HESI RN Fundamentals Practice Exam With Answers (75 Solved Questions)

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HESI RN FUNDAMENTALS EXAM QUESTIONS WITHANSWERS AND EXPLANATIONS UPDATED•Whenturninganimmobile bedriddenclient withoutassistance,whichactionbythenursebest ensures clientsafety?ASecurely grasptheclient's armand leg.B.Putbedrailsupon theside ofbedopposite fromthenurse.C.Correctly positionanduseaturnsheet.DLowertheheadofthe client'sbed slowly..Rationale:Because the nurse can only stand on one side of the bed, bed rails should be up on theoppositesidetoensurethattheclientdoesnotfalloutofbed.Option Acancause clientinjurytotheskinor joint. Options C and D are useful techniques while turning a client but have lesspriority intermsof safety thanuseof thebed rails.•The nurse identifies a potential for infection in a client with partial-thickness (second-degree)andfull-thickness(third-degree)burns.Whatinterventionhasthehighestpriorityin decreasingtheclient'sriskof infection?•Administrationofplasmaexpanders•Useofcarefulhandwashingtechnique•Applicationofatopicalantibacterialcream•Limitingvisitors totheclientwithburnsRationale:Careful handwashing technique is the single most effective intervention for the prevention ofcontamination to all clients. Option A reverses the hypovolemia that initially accompanies burntraumabutisnotrelatedtodecreasingtheproliferationofinfectiveorganisms.OptionsCandDarerecommendedbyvarious burncentersaspossible waystoreducethechanceofinfection.OptionBisaproventechniquetopreventinfection.

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•The nurse is aware that malnutrition is a common problem among clients served byacommunity healthclinic forthehomeless.Whichlaboratory valueisthemostreliableindicatorof chronicproteinmalnutrition?•Lowserumalbuminlevel•Lowserumtransferrinlevel•Highhemoglobinlevel•Highcholesterol levelRationale:Long-term protein deficiency is required to cause significantly lowered serum albumin levels.Albumin is made by the liver only when adequate amounts of amino acids (from proteinbreakdown) are available. Albumin has a long half-life, so acute protein loss does notsignificantlyalterserumlevels.OptionBisaserumprotein withahalf-life ofonly8to10days,so it will drop with an acute protein deficiency. Options C and D are not clinicalmeasures ofprotein malnutrition.•In completing a client's preoperative routine, the nurse finds that the operative permitisnotsigned.Theclientbeginstoaskmorequestionsaboutthesurgicalprocedure.Whichaction should thenursetakenext?•Witnesstheclient's signaturetothepermit.•Answertheclient's questionsaboutthesurgery.•Informthesurgeonthat theoperative permitisnotsignedandtheclienthasquestions aboutthesurgery.•Reassuretheclientthatthesurgeonwillansweranyquestionsbeforetheanesthesiaisadministered.Rationale:Thesurgeonshouldbeinformedimmediatelythatthepermitisnotsigned.Itisthesurgeon'sresponsibility to explain the procedure to the client and obtain the client's signature on thepermit.Althoughthenursecan witnessanoperative permit,theprocedure mustfirst beexplained bythehealthcareproviderorsurgeon,includingansweringtheclient'squestions.Theclient'squestions shouldbeaddressedbeforethepermit is signed.

