HESI RN FUNDAMENTALS EXIT EXAM 100 QUESTIONS AND CORRECT
ANSWERS WITH RATIOANLES
The nurse is called to the waiting room of a B.
pediatric clinic. The frantic mother states, "I think With the nurse's feet spread apart and knees
my 4-month-old baby is choking!" What steps will aligned with the client's knees, stand and pivot
the nurse take? (Select all that apply.) the client into the chair.
A. C.
Compress the chest once between the nipples Assist the client to a standing position by gently
with two fingers. lifting upward, underneath the axillae.
B. D.
Note any obstruction or absence of breathing. Stand beside the client, place the client's arms
C. around the nurse's neck, and gently move the
Deliver five backslaps between the shoulder client to the chair. - -B
blades. Rationale: Option B describes the correct
D. positioning of the nurse and affords the nurse a
Place the infant over the nurse's arm. wide base of support while stabilizing the client's
E. knees when assisting to a standing position. The
Perform a blind finger sweep. - - B, C, D chair should be placed at a 45-degree angle to
Rationale: The fingers are placed at the same the bed, with the back of the chair toward the
location on an infant as chest compressions for head of the bed. Clients should never be lifted
CPR; however, the nurse must deliver five chest under the axillae; this could damage nerves and
thrusts, after the five back slaps. Blind sweeps strain the nurse's back. The client should be
are not used as this action may push the object instructed to use the arms of the chair and should
deeper into the throat. The remaining steps are never place his or her arms around the nurse's
correct. neck; this places undue stress on the nurse's
neck and back and increases the risk for a fall.
Which fluid will the nurse select to administer
with the prescribed blood transfusion? How many mL will the nurse document on the
A. client's intake and output record from the items
5% Dextrose and water listed? _____ mL
B. 1200 mL water
Normal saline 4 ounce container of gelatin
C. 8 ounces of orange juice
Lactated Ringers solution 355 mL can of soda1 cup of soup - -
D. Answer: 2155
5% Dextrose and lactated ringers - -B Rationale: 1200 + 240 (8 oz) + 240 (1 cup) + 120
Rationale: Normal saline solution is the only (4 oz) + 355 = 2155
solution that is compatible with blood.
The nurse observes a UAP taking a client's blood
When assisting a client from the bed to a chair, pressure in the lower extremity. Which
which procedure is best for the nurse to follow? observation of this procedure requires the nurse
A. to intervene with the UAP's approach?
Place the chair parallel to the bed, with its back A.
toward the head of the bed and assist the client The cuff wraps around the girth of the leg.
in moving to the chair. B.
,HESI RN FUNDAMENTALS EXIT EXAM 100 QUESTIONS AND CORRECT
ANSWERS WITH RATIOANLES
The UAP auscultates the popliteal pulse with the
cuff on the lower leg.
C. The nurse identifies a potential for infection in a
The client is placed in a prone position. client with partial-thickness (second-degree) and
D. full-thickness (third-degree) burns. What action
The systolic reading is 20 mm Hg higher than the has the highest priority in decreasing the client's
blood pressure in the client's arm. - -B risk of infection?
Rationale: When obtaining the blood pressure in A.
the lower extremities, the popliteal pulse is the Administration of plasma expanders
site for auscultation when the blood pressure cuff B.
is applied around the thigh. The nurse should Use of careful handwashing technique
intervene with the UAP who has applied the cuff C.
on the lower leg. Option A ensures an accurate Application of a topical antibacterial cream
assessment, and option C provides the best D.
access to the artery. Systolic pressure in the Limiting visitors to the client with burns - -B
popliteal artery is usually 10 to 40 mm Hg higher Rationale: Careful handwashing technique is the
than in the brachial artery. single most effective intervention for the
prevention of contamination to all clients. Option
A reverses the hypovolemia that initially
During a clinic visit, the mother of a 7-year-old accompanies burn trauma but is not related to
reports to the nurse that her child is often awake decreasing the proliferation of infective
until midnight playing and is then very difficult to organisms. Options C and D are recommended
awaken in the morning for school. Which by various burn centers as possible ways to
assessment data should the nurse obtain in reduce the chance of infection. Option B is a
response to the mother's concern? proven technique to prevent infection.
