HESI RN FUNDAMENTALS EXIT EXAM
LATEST 2024-2025 ACTUAL EXAM
100 QUESTIONS AND CORRECT
ANSWERS WITH RATIOANLES
(VERIFIED ANSWERS)
C
Terms in this set (125)
The nurse is called to the waiting room of a B, C, D
pediatric clinic. The frantic mother states, "I Rationale: The fingers are placed at the same
location on an think my 4-month-old baby is choking!" infant as chest compressions for CPR;
however, the nurse must What steps will the nurse take? (Select alldeliver five chest thrusts,
after the five back slaps. Blind
that apply.) sweeps are not used as this action may push the object
A. 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 B
administer with the prescribed blood Rationale: Normal saline solution is the only solution
that is transfusion? compatible with blood.
A.
5% Dextrose and
water B.
Normal
saline C.
Lactated Ringers
solution D.
5% Dextrose and lactated ringers
When assisting a client from the bed to a B
chair, which procedure is best for the nurse Rationale: Option B describes the correct
positioning of the to follow? nurse and affords the nurse a wide base of support
while
A. stabilizing the client's knees when assisting to a standing
Place the chair parallel to the bed, with its position. The chair should be placed at a 45-
degree angle to back toward the head of the bed and assist the bed, with the back of
the chair toward the head of the the client in moving to the chair. bed. Clients should never
be lifted under the axillae; this
B. could damage nerves and strain the nurse's back.
The client With the nurse's feet spread apart and knees should be instructed to use the
arms of the chair and should aligned with the client's knees, stand and never place his or
her arms around the nurse's neck; this pivot the client into the chair. places undue
stress on the nurse's neck and back and
C. increases the risk for a fall.
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 Answer: 2155
the client's intake and output record from Rationale: 1200 + 240 (8 oz) + 240 (1 cup) + 120 (4 oz)
+ 355 = the items listed? _____ mL 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 B
,blood pressure in the lower extremity. Which Rationale: When obtaining the blood
pressure in the lower observation of this procedure requires the extremities, the popliteal
pulse is the site for auscultation
nurse to intervene with the UAP's approach? when the blood pressure cuff is applied around
the thigh. The
A. nurse should intervene with the UAP who has
applied the cuff The cuff wraps around the girth of the leg. on the lower leg. Option A
ensures an accurate assessment,
B. and option C provides the best access to the
artery. Systolic The UAP auscultates the popliteal pulse with pressure in the popliteal
artery is usually 10 to 40 mm Hg the cuff on the lower leg. higher than in the brachial
artery.
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- D
old reports to the nurse that her child is Rationale: School-age children often resist bedtime.
The nurse often awake until midnight playing and is should begin by assessing the
environment of the home to then very difficult to awaken in the morning determine factors
that may not be conducive to the
for school. Which assessment data shouldestablishment of bedtime rituals that promote sleep.
Option A the nurse obtain in response to the mother's often causes daytime fatigue rather
than resistance to going concern? to sleep. Option B is unlikely to provide useful data.
The nurse
A. 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
The nurse identifies a potential for infection B
in a client with partial-thickness (second- Rationale: Careful handwashing technique is the
single most degree) and full-thickness (third-degree) effective intervention for the
prevention of contamination to burns. What action has the highest priority in all clients.
Option A reverses the hypovolemia that initially
decreasing the client's risk of infection? accompanies burn trauma but is not related to
decreasing the
A. proliferation of infective organisms. Options C and
D are Administration of plasma expanders recommended by various burn centers as
possible ways to
B. reduce the chance of infection. Option B is a
proven Use of careful handwashing technique technique to prevent infection.
C.
Application of a topical antibacterial
cream D.
Limiting visitors to the client with burns
The nurse assesses a 2-year-old who is B
admitted for dehydration and finds that the Rationale: The nurse should first check the
tubing and height peripheral IV rate by gravity has slowed, of the bag on the IV pole,
which are common factors that may even though the venous access site isslow the rate.