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•Thenurseisassessingseveralclients priortosurgery.Whichfactorinaclient'shistoryposesthegreatestthreatforcomplicationstooccurduringsurgery?•Takingbirthcontrolpillsforthepast2years•Takinganticoagulantsforthepastyear•Recentlycompletingantibiotictherapy•Havingtakenlaxatives PRNforthelast6monthsRationale:Anticoagulants increase the risk for bleeding during surgery, which can pose a threat for thedevelopment of surgical complications. The health care provider should be informed that theclientistakingthese drugs. Althoughclientswhotakebirthcontrol pillsmaybe moresusceptibletothedevelopmentofthrombi,suchproblemsusuallyoccurpostoperatively.Aclientwith option Cor D isatless ofasurgicalriskthan with option B.•Whenassistingaclientfromthebedtoa chair,which procedureisbestforthenursetofollow?APlacethechairparalleltothebed,withits backtowardthe.headofthebedandassisttheclientin movingtothechair.B.Withthenurse'sfeetspreadapartandkneesalignedwiththeclient'sknees,standandpivottheclientintothechair.C.Assisttheclienttoastandingpositionbygentlyliftingupward,underneaththeaxillae.DStandbesidetheclient,placetheclient's armsaroundthe.nurse'sneck,andgentlymovetheclienttothechair.Rationale:Option B describes the correct positioning of the nurse and affords the nurse a wide baseofsupportwhilestabilizing theclient's kneeswhenassistingtoastandingposition.Thechairshould be placed at a 45-degree angle to the bed, with the back of the chair toward the head ofthe bed. Clients should never be lifted under the axillae; this could damage nerves and strainthenurse's back. The client should be instructed to use the armsof the chair and should never

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placehisorher armsaroundthenurse'sneck;thisplacesunduestressonthenurse'sneckandbackandincreasestherisk for afall.•Whichstep(s)shouldthenursetakewhenadministeringeardropstoanadultclient?(Selectallthat apply.)APlace theclientinaside-lyingposition.B.Pullthe auricleupwardandoutward.C.Holdthedropper6cmabovetheearcanal.DPlace acottonball intotheinner canal..E.Pullthe auricle downandback.Rationale:The correct answers (A and B) are the appropriate administration of ear drops. The droppershould be held 1 cm (½ inch) above the ear canal (C). A cotton ball should be placed in theoutermostcanal(D).Theauricle ispulled downandbackforachildyoungerthan3yearsofage,butnotan adult(E).•Thenurseisinstructingaclientintheproperuseofametered-doseinhaler.Whichinstructionshouldthe nurseprovidetheclienttoensuretheoptimal benefitsfromthedrug?•"Fillyourlungswithair throughyourmouth andthencompresstheinhaler."•"Compresstheinhalerwhileslowlybreathinginthroughyourmouth."•"Compresstheinhalerwhileinhalingquicklythroughyournose."•"Exhalecompletely aftercompressingtheinhaler andtheninhale."Rationale:Themedicationshouldbeinhaledthroughthemouthsimultaneouslywithcompressionoftheinhaler.This willfacilitatethedesireddestinationoftheaerosolmedication deepinthelungsforanoptimal bronchodilationeffect.OptionsA,C,andDdonotallowfordeeplungpenetration

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•A20-year-oldfemaleclientwithanoticeablebodyodorhasrefusedtoshowerforthelast3days. She states, "I have been told that it is harmful to bathe during my period." Whichactionshouldthenursetakefirst?•Acceptanddocumenttheclient'swishtorefrainfrombathing.•Offertogivetheclientabed bath,avoidingthe perinealarea.•Obtainwrittenbrochuresaboutmenstruationtogivetotheclient.•Teachtheimportanceofpersonalhygieneduringmenstruationwiththeclient.Rationale:Becauseashowerismostbeneficialfortheclientintermsofhygiene,theclientshouldreceiveteaching first, respecting any personal beliefs such as cultural or spiritual values. After clientteaching,theclientmaystill choose optionAorB.Brochuresreinforce the teaching.•Whilereviewingthesideeffects ofanewlyprescribedmedication,a72-year-oldclientnotesthat one of the side effects is a reduction in sexual drive. Which is the best response bythenurse?A"Howwillthisaffectyourpresentsexualactivity?".B."Howactiveisyourcurrentsexlife?"C."Howhasyoursexlifechanged asyouhavebecomeolder?"D"Tellme aboutyoursexual needsasanolderadult.".Rationale:

