HESI RN FUNDAMENTALS EXIT EXAM LATEST 2024-2025 ACTUAL
EXAM 100 QUESTIONS AND CORRECT ANSWERS WITH RATIOANLES
(VERIFIED ANSWERS)
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The nurse is called to the waiting room o𝑓 a pediatric B, C, D
clinic. The 𝑓rantic mother states, "I think my 4-month-old Rationale: The 𝑓ingers are placed at the same location on an
in𝑓ant as chest baby is choking!" What steps will the nurse take? (Select compressions 𝑓or CPR; however, the nurse must
deliver 𝑓ive chest thrusts, a𝑓ter all that apply.) the 𝑓ive back slaps. Blind sweeps are not used as this action may
push the A. object deeper into the throat. The remaining steps are correct.
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.
Which 𝑓luid will the nurse select to administer with the B
prescribed blood trans𝑓usion? Rationale: Normal saline solution is the only solution that is compatible with A.
blood.
5% Dextrose and
water
B.
Normal
saline
C.
Lactated Ringers
solution
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,4/26/26, 2:55 PM HESI RN FUNDAMENTALS EXIT EXAM LATEST 2024-2025 ACTUAL
EXAM 100 QUESTIONS AND CORRECT ANSWERS …
When assisting a client 𝑓rom the bed to a chair, which B
procedure is best 𝑓or the nurse to 𝑓ollow? Rationale: Option B describes the correct positioning o𝑓 the nurse and a𝑓𝑓ords A. the
nurse a wide base o𝑓 support while stabilizing the client's knees when Place the chair parallel to the bed, with its back toward
assisting to a standing position. The chair should be placed at a 45-degree the head o𝑓 the bed and assist the client in moving to
angle to the bed, with the back o𝑓 the chair toward the head o𝑓 the bed. Clients the chair. should never be li𝑓ted under the
axillae; this could damage nerves and strain B. the nurse's back. The client should be instructed to use the arms o𝑓 the chair With
the nurse's 𝑓eet spread apart and knees aligned and should never place his or her arms around the nurse's neck; this places with the
client's knees, stand and pivot the client into undue stress on the nurse's neck and back and increases the risk 𝑓or a 𝑓all. 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.
How many mL will the nurse document on the client's Answer: 2155
intake and output record 𝑓rom the items listed? _____ mL Rationale: 1200 + 240 (8 oz) + 240 (1 cup) + 120 (4 oz) + 355 =
2155 1200 mL water
4 ounce container o𝑓 gelatin
8 ounces o𝑓 orange juice
355 mL can o𝑓 soda1 cup o𝑓 soup
The nurse observes a UAP taking a client's blood B
pressure in the lower extremity. Which observation o𝑓 Rationale: When obtaining the blood pressure in the lower extremities, the
this procedure requires the nurse to intervene with the popliteal pulse is the site 𝑓or auscultation when the blood pressure cu𝑓𝑓
is UAP's approach? applied around the thigh. The nurse should intervene with the UAP who has A. applied the cu𝑓𝑓 on the lower leg.
Option A ensures an accurate assessment, The cu𝑓𝑓 wraps around the girth o𝑓 the leg. and option C provides the best access to the
artery. Systolic pressure in the B. popliteal artery is usually 10 to 40 mm Hg higher than in the brachial artery.
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.
During a clinic visit, the mother o𝑓 a 7-year-old reports D
to the nurse that her child is o𝑓ten awake until midnight Rationale: School-age children o𝑓ten resist bedtime. The nurse should begin
by playing and is then very di𝑓𝑓icult to awaken in the assessing the environment o𝑓 the home to determine 𝑓actors that may not be
morning 𝑓or school. Which assessment data should the conducive to the establishment o𝑓 bedtime rituals that promote sleep. Option A
nurse obtain in response to the mother's concern? o𝑓ten causes daytime 𝑓atigue rather than resistance to going to sleep. Option B A.
is unlikely to provide use𝑓ul data. The nurse cannot determine option C.
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
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, 4/26/26, 2:55 PM HESI RN FUNDAMENTALS EXIT EXAM LATEST 2024-2025 ACTUAL
EXAM 100 QUESTIONS AND CORRECT ANSWERS …
The nurse identi𝑓ies a potential 𝑓or in𝑓ection in a client B
with partial-thickness (second-degree) and 𝑓ull-Rationale: Care𝑓ul handwashing technique is the single most e𝑓𝑓ective thickness
(third-degree) burns. What action has the intervention 𝑓or the prevention o𝑓 contamination to all clients. Option A highest priority
in decreasing the client's risk o𝑓 reverses the hypovolemia that initially accompanies burn trauma but is not in𝑓ection? related to
decreasing the proli𝑓eration o𝑓 in𝑓ective organisms. Options C and D A. are recommended by various burn centers as possible ways to
reduce the Administration o𝑓 plasma expanders chance o𝑓 in𝑓ection. Option B is a proven technique to prevent in𝑓ection. B.
Use o𝑓 care𝑓ul handwashing technique
C.
Application o𝑓 a topical antibacterial cream
D.
Limiting visitors to the client with burns
The nurse assesses a 2-year-old who is admitted 𝑓or B
dehydration and 𝑓inds that the peripheral IV rate by Rationale: The nurse should 𝑓irst check the tubing and height o𝑓 the bag on the
gravity has slowed, even though the venous access site IV pole, which are common 𝑓actors that may slow the rate. Gravity in𝑓usion
rates is healthy. What should the nurse do next? are in𝑓luenced by the height o𝑓 the bag, tubing clamp closure or kinks, needle A.
size or position, 𝑓luid viscosity, client blood pressure (crying in the pediatric Apply a warm compress proximal to the site.
client), and in𝑓iltration. Venospasm can slow the rate and o𝑓ten responds to B. warmth over the vessel, but the nurse should 𝑓irst
adjust the IV pole height. The Check 𝑓or kinks in the tubing and raise the IV pole. nurse may need to adjust the stabilizing tape on
a positional needle or 𝑓lush the C. venous access with normal saline, but less invasive actions should be Adjust the tape that
stabilizes the needle. implemented 𝑓irst.
D.
Flush with normal saline and recount the drop rate.
The nurse manager o𝑓 a skilled nursing (chronic care) A
unit is instructing UAPs on ways to prevent Rationale: Per𝑓orming range-o𝑓-motion exercises is bene𝑓icial in reducing
complications o𝑓 immobility. Which action should be contractures around joints. Options B, C, and D are all potentially harm𝑓ul
included in this instruction? practices that place the immobile client at risk o𝑓 complications. 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.
The nurse administered 10 mg o𝑓 diazepam to the B, C, D
preoperative client. What steps will the nurse take next? Rationale: Diazepam is a common preoperative medication. Close observation
(Select all that apply.) by placing the client close to the nurse's station is not necessary. The A. medication has a sedative e𝑓𝑓ect
and the client should not get out o𝑓 bed, even Place the client in the bed next to the nurse's station. with assistance. The
remaining selections are correct.
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
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