HESI RN FUNDAMENTALS EXIT EXAM LATEST 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 f ive back slaps. Blind sweeps are not used as this action may push the object deeper into the throat. The remaining steps are correct. 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. A terminally ill client tells the nurse, "I am so tired and in so much pain! Please help me to die." Which is the best response for the nurse to provide? A. Administer the prescribed maximum dose of pain medication. B. Talk with the client about thoughts and feelings about death. C. Collaborate with the health care provider about initiating antidepressant therapy. D. Refer the client to the ethics committee of her local health care facility. - answer-B Rationale: The nurse should first assess the client's feelings about death and determine the extent to which this statement expresses the client's true feelings. The client may need additional pain management, but further assessment is needed before implementing option A. Options C and D are both premature interventions and should not be implemented until further assessment is obtained.