HESI RN FUNDAMENTALS EXIT EXAM LATEST 2024-2025
ACTUAL EXAM 100 QUESTIONS AND CORRECT
ANSWERS WITH RATIOANLES (VERIFIED ANSWERS)
A client is laughing at a television program when the evening nurse enters the
room. The client states, "My foot is hurting. I would like a pain pill." How should
the nurse respond?
A.
Ask the client to rate the pain using a 1 to 10 scale.
B.
Encourage the client to wait until bedtime for the pill.
C.
Attend to an acutely ill client's needs first because this client is laughing.
D.
Instruct the client in the use of deep breathing exercises for pain control.
A
Rationale: Obtaining a subjective estimate of the pain experience by asking the
client to rate his pain helps the nurse determine which pain medication should be
administered and also provides a baseline for evaluating the effectiveness of the
medication. Medicating for pain should not be delayed so that it can be used as a
sleep medication. Option C is judgmental. Option D should be used as an adjunct
to pain medication, not instead of medication.
Which action is most important for the nurse to include in the plan of care for a
client at high risk for the development of postoperative thrombus formation?
A.
Instruct in the use of the incentive spirometer.
B.
Elevate the head of the bed during all meals.
C.
,Use aseptic technique to change the dressing.
D.
Encourage frequent ambulation in the hallway.
D
Rationale: Thrombus (clot) formation can occur in the lower extremities of
immobile clients, so the nurse should plan to encourage activities to increase
mobility, such as frequent ambulation in the hallway. Option A helps promote
alveolar expansion, reducing the risk for atelectasis. Option B reduces the risk for
aspiration. Option C reduces the risk for postoperative infection.
A client has a nasogastric tube connected to low intermittent suction. When
administering medications through the nasogastric tube, which action should
the nurse do first?
A.
Clamp the nasogastric tube.
B.
Confirm placement of the tube.
C.
Use a syringe to instill the medications.
D.
Turn off the intermittent suction device.
D
Rationale: The nurse should first turn off the suction and then confirm placement
of the tube in the stomach before instilling the medications. To prevent
immediate removal of the instilled medications and allow absorption, the tube
should be clamped for a period of time before reconnecting the suction.
A client with frequent urinary tract infections (UTIs) asks the nurse to explain a
friend's advice about drinking a glass of juice daily to prevent future UTIs. Which
response is best for the nurse to provide?
A.
"Orange juice has vitamin C that deters bacterial growth."
B.
"Apple juice is the most useful in acidifying the urine."
C.
,"Cranberry juice stops pathogens' adherence to the bladder."
D.
"Grapefruit juice increases absorption of most antibiotics."
C
Rationale: Cranberry juice maintains urinary tract health by reducing the
adherence of Escherichia coli bacteria to cells within the bladder. Options A, B,
and D have not been shown to be as effective as cranberry juice in preventing
UTIs.
After receiving written and verbal instructions from a clinic nurse about a newly
prescribed medication, a client asks the nurse what to do if questions arise
about the medication after getting home. How should the nurse respond?
A.
Provide the client with a list of Internet sites that answer frequently asked
questions about medications.
B.
Advise the client to obtain a current edition of a drug reference book from a
local bookstore or library.
C.
Reassure the client that information about the medication is included in the
written instructions.
D.
Encourage the client to call the clinic nurse or health care provider if any
questions arise.
D
Rationale: To ensure safe medication use, the nurse should encourage the client
to call the nurse or health care provider if any questions arise. Options A, B, and C
may all include useful information, but these sources of information cannot
evaluate the nature of the client's questions and the follow-up needed.
The nurse is preparing a liquid medication for a 2-year-old. The dose is 2.2 mL.
What delivery devise will the nurse select to prepare the medication?
A.
30 mL medication cup
B.
, 10 mL medication spoon
C.
3 mL needleless syringe
D.
5 mL medicine dropper
C
Rationale: Accuracy is most important when delivering small amounts of
medication to a child. The most accurate dispensing devise is the 3 mL needleless
syringe that is marked off in increments of tenths.
The nurse is providing care to a client receiving high doses of chemotherapy.
Which situation will cause the nurse to intervene for this client?
A.
Co-workers walk into the room with a 2′ × 3′ get well card.
B.
A neighbor stops by with a box of chocolate candy.
C.
A clergy member places a book of prayers at the client's bedside.
D.
The florist delivers an arrangement of fresh flowers.
D
Rationale: A common side effect of chemotherapy is the inability to fight infection
secondary to neutropenia. Fresh fruits and fresh flowers are sources of infection
that must be avoided for these clients. The remaining options pose a low risk for
infection.
The nurse prepares to insert a nasogastric tube in a client with hyperemesis who
is awake and alert. Which nursing actions are correct? (Select all that apply.)
A.
Place the client in a high Fowler position.
B.
Explain that placement of the tube is painless.
C.