Gravity infusion rates are influenced by the
healthy. What should the nurse do next? height of the bag, tubing clamp closure or kinks, needle
LATEST 2024-2025 ACTUAL EXAM
100 QUESTIONS AND CORRECT
ANSWERS WITH RATIOANLES
(VERIFIED ANSWERS)
C
Terms in this set (125)
The nurse is called to the waiting room of a B, C, D
pediatric clinic. The frantic mother states, "I Rationale: The fingers are placed at the same
location on an think my 4-month-old baby is choking!" infant as chest compressions for CPR;
however, the nurse must What steps will the nurse take? (Select alldeliver five chest thrusts,
after the five back slaps. Blind
that apply.) sweeps are not used as this action may push the object
A. 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 B
administer with the prescribed blood Rationale: Normal saline solution is the only solution
that is transfusion? compatible with blood.
A.
5% Dextrose and
water B.
Normal
saline C.
Lactated Ringers
solution D.
5% Dextrose and lactated ringers
When assisting a client from the bed to a B
chair, which procedure is best for the nurse Rationale: Option B describes the correct
positioning of the to follow? nurse and affords the nurse a wide base of support
while
A. stabilizing the client's knees when assisting to a standing
Place the chair parallel to the bed, with its position. The chair should be placed at a 45-
degree angle to back toward the head of the bed and assist the bed, with the back of
the chair toward the head of the the client in moving to the chair. bed. Clients should never
be lifted under the axillae; this
B. could damage nerves and strain the nurse's back.
The client With the nurse's feet spread apart and knees should be instructed to use the
arms of the chair and should aligned with the client's knees, stand and never place his or
her arms around the nurse's neck; this pivot the client into the chair. places undue
stress on the nurse's neck and back and
C. increases the risk for a fall.
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 Answer: 2155
the client's intake and output record from Rationale: 1200 + 240 (8 oz) + 240 (1 cup) + 120 (4 oz)
+ 355 = the items listed? _____ mL 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 B
,blood pressure in the lower extremity. Which Rationale: When obtaining the blood
pressure in the lower observation of this procedure requires the extremities, the popliteal
pulse is the site for auscultation
nurse to intervene with the UAP's approach? when the blood pressure cuff is applied around
the thigh. The
A. nurse should intervene with the UAP who has
applied the cuff The cuff wraps around the girth of the leg. on the lower leg. Option A
ensures an accurate assessment,
B. and option C provides the best access to the
artery. Systolic The UAP auscultates the popliteal pulse with pressure in the popliteal
artery is usually 10 to 40 mm Hg the cuff on the lower leg. higher than in the brachial
artery.
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- D
old reports to the nurse that her child is Rationale: School-age children often resist bedtime.
The nurse often awake until midnight playing and is should begin by assessing the
environment of the home to then very difficult to awaken in the morning determine factors
that may not be conducive to the
for school. Which assessment data shouldestablishment of bedtime rituals that promote sleep.
Option A the nurse obtain in response to the mother's often causes daytime fatigue rather
than resistance to going concern? to sleep. Option B is unlikely to provide useful data.
The nurse
A. 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
The nurse identifies a potential for infection B
in a client with partial-thickness (second- Rationale: Careful handwashing technique is the
single most degree) and full-thickness (third-degree) effective intervention for the
prevention of contamination to burns. What action has the highest priority in all clients.
Option A reverses the hypovolemia that initially
decreasing the client's risk of infection? accompanies burn trauma but is not related to
decreasing the
A. proliferation of infective organisms. Options C and
D are Administration of plasma expanders recommended by various burn centers as
possible ways to
B. reduce the chance of infection. Option B is a
proven Use of careful handwashing technique technique to prevent infection.
C.
Application of a topical antibacterial
cream D.
Limiting visitors to the client with burns
The nurse assesses a 2-year-old who is B
admitted for dehydration and finds that the Rationale: The nurse should first check the
tubing and height peripheral IV rate by gravity has slowed, of the bag on the IV pole,
which are common factors that may even though the venous access site isslow the rate.
Gravity infusion rates are influenced by the
healthy. What should the nurse do next? height of the bag, tubing clamp closure or kinks, needle