A.
The occurrence of any episodes of sleep apnea
B. The nurse assesses a 2-year-old who is admitted
The child's blood pressure, pulse, and for dehydration and finds that the peripheral IV
respirations rate by gravity has slowed, even though the
C. venous access site is healthy. What should the
Length of rapid eye movement (REM) sleep that nurse do next?
the child is experiencing A.
D. Apply a warm compress proximal to the site.
Description of the family's home environment - B.
-D Check for kinks in the tubing and raise the IV
Rationale: School-age children often resist pole.
bedtime. The nurse should begin by assessing C.
the environment of the home to determine factors Adjust the tape that stabilizes the needle.
that may not be conducive to the establishment D.
of bedtime rituals that promote sleep. Option A Flush with normal saline and recount the drop
often causes daytime fatigue rather than rate. - -B
resistance to going to sleep. Option B is unlikely Rationale: The nurse should first check the tubing
to provide useful data. The nurse cannot and height of the bag on the IV pole, which are
determine option C. common factors that may slow the rate. Gravity
,HESI RN FUNDAMENTALS EXIT EXAM 100 QUESTIONS AND CORRECT
ANSWERS WITH RATIOANLES
infusion rates are influenced by the height of the Place the call bell within the client's reach.
bag, tubing clamp closure or kinks, needle size D.
or position, fluid viscosity, client blood pressure Place the side rails up, according to institutional
(crying in the pediatric client), and infiltration. policy.
Venospasm can slow the rate and often E.
responds to warmth over the vessel, but the Assist the client to the bathroom - - B, C, D
nurse should first adjust the IV pole height. The Rationale: Diazepam is a common preoperative
nurse may need to adjust the stabilizing tape on medication. Close observation by placing the
a positional needle or flush the venous access client close to the nurse's station is not
with normal saline, but less invasive actions necessary. The medication has a sedative effect
should be implemented first. and the client should not get out of bed, even
with assistance. The remaining selections are
correct.
The nurse manager of a skilled nursing (chronic
care) unit is instructing UAPs on ways to prevent
complications of immobility. Which action should A terminally ill client tells the nurse, "I am so tired
be included in this instruction? and in so much pain! Please help me to die."
A. Which is the best response for the nurse to
Perform range-of-motion exercises to prevent provide?
contractures. A.
B. Administer the prescribed maximum dose of pain
Decrease the client's fluid intake to prevent medication.
diarrhea. B.
C. Talk with the client about thoughts and feelings
Massage the client's legs to reduce embolism about death.
occurrence. C.
D. Collaborate with the health care provider about
Turn the client from side to back every shift. - initiating antidepressant therapy.
-A D.
Rationale: Performing range-of-motion exercises Refer the client to the ethics committee of her
is beneficial in reducing contractures around local health care facility. - -B
joints. Options B, C, and D are all potentially Rationale: The nurse should first assess the
harmful practices that place the immobile client client's feelings about death and determine the
at risk of complications. extent to which this statement expresses the
client's true feelings. The client may need
additional pain management, but further
The nurse administered 10 mg of diazepam to assessment is needed before implementing
the preoperative client. What steps will the nurse option A. Options C and D are both premature
take next? (Select all that apply.) interventions and should not be implemented
A. until further assessment is obtained.
Place the client in the bed next to the nurse's
station.
B. A nurse stops at a motor vehicle collision site to
Instruct the client not to get out of bed. render aid until the emergency personnel arrive
C. and applies pressure to a groin wound that is
, HESI RN FUNDAMENTALS EXIT EXAM 100 QUESTIONS AND CORRECT
ANSWERS WITH RATIOANLES
bleeding profusely. Later the client has to have movement or void.
the leg amputated and sues the nurse for D.
malpractice. Which statement reflects the likely Assess the client's bladder to determine if the
outcome for the nurse? client needs to urinate. - -A
A. Rationale: Barbiturates cause central nervous
The Patient's Bill of Rights protects clients from system (CNS) depression, and individuals taking
malicious intents, so the nurse could lose the these medications are at greater risk for falls. The
case. nurse should assist the client to the bathroom. A
B. bedpan is not necessary as long as safety is
The lawsuit may be settled out of court, but the ensured. Whether the client needs to void or
nurse's license is likely to be revoked. have a bowel movement, option C is irrelevant in
C. terms of meeting this client's safety needs. There
There will be no judgment against the nurse, is no indication that this client cannot voice her or
whose actions are protected under the Good his needs, so assessment of the bladder is not
Samaritan Act. needed.
