FUNDAMENTALS RN EXIT HESI 2 TEST BANK
QUESTIONS; NEWEST ACTUAL EXAM REVIEW;
170+ QUESTIONS AND CORRECT ANSWERS
(VERIFIED ANSWERS) A GRADE
An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest
risk for a malpractice judgment?
A) A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes.
B) The nurse assigned to care for the client who was at lunch at the time of the fall.
C) The nurse who transferred the client to the chair when the fall occurred.
D) The charge nurse who completed rounds 30 minutes before the fall occurred. - ANS-C) The nurse who
transferred the client to the chair when the fall occurred
The four elements of malpractice are: breach of duty owed, failure to adhere to the recognized standard
of care, direct causation of injury, and evidence of actual injury. The hip fracture is the actual injury and
the standard of care was "frequent monitoring." (C) implies that duty was owed and the injury occurred
while the nurse was in charge of the client's care. There is no evidence of negligence in (A, B, and D)
The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff
that is too small, but the blood pressure reading obtained is within the client's usual range. What action
is most important for the nurse to implement?
A) Tell the UAP to use a larger cuff at the next scheduled assessment.
B) Reassess the client's blood pressure using a larger cuff.
C) Have the unit educator review this procedure with the UAPs.
D) Teach the UAP the correct technique for assessing blood pressure. - ANS-B) Reassess the client's
blood pressure using a larger cuff
The most important action is to ensure that an accurate BP reading is obtained. The nurse should
reassess the BP with the correct size cuff (B). Reassessment should not be postponed (A). Though (C and
D) are likely indicated, these actions do not have the priority of (B).
An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the
client's nursing care?
, A) Massage any reddened areas for at least five minutes.
B) Encourage active range of motion exercises on extremities.
C) Position the client laterally, prone, and dorsally in sequence.
D) Gently lift the client when moving into a desired position. - ANS-D) Gently lift the client when moving
into a desired position
To avoid shearing forces when repositioning, the client should be lifted gently across a surface (D).
Reddened areas should not be massaged (A) since this may increase the damage to already traumatized
skin. To control pain and muscle spasms, active range of motion (B) may be limited on the affected leg.
The position described in (C) is contraindicated for a client with a fractured left hip.
A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based
on these findings, which intervention should the nurse implement first?
A) Assist the ambulating client back to the bed.
B) Encourage the client to ambulate to resolve pneumonia.
C) Obtain a prescription for portable oxygen while ambulating.
D) Move the oximetry probe from the finger to the earlobe. - ANS-A) Assist the ambulating client back to
the bed
An oxygen saturation below 90% indicates inadequate oxygenation. First, the client should be assisted to
return to bed (A) to minimize oxygen demands. Ambulation increases aeration of the lungs to prevent
pooling of respiratory secretions, but the client's activity at this time is depleting oxygen saturation of
the blood, so (B) is contraindicated. Increased activity increases respiratory effort, and oxygen may be
necessary to continue ambulation (C), but first the client should return to bed to rest. Oxygen saturation
levels at different sites should be evaluated after the client returns to bed (D).
During the initial morning assessment, a male client denies dysuria but reports that his urine appears
dark amber. Which intervention should the nurse implement?
A) Provide additional coffee on the client's breakfast tray.
B) Exchange the client's grape juice for cranberry juice.
C) Bring the client additional fruit at mid-morning.
D) Encourage additional oral intake of juices and water. - ANS-D) Encourage additional oral intake of
juices and water
Dark amber urine is characteristic of fluid volume deficit, and the client should be encouraged to
increase fluid intake (D). Caffeine, however, is a diuretic (A), and may worsen the fluid volume deficit.
Any type of juice will be beneficial (B), since the client is not dysuric, a sign of an urinary tract infection.
The client needs to restore fluid volume more than solid foods (C).
The nurse notices that the mother a 9-year-old Vietnamese child always looks at the floor when she
talks to the nurse. What action should the nurse take?
A) Talk directly to the child instead of the mother.
B) Continue asking the mother questions about the child.
