <<answer>>-A, B
Rationale: The correct answers (A and B) are the appropriate administration of
ear drops. The dropper should be held 1 cm (½ inch) above the ear canal (C). A
cotton ball should be placed in the outermost canal (D). The auricle is pulled down
and back for a child younger than 3 years of age, but not an adult (E).
The nurse is evaluating measures implemented for the non-responsive client.
Which findings indicate the effectiveness of the care delivered? (Select all that
apply.)
A.
,Footboard at the end of the bed
B.
Heals without redness bilaterally
C.
Skin intact on the back
D.
Sheepskin booties in place
E.
Elbow joint fully flexes and extends.
F.
Ankle joint rotates 360 degrees freely. - <<answer>>-B, C, E, F
Rationale: The footboard helps prevent foot drop, but does not measure the
effectiveness of the treatment. The sheepskin booties are in place to protect the
heal, but they do not demonstrate the effectiveness. The remaining are
assessments that demonstrate the interventions are effective.
The nurse is assessing several clients prior to surgery. Which factor in a client's
history poses the greatest threat for complications to occur during surgery?
A.
Taking birth control pills for the past 2 years
B.
Taking anticoagulants for the past year
C.
Recently completing antibiotic therapy
D.
Having taken laxatives PRN for the last 6 months - <<answer>>-B
,Rationale: Anticoagulants increase the risk for bleeding during surgery, which can
pose a threat for the development of surgical complications. The health care
provider should be informed that the client is taking these drugs. Although clients
who take birth control pills may be more susceptible to the development of
thrombi, such problems usually occur postoperatively. A client with option C or D
is at less of a surgical risk than with option B.
The nurse is performing an intake interview for a newly admitted client to the
rehabilitation unit. Which questions will the nurse include in the interview?
(Select all that apply.)
A.
"When do you usually go to bed? And, when do you usually wake up?"
B.
"Do you usually bathe/shower in the morning or in the evening?"
C.
"Do you have any intolerance to food that we need to know about?"
D.
"How long do you think you will be here on the rehabilitation unit?"
E.
"Do you urinate every hour, on the hour, when you are awake?" - <<answer>>-A,
B, C, D
Rationale: The goal of the intake interview is to understand the client's daily
routines so those routines can be observed and upheld while residing on the
rehabilitation unit. Asking about how long the client will be on the rehabilitation
unit helps the nurse to understand the client's expectations of the duration of the
stay. Urinary and bowel patterns are important to understand, but the issue with
this assessment is the frequency of urination. The better question is, "How often
do you urinate when you are awake?"
, The nurse is providing care to a client immediately after a total right mastectomy.
What steps will the nurse include when positioning the client? (Select all that
apply.)
A.
Raise the head of the bed 30 to 45 degrees.
B.
Roll the client to her right side and place a pillow behind her back.
C.
Elevate her right arm under two pillows.
D.
Require the client to stay in bed for 72 hours post procedure.
E.
Place a sandbag on the incision. - <<answer>>-A, C
Rationale: The client must stay on her back or on the unaffected side, not on the
operative side. Mobility as tolerated; there is no need to remain immobile. A
sandbag is used when there is risk of bleeding from the wound. There is no
mention of that risk in the stem. Sitting up and elevating the arm will help lymph
drainage.
The nurse is teaching an obese client, newly diagnosed with arteriosclerosis,
about reducing the risk of a heart attack or stroke. Which health promotion
brochure is most important for the nurse to provide to this client?
A.
"Monitoring Your Blood Pressure at Home"
B.
"Smoking Cessation as a Lifelong Commitment"
C.