D.
The client will win because the four elements of
negligence (duty, breach, causation, and The nurse is planning care for a client with an
damages) can be proved. - -C indwelling urinary catheter. Which nursing action
Rationale: The Good Samaritan Act protects has the highest priority?
health care professionals who practice in good A.
faith and provide reasonable care from Assist the client with daily cleansing.
malpractice claims, regardless of the client B.
outcome. Although the Patient's Bill of Rights Tell the client that incontinence happens with
protects clients, this nurse is protected by the aging.
Good Samaritan Act. The state Board of Nursing C.
has no reason to revoke a registered nurse's Offer 200 mL of fluid every 2 hours while awake.
license unless there was evidence that actions D.
taken in the emergency were not done in good Take the client's temperature every 4 hours. -
faith or that reasonable care was not provided. -D
All four elements of malpractice were not shown. Rationale: Indwelling urinary catheters are a
major source of infection. Option A is a problem
that may develop from having an indwelling
An older client who had abdominal surgery 3 catheter. Option B may or may not be true for the
days earlier was given a barbiturate for sleep and client. Option C is not affected by an indwelling
is now requesting to go to the bathroom. What is catheter.
the priority nursing action for this client?
A.
Assist the client to walk to the bathroom and do When bathing an uncircumcised boy older than 3
not leave the client alone. years, which action should the nurse take?
B. A.
Request that the UAP assist the client onto a Remind the child to clean his genital area.
bedpan. B.
C. Defer perineal care because of the child's age.
Ask if the client needs to have a bowel C.
ANSWERS WITH RATIOANLES
The nurse is called to the waiting room of a B.
pediatric clinic. The frantic mother states, "I think With the nurse's feet spread apart and knees
my 4-month-old baby is choking!" What steps will aligned with the client's knees, stand and pivot
the nurse take? (Select all that apply.) the client into the chair.
A. C.
Compress the chest once between the nipples Assist the client to a standing position by gently
with two fingers. lifting upward, underneath the axillae.
B. D.
Note any obstruction or absence of breathing. Stand beside the client, place the client's arms
C. around the nurse's neck, and gently move the
Deliver five backslaps between the shoulder client to the chair. - -B
blades. Rationale: Option B describes the correct
D. positioning of the nurse and affords the nurse a
Place the infant over the nurse's arm. wide base of support while stabilizing the client's
E. knees when assisting to a standing position. The
Perform a blind finger sweep. - - B, C, D chair should be placed at a 45-degree angle to
Rationale: The fingers are placed at the same the bed, with the back of the chair toward the
location on an infant as chest compressions for head of the bed. Clients should never be lifted
CPR; however, the nurse must deliver five chest under the axillae; this could damage nerves and
thrusts, after the five back slaps. Blind sweeps strain the nurse's back. The client should be
are not used as this action may push the object instructed to use the arms of the chair and should
deeper into the throat. The remaining steps are never place his or her arms around the nurse's
correct. neck; this places undue stress on the nurse's
neck and back and increases the risk for a fall.
Which fluid will the nurse select to administer
with the prescribed blood transfusion? How many mL will the nurse document on the
A. client's intake and output record from the items
5% Dextrose and water listed? _____ mL
B. 1200 mL water
Normal saline 4 ounce container of gelatin
C. 8 ounces of orange juice
Lactated Ringers solution 355 mL can of soda1 cup of soup - -
D. Answer: 2155
5% Dextrose and lactated ringers - -B Rationale: 1200 + 240 (8 oz) + 240 (1 cup) + 120
Rationale: Normal saline solution is the only (4 oz) + 355 = 2155
solution that is compatible with blood.