Measure the tube from the tip of the nose to the umbilicus.
D.
ACTUAL EXAM 100 QUESTIONS AND CORRECT
ANSWERS WITH RATIOANLES (VERIFIED ANSWERS)
A client is laughing at a television program when the evening nurse enters the
room. The client states, "My foot is hurting. I would like a pain pill." How should
the nurse respond?
A.
Ask the client to rate the pain using a 1 to 10 scale.
B.
Encourage the client to wait until bedtime for the pill.
C.
Attend to an acutely ill client's needs first because this client is laughing.
D.
Instruct the client in the use of deep breathing exercises for pain control.
A
Rationale: Obtaining a subjective estimate of the pain experience by asking the
client to rate his pain helps the nurse determine which pain medication should be
administered and also provides a baseline for evaluating the effectiveness of the
medication. Medicating for pain should not be delayed so that it can be used as a
sleep medication. Option C is judgmental. Option D should be used as an adjunct
to pain medication, not instead of medication.
Which action is most important for the nurse to include in the plan of care for a
client at high risk for the development of postoperative thrombus formation?
A.
Instruct in the use of the incentive spirometer.
B.
Elevate the head of the bed during all meals.
C.
,Use aseptic technique to change the dressing.
D.
Encourage frequent ambulation in the hallway.
D
Rationale: Thrombus (clot) formation can occur in the lower extremities of
immobile clients, so the nurse should plan to encourage activities to increase
mobility, such as frequent ambulation in the hallway. Option A helps promote
alveolar expansion, reducing the risk for atelectasis. Option B reduces the risk for
aspiration. Option C reduces the risk for postoperative infection.
A client has a nasogastric tube connected to low intermittent suction. When
administering medications through the nasogastric tube, which action should
the nurse do first?
A.
Clamp the nasogastric tube.
B.
Confirm placement of the tube.
C.
Use a syringe to instill the medications.
D.
Turn off the intermittent suction device.
D
Rationale: The nurse should first turn off the suction and then confirm placement
of the tube in the stomach before instilling the medications. To prevent
immediate removal of the instilled medications and allow absorption, the tube
should be clamped for a period of time before reconnecting the suction.
A client with frequent urinary tract infections (UTIs) asks the nurse to explain a
friend's advice about drinking a glass of juice daily to prevent future UTIs. Which
response is best for the nurse to provide?
A.
"Orange juice has vitamin C that deters bacterial growth."
B.
"Apple juice is the most useful in acidifying the urine."
C.
,"Cranberry juice stops pathogens' adherence to the bladder."
D.
"Grapefruit juice increases absorption of most antibiotics."
C
Rationale: Cranberry juice maintains urinary tract health by reducing the
adherence of Escherichia coli bacteria to cells within the bladder. Options A, B,
and D have not been shown to be as effective as cranberry juice in preventing
UTIs.
After receiving written and verbal instructions from a clinic nurse about a newly
prescribed medication, a client asks the nurse what to do if questions arise
about the medication after getting home. How should the nurse respond?
A.
Provide the client with a list of Internet sites that answer frequently asked
questions about medications.
B.
Advise the client to obtain a current edition of a drug reference book from a
local bookstore or library.
C.
Reassure the client that information about the medication is included in the
written instructions.
D.
Encourage the client to call the clinic nurse or health care provider if any
questions arise.
D
Rationale: To ensure safe medication use, the nurse should encourage the client
to call the nurse or health care provider if any questions arise. Options A, B, and C
may all include useful information, but these sources of information cannot
evaluate the nature of the client's questions and the follow-up needed.
The nurse is preparing a liquid medication for a 2-year-old. The dose is 2.2 mL.
What delivery devise will the nurse select to prepare the medication?
A.
30 mL medication cup
B.
, 10 mL medication spoon
C.
3 mL needleless syringe
D.
5 mL medicine dropper
C
Rationale: Accuracy is most important when delivering small amounts of
medication to a child. The most accurate dispensing devise is the 3 mL needleless
syringe that is marked off in increments of tenths.
The nurse is providing care to a client receiving high doses of chemotherapy.
Which situation will cause the nurse to intervene for this client?
A.
Co-workers walk into the room with a 2′ × 3′ get well card.
B.
A neighbor stops by with a box of chocolate candy.
C.
A clergy member places a book of prayers at the client's bedside.
D.
The florist delivers an arrangement of fresh flowers.
D
Rationale: A common side effect of chemotherapy is the inability to fight infection
secondary to neutropenia. Fresh fruits and fresh flowers are sources of infection
that must be avoided for these clients. The remaining options pose a low risk for
infection.
The nurse prepares to insert a nasogastric tube in a client with hyperemesis who
is awake and alert. Which nursing actions are correct? (Select all that apply.)
A.
Place the client in a high Fowler position.
B.
Explain that placement of the tube is painless.
C.
Measure the tube from the tip of the nose to the umbilicus.
D.