C) Ask another nurse to interview the mother now.
QUESTIONS; NEWEST ACTUAL EXAM REVIEW;
170+ QUESTIONS AND CORRECT ANSWERS
(VERIFIED ANSWERS) A GRADE
An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest
risk for a malpractice judgment?
A) A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes.
B) The nurse assigned to care for the client who was at lunch at the time of the fall.
C) The nurse who transferred the client to the chair when the fall occurred.
D) The charge nurse who completed rounds 30 minutes before the fall occurred. - ANS-C) The nurse who
transferred the client to the chair when the fall occurred
The four elements of malpractice are: breach of duty owed, failure to adhere to the recognized standard
of care, direct causation of injury, and evidence of actual injury. The hip fracture is the actual injury and
the standard of care was "frequent monitoring." (C) implies that duty was owed and the injury occurred
while the nurse was in charge of the client's care. There is no evidence of negligence in (A, B, and D)
The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff
that is too small, but the blood pressure reading obtained is within the client's usual range. What action
is most important for the nurse to implement?
A) Tell the UAP to use a larger cuff at the next scheduled assessment.
B) Reassess the client's blood pressure using a larger cuff.
C) Have the unit educator review this procedure with the UAPs.
D) Teach the UAP the correct technique for assessing blood pressure. - ANS-B) Reassess the client's
blood pressure using a larger cuff
The most important action is to ensure that an accurate BP reading is obtained. The nurse should
reassess the BP with the correct size cuff (B). Reassessment should not be postponed (A). Though (C and
D) are likely indicated, these actions do not have the priority of (B).
An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the
client's nursing care?
, A) Massage any reddened areas for at least five minutes.
B) Encourage active range of motion exercises on extremities.
C) Position the client laterally, prone, and dorsally in sequence.
D) Gently lift the client when moving into a desired position. - ANS-D) Gently lift the client when moving
into a desired position
To avoid shearing forces when repositioning, the client should be lifted gently across a surface (D).
Reddened areas should not be massaged (A) since this may increase the damage to already traumatized
skin. To control pain and muscle spasms, active range of motion (B) may be limited on the affected leg.
The position described in (C) is contraindicated for a client with a fractured left hip.
A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based
on these findings, which intervention should the nurse implement first?
A) Assist the ambulating client back to the bed.
B) Encourage the client to ambulate to resolve pneumonia.
C) Obtain a prescription for portable oxygen while ambulating.
D) Move the oximetry probe from the finger to the earlobe. - ANS-A) Assist the ambulating client back to
the bed
An oxygen saturation below 90% indicates inadequate oxygenation. First, the client should be assisted to
return to bed (A) to minimize oxygen demands. Ambulation increases aeration of the lungs to prevent
pooling of respiratory secretions, but the client's activity at this time is depleting oxygen saturation of
the blood, so (B) is contraindicated. Increased activity increases respiratory effort, and oxygen may be
necessary to continue ambulation (C), but first the client should return to bed to rest. Oxygen saturation
levels at different sites should be evaluated after the client returns to bed (D).
During the initial morning assessment, a male client denies dysuria but reports that his urine appears
dark amber. Which intervention should the nurse implement?
A) Provide additional coffee on the client's breakfast tray.
B) Exchange the client's grape juice for cranberry juice.
C) Bring the client additional fruit at mid-morning.
D) Encourage additional oral intake of juices and water. - ANS-D) Encourage additional oral intake of
juices and water
Dark amber urine is characteristic of fluid volume deficit, and the client should be encouraged to
increase fluid intake (D). Caffeine, however, is a diuretic (A), and may worsen the fluid volume deficit.
Any type of juice will be beneficial (B), since the client is not dysuric, a sign of an urinary tract infection.
The client needs to restore fluid volume more than solid foods (C).
The nurse notices that the mother a 9-year-old Vietnamese child always looks at the floor when she
talks to the nurse. What action should the nurse take?
A) Talk directly to the child instead of the mother.
B) Continue asking the mother questions about the child.
C) Ask another nurse to interview the mother now.