The nurse observes a UAP taking a client's blood
When assisting a client from the bed to a chair, pressure in the lower extremity. Which
which procedure is best for the nurse to follow? observation of this procedure requires the nurse
A. to intervene with the UAP's approach?
Place the chair parallel to the bed, with its back A.
toward the head of the bed and assist the client The cuff wraps around the girth of the leg.
in moving to the chair. B.
,HESI RN FUNDAMENTALS EXIT EXAM 100 QUESTIONS AND CORRECT
ANSWERS WITH RATIOANLES
The UAP auscultates the popliteal pulse with the
cuff on the lower leg.
C. The nurse identifies a potential for infection in a
The client is placed in a prone position. client with partial-thickness (second-degree) and
D. full-thickness (third-degree) burns. What action
The systolic reading is 20 mm Hg higher than the has the highest priority in decreasing the client's
blood pressure in the client's arm. - -B risk of infection?
Rationale: When obtaining the blood pressure in A.
the lower extremities, the popliteal pulse is the Administration of plasma expanders
site for auscultation when the blood pressure cuff B.
is applied around the thigh. The nurse should Use of careful handwashing technique
intervene with the UAP who has applied the cuff C.
on the lower leg. Option A ensures an accurate Application of a topical antibacterial cream
assessment, and option C provides the best D.
access to the artery. Systolic pressure in the Limiting visitors to the client with burns - -B
popliteal artery is usually 10 to 40 mm Hg higher Rationale: Careful handwashing technique is the
than in the brachial artery. single most effective intervention for the
prevention of contamination to all clients. Option
A reverses the hypovolemia that initially
During a clinic visit, the mother of a 7-year-old accompanies burn trauma but is not related to
reports to the nurse that her child is often awake decreasing the proliferation of infective
until midnight playing and is then very difficult to organisms. Options C and D are recommended
awaken in the morning for school. Which by various burn centers as possible ways to
assessment data should the nurse obtain in reduce the chance of infection. Option B is a
response to the mother's concern? proven technique to prevent infection.
A.
The occurrence of any episodes of sleep apnea
B. The nurse assesses a 2-year-old who is admitted
The child's blood pressure, pulse, and for dehydration and finds that the peripheral IV
respirations rate by gravity has slowed, even though the
C. venous access site is healthy. What should the
Length of rapid eye movement (REM) sleep that nurse do next?
the child is experiencing A.
D. Apply a warm compress proximal to the site.
Description of the family's home environment - B.
-D Check for kinks in the tubing and raise the IV
Rationale: School-age children often resist pole.
bedtime. The nurse should begin by assessing C.
the environment of the home to determine factors Adjust the tape that stabilizes the needle.
that may not be conducive to the establishment D.
of bedtime rituals that promote sleep. Option A Flush with normal saline and recount the drop
often causes daytime fatigue rather than rate. - -B
resistance to going to sleep. Option B is unlikely Rationale: The nurse should first check the tubing
to provide useful data. The nurse cannot and height of the bag on the IV pole, which are
determine option C. common factors that may slow the rate. Gravity
,HESI RN FUNDAMENTALS EXIT EXAM 100 QUESTIONS AND CORRECT
ANSWERS WITH RATIOANLES
infusion rates are influenced by the height of the Place the call bell within the client's reach.
bag, tubing clamp closure or kinks, needle size D.
or position, fluid viscosity, client blood pressure Place the side rails up, according to institutional
(crying in the pediatric client), and infiltration. policy.
Venospasm can slow the rate and often E.
responds to warmth over the vessel, but the Assist the client to the bathroom - - B, C, D
nurse should first adjust the IV pole height. The Rationale: Diazepam is a common preoperative
nurse may need to adjust the stabilizing tape on medication. Close observation by placing the
a positional needle or flush the venous access client close to the nurse's station is not
with normal saline, but less invasive actions necessary. The medication has a sedative effect
should be implemented first. and the client should not get out of bed, even
with assistance. The remaining selections are
correct.
