HESI-RN Fundamentals 2024 WITH
CORRECT AND VERRIFIED
ANSWERS
The nurse assesses a 2-year-old who is admitted for dehydration and finds that the
peripheral IV rate by gravity has slowed, even though the venous access site is healthy.
What should the nurse do next?
A.
Apply a warm compress proximal to the site.
B.
Check for kinks in the tubing and raise the IV pole.
C.
Adjust the tape that stabilizes the needle.
D.
Flush with normal saline and recount the drop rate. - CORRECT ANSWERS-B
,Rationale: The nurse should first check the tubing and height of the bag on the IV pole,
which are common factors that may slow the rate. Gravity infusion rates are influenced
by the height of the bag, tubing clamp closure or kinks, needle size or position, fluid
viscosity, client blood pressure (crying in the pediatric client), and infiltration.
Venospasm can slow the rate and often responds to warmth over the vessel, but the
nurse should first adjust the IV pole height. The nurse may need to adjust the stabilizing
tape on a positional needle or flush the venous access with normal saline, but less
invasive actions should be implemented first.
The nurse manager of a skilled nursing (chronic care) unit is instructing UAPs on ways
to prevent complications of immobility. Which action should be included in this
instruction?
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. - CORRECT ANSWERS-A
Rationale: Performing range-of-motion exercises is beneficial in reducing contractures
around joints. Options B, C, and D are all potentially harmful practices that place the
immobile client at risk of complications.
,The nurse is called to the waiting room of a pediatric clinic. The frantic mother states, "I
think my 4-month-old baby is choking!" What steps will the nurse take? (Select all that
apply.)
A.
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. - CORRECT ANSWERS-B, C, D
Rationale: The fingers are placed at the same location on an infant as chest
compressions for CPR; however, the nurse must deliver five chest thrusts, after the five
back slaps. Blind sweeps are not used as this action may push the object deeper into
the throat. The remaining steps are correct.
Which fluid will the nurse select to administer with the prescribed blood transfusion?
A.
5% Dextrose and water
B.
Normal saline
C.
Lactated Ringers solution
D.
5% Dextrose and lactated ringers - CORRECT ANSWERS-B
Rationale: Normal saline solution is the only solution that is compatible with blood.
When assisting a client from the bed to a chair, which procedure is best for the nurse to
follow?
A.
Place the chair parallel to the bed, with its back toward the head of the bed and assist
the client in moving to the chair.
B.
With the nurse's feet spread apart and knees aligned with the client's knees, stand and
pivot the client into 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. - CORRECT ANSWERS-B
Rationale: Option B describes the correct positioning of the nurse and affords the nurse
a wide base of support while stabilizing the client's knees when assisting to a standing
position. The chair should be placed at a 45-degree angle to the bed, with the back of
the chair toward the head of the bed. Clients should never be lifted under the axillae;
this could damage nerves and strain the nurse's back. The client should be instructed to
use the arms of the chair and should never place his or her arms around the nurse's
neck; this places undue stress on the nurse's neck and back and increases the risk for a
fall.
How many mL will the nurse document on the client's intake and output record from the
items listed? _____ mL
1200 mL water
4 ounce container of gelatin
8 ounces of orange juice
355 mL can of soda1 cup of soup - CORRECT ANSWERS-Answer: 2155
Rationale: 1200 + 240 (8 oz) + 240 (1 cup) + 120 (4 oz) + 355 = 2155
The nurse observes a UAP taking a client's blood pressure in the lower extremity.
Which observation of this procedure requires the nurse to intervene with the UAP's
approach?
A.
The cuff wraps around the girth of the leg.
B.
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. -
CORRECT ANSWERS-B
Rationale: When obtaining the blood pressure in the lower extremities, the popliteal
pulse is the site for auscultation when the blood pressure cuff is applied around the
thigh. The nurse should intervene with the UAP who has applied the cuff on the lower
leg. Option A ensures an accurate assessment, and option C provides the best access
to the artery. Systolic pressure in the popliteal artery is usually 10 to 40 mm Hg higher
than in the brachial artery.
One week after being told that she has terminal cancer with a life expectancy of 3
weeks, the client tells the nurse, "I think I will plan a big party for all my friends." How
should the nurse respond?
A.
"You may not have enough energy before long to hold a big party."
B.
"Do you mean to say that you want to plan your funeral and wake?"
CORRECT AND VERRIFIED
ANSWERS
The nurse assesses a 2-year-old who is admitted for dehydration and finds that the
peripheral IV rate by gravity has slowed, even though the venous access site is healthy.
What should the nurse do next?
A.
Apply a warm compress proximal to the site.
B.
Check for kinks in the tubing and raise the IV pole.
C.
Adjust the tape that stabilizes the needle.
D.
Flush with normal saline and recount the drop rate. - CORRECT ANSWERS-B
,Rationale: The nurse should first check the tubing and height of the bag on the IV pole,
which are common factors that may slow the rate. Gravity infusion rates are influenced
by the height of the bag, tubing clamp closure or kinks, needle size or position, fluid
viscosity, client blood pressure (crying in the pediatric client), and infiltration.
Venospasm can slow the rate and often responds to warmth over the vessel, but the
nurse should first adjust the IV pole height. The nurse may need to adjust the stabilizing
tape on a positional needle or flush the venous access with normal saline, but less
invasive actions should be implemented first.
The nurse manager of a skilled nursing (chronic care) unit is instructing UAPs on ways
to prevent complications of immobility. Which action should be included in this
instruction?
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. - CORRECT ANSWERS-A
Rationale: Performing range-of-motion exercises is beneficial in reducing contractures
around joints. Options B, C, and D are all potentially harmful practices that place the
immobile client at risk of complications.
,The nurse is called to the waiting room of a pediatric clinic. The frantic mother states, "I
think my 4-month-old baby is choking!" What steps will the nurse take? (Select all that
apply.)
A.
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. - CORRECT ANSWERS-B, C, D
Rationale: The fingers are placed at the same location on an infant as chest
compressions for CPR; however, the nurse must deliver five chest thrusts, after the five
back slaps. Blind sweeps are not used as this action may push the object deeper into
the throat. The remaining steps are correct.
Which fluid will the nurse select to administer with the prescribed blood transfusion?
A.
5% Dextrose and water
B.
Normal saline
C.
Lactated Ringers solution
D.
5% Dextrose and lactated ringers - CORRECT ANSWERS-B
Rationale: Normal saline solution is the only solution that is compatible with blood.
When assisting a client from the bed to a chair, which procedure is best for the nurse to
follow?
A.
Place the chair parallel to the bed, with its back toward the head of the bed and assist
the client in moving to the chair.
B.
With the nurse's feet spread apart and knees aligned with the client's knees, stand and
pivot the client into 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. - CORRECT ANSWERS-B
Rationale: Option B describes the correct positioning of the nurse and affords the nurse
a wide base of support while stabilizing the client's knees when assisting to a standing
position. The chair should be placed at a 45-degree angle to the bed, with the back of
the chair toward the head of the bed. Clients should never be lifted under the axillae;
this could damage nerves and strain the nurse's back. The client should be instructed to
use the arms of the chair and should never place his or her arms around the nurse's
neck; this places undue stress on the nurse's neck and back and increases the risk for a
fall.
How many mL will the nurse document on the client's intake and output record from the
items listed? _____ mL
1200 mL water
4 ounce container of gelatin
8 ounces of orange juice
355 mL can of soda1 cup of soup - CORRECT ANSWERS-Answer: 2155
Rationale: 1200 + 240 (8 oz) + 240 (1 cup) + 120 (4 oz) + 355 = 2155
The nurse observes a UAP taking a client's blood pressure in the lower extremity.
Which observation of this procedure requires the nurse to intervene with the UAP's
approach?
A.
The cuff wraps around the girth of the leg.
B.
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. -
CORRECT ANSWERS-B
Rationale: When obtaining the blood pressure in the lower extremities, the popliteal
pulse is the site for auscultation when the blood pressure cuff is applied around the
thigh. The nurse should intervene with the UAP who has applied the cuff on the lower
leg. Option A ensures an accurate assessment, and option C provides the best access
to the artery. Systolic pressure in the popliteal artery is usually 10 to 40 mm Hg higher
than in the brachial artery.
One week after being told that she has terminal cancer with a life expectancy of 3
weeks, the client tells the nurse, "I think I will plan a big party for all my friends." How
should the nurse respond?
A.
"You may not have enough energy before long to hold a big party."
B.
"Do you mean to say that you want to plan your funeral and wake?"