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OptionAoffersanopen-ended questionmost relevantto the client'sstatement.Option B doesnotoffertheclienttheopportunitytoexpressconcerns.OptionsCandDareevenlessrelevanttothe client'sstatement.•ThenurseisusingtheGlasgowComaScaletoperformaneurologicassessment.Acomatoseclientwincesandpulls awayfromapainfulstimulus.Whichactionshouldthenursetakenext?•Documentthattheclientrespondstopainfulstimulus.•Observetheclient'sresponsetoverbalstimulation.•Placetheclientonseizureprecautions for24hours.•Reportdecorticateposturingtothehealthcareprovider.Rationale:The client has demonstrated a purposeful response to pain, which should be documented assuch.Responsetopainfulstimulusisassessedafterresponsetoverbalstimulus,notbefore.Thereisnoindication for placing the client on seizure precautions. Reporting decorticateposturing to thehealth careprovideris nonpurposefulmovement.•Thenurseplanstoadministerdiazepam,4mgIVpush,toaclientwithsevereanxiety.Howmany millilitersshould the nurseadminister?(Roundto the nearesttenth.)•0.2mL•0.8mL•1.25mL•2.0mLRationale:(1mL × 4mg)/5 mg =0.8mL

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•Thenursepreparestoinsertanasogastrictubeinaclientwithhyperemesis whoisawakeandalert. Whichintervention(s) is(are) correct?(Selectall that apply.)APlacetheclientinahighFowlerposition..B.Helptheclientassumealeftside-lyingposition.C.Measurethetube fromthe tip ofthenosetothe umbilicus.DInstructtheclienttoswallow afterthetubehaspassedthe.pharynx.E.Assisttheclientin extendingtheneck backsothe tubemayenterthelarynx.Rationale:(A and D) are the correct steps to follow during nasogastric intubation. Only the unconsciousorobtunded client should be placed in a left side-lying position (B). The tube should bemeasuredfrom the tip of the nose to behind the ear and then from behind the ear to the xiphoidprocess (C).The neck should only be extended back prior to the tube passing the pharynx andthen the clientshouldbeinstructedto position theneckforward(E).•The nurse teaches the use of a gait belt to a male caregiver whose wife has right-sidedweaknessandneedsassistancewithambulation.Thecaregiverperformsareturndemonstrationof the skill. Which observation indicates that the caregiver has learned how toperform thisprocedure correctly?AStandingonhiswife'sstrongside,the caregiverisreadyto.holdthegait beltifanyevidenceofweaknessisobserved.B.Standingonhiswife'sweakside,thecaregiverprovidessecuritybyholdingthe gaitbeltfromtheback.C. Standing behind his wife, the caregiver providesbalancebyholding bothsidesof thegait belt.DStandingslightly in frontandto therightofhiswife,the.caregiverguidesherforwardbygentlypullingonthegaitbelt.

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Rationale:Hiswifeismost likelytoleantowardtheweaksideandneeds extrasupportonthat sideandfromtheback to preventfalling. Options A,C,andD providelesssecurityforher.•Whichnursingdiagnosishasthehighestprioritywhenplanning careforaclientwithanindwellingurinary catheter?.•Self-caredeficit•Functionalincontinence•Fluidvolumedeficit•HighriskforinfectionRationale:Indwellingurinarycatheters areamajorsourceofinfection.OptionsAandBarebothproblemsthatmayrequireanindwellingcatheter.Option Cisnotaffectedbyanindwelling catheter•AclienthasanursingdiagnosisofAlteredsleeppatterns relatedtonocturia.Whichclientinstructionis important for the nurseto provide?•Decreaseintakeoffluidsaftertheeveningmeal.•Drinkaglassofcranberryjuiceevery day.•Drinkaglassofwarmdecaffeinatedbeverageatbedtime.•Consultthehealthcareprovideraboutasleepingpill.Rationale:Nocturiaisurinationduringthenight. OptionAishelpfultodecreasetheproductionofurine,thusdecreasingtheneedtovoidatnight.OptionBhelpspreventbladderinfections.OptionCmay promote sleep, but the fluid will contribute to nocturia. Option D may result in urinaryincontinence iftheclientissedated anddoesnotawakentovoid.•Whenperformingsterilewoundcareintheacutecaresetting,thenurseobtains abottleofnormal saline from the bedside table that is labeled "opened" and dated 48 hours prior tothecurrentdate.Whichisthebestaction for thenurseto take?AUsethenormal salinesolutiononce moreand then.discard.B.Obtainanewsterilesyringetodrawupthelabeledsaline