The nurse manager of a skilled nursing (chronic
care) unit is instructing UAPs on ways to prevent
complications of immobility. Which action should A terminally ill client tells the nurse, "I am so tired
be included in this instruction? and in so much pain! Please help me to die."
A. Which is the best response for the nurse to
Perform range-of-motion exercises to prevent provide?
contractures. A.
B. Administer the prescribed maximum dose of pain
Decrease the client's fluid intake to prevent medication.
diarrhea. B.
C. Talk with the client about thoughts and feelings
Massage the client's legs to reduce embolism about death.
occurrence. C.
D. Collaborate with the health care provider about
Turn the client from side to back every shift. - initiating antidepressant therapy.
-A D.
Rationale: Performing range-of-motion exercises Refer the client to the ethics committee of her
is beneficial in reducing contractures around local health care facility. - -B
joints. Options B, C, and D are all potentially Rationale: The nurse should first assess the
harmful practices that place the immobile client client's feelings about death and determine the
at risk of complications. extent to which this statement expresses the
client's true feelings. The client may need
additional pain management, but further
The nurse administered 10 mg of diazepam to assessment is needed before implementing
the preoperative client. What steps will the nurse option A. Options C and D are both premature
take next? (Select all that apply.) interventions and should not be implemented
A. until further assessment is obtained.
Place the client in the bed next to the nurse's
station.
B. A nurse stops at a motor vehicle collision site to
Instruct the client not to get out of bed. render aid until the emergency personnel arrive
C. and applies pressure to a groin wound that is
, HESI RN FUNDAMENTALS EXIT EXAM 100 QUESTIONS AND CORRECT
ANSWERS WITH RATIOANLES
bleeding profusely. Later the client has to have movement or void.
the leg amputated and sues the nurse for D.
malpractice. Which statement reflects the likely Assess the client's bladder to determine if the
outcome for the nurse? client needs to urinate. - -A
A. Rationale: Barbiturates cause central nervous
The Patient's Bill of Rights protects clients from system (CNS) depression, and individuals taking
malicious intents, so the nurse could lose the these medications are at greater risk for falls. The
case. nurse should assist the client to the bathroom. A
B. bedpan is not necessary as long as safety is
The lawsuit may be settled out of court, but the ensured. Whether the client needs to void or
nurse's license is likely to be revoked. have a bowel movement, option C is irrelevant in
C. terms of meeting this client's safety needs. There
There will be no judgment against the nurse, is no indication that this client cannot voice her or
whose actions are protected under the Good his needs, so assessment of the bladder is not
Samaritan Act. needed.
D.
The client will win because the four elements of
negligence (duty, breach, causation, and The nurse is planning care for a client with an
damages) can be proved. - -C indwelling urinary catheter. Which nursing action
Rationale: The Good Samaritan Act protects has the highest priority?
health care professionals who practice in good A.
faith and provide reasonable care from Assist the client with daily cleansing.
malpractice claims, regardless of the client B.
outcome. Although the Patient's Bill of Rights Tell the client that incontinence happens with
protects clients, this nurse is protected by the aging.
Good Samaritan Act. The state Board of Nursing C.
has no reason to revoke a registered nurse's Offer 200 mL of fluid every 2 hours while awake.
license unless there was evidence that actions D.
taken in the emergency were not done in good Take the client's temperature every 4 hours. -
faith or that reasonable care was not provided. -D
All four elements of malpractice were not shown. Rationale: Indwelling urinary catheters are a
major source of infection. Option A is a problem
that may develop from having an indwelling
An older client who had abdominal surgery 3 catheter. Option B may or may not be true for the
days earlier was given a barbiturate for sleep and client. Option C is not affected by an indwelling
is now requesting to go to the bathroom. What is catheter.
the priority nursing action for this client?
A.
Assist the client to walk to the bathroom and do When bathing an uncircumcised boy older than 3
not leave the client alone. years, which action should the nurse take?
B. A.
Request that the UAP assist the client onto a Remind the child to clean his genital area.
bedpan. B.
C. Defer perineal care because of the child's age.
Ask if the client needs to have a bowel C.
