Fundamentals RN Exit Hesi 2 Exam Preparation Kit
2025/26 | Authentic and Verified Answers
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. - 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. - 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. - 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. - 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
2025/26 | Authentic and Verified Answers
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. - 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. - 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. - 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. - 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