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solution.C.Usethesalinesolutionandthenrelabel thebottlewiththecurrentdate.DDiscardthesalinesolutionandobtain anewunopened.bottle.Rationale:Solutions labeled as opened within 24 hours may be used for clean procedures, but only newlyopenedsolutions areconsideredsterile.Thissolutionisnotnewlyopenedandisoutofdate,soitshouldbediscarded.Options A, B,and Cdescribeincorrectprocedures.•Basedonthenursingdiagnosisofriskforinfection,whichinterventionisbestforthenurseto implementwhen providing care for anolderincontinentclient?•Maintainstandardprecautions.•Initiatecontactisolationmeasures.•Insertanindwellingurinarycatheter.•Instructclientin theuseofadult diapers.Rationale:Thebestactiontodecreasetheriskofinfection invulnerableclientsishandwashing.OptionBisnot necessary unless the client has an infection. Option C increases the risk of infection.OptionDdoes notreducetherisk of infection.•Whentakingaclient's bloodpressure,thenurseisunabletodistinguishthe pointatwhichthe firstsoundwas heard. Whichisthebest actionfor thenurseto take?•Deflatethecuffcompletelyandimmediatelyreattemptthereading.•Reinflatethecuffcompletelyandleaveitinflatedfor90to110secondsbefore takingthesecondreading.•Deflatethe cuffto zeroandwait30to60secondsbeforereattemptingthereading.

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•Documentthe exactlevel visualizedonthesphygmomanometerwherethefirstfluctuation wasseen.Rationale:Deflatingthecufffor30to60secondsallows bloodflowtoreturntothe extremitysothatanaccurate reading can be obtained on that extremity a second time. Option A could result in afalsely high reading. Option B reduces circulation, causes pain, and could alter the reading.Option Dis notan accuratemethod of assessing bloodpressure.•Aclient's bloodpressurereadingis156/94mmHg.Whichaction shouldthenursetakefirst?•Telltheclientthat thebloodpressureishighandthatthereading needsto beverifiedbyanother nurse.•Contactthehealthcareprovidertoreportthereadingandobtainaprescriptionforanantihypertensivemedication.•Replacethecuffwithalargeronetoensureanamplefitfortheclienttoincreasearmcomfort.•Comparethecurrentreadingwiththeclient'spreviouslydocumented bloodpressurereadings.Rationale:Comparingthis readingwithpreviousreadingswillprovideinformationaboutwhatisnormalforthis client; this action shouldbetakenfirst.OptionAmightunnecessarily alarmtheclient.OptionBispremature.Furtherassessmentisneededtodetermineifthereadingisabnormalforthis client. Option C could falsely decrease the reading and is not the correct procedure forobtainingablood pressurereading.•A nurse stops at a motor vehicle collision site to render aid until the emergency personnelarrive and applies pressure to a groin wound that is bleeding profusely. Later the client has tohave the leg amputated and sues the nurse for malpractice. Which isthe most likely outcomeofthislawsuit?

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AThePatient's BillofRightsprotectsclients frommalicious.intents,sothenursecouldlosethecase.B.Thelawsuit maybesettled outofcourt,butthenurse'slicenseislikelytoberevoked.C.Therewillbenojudgmentagainstthenurse,whoseactionswereprotectedundertheGoodSamaritanAct.DTheclientwill winbecausethe fourelementsof.negligence (duty, breach, causation, and damages) canbeproved.Rationale:The Good Samaritan Act protects health care professionals who practice in good faith andprovidereasonablecarefrommalpractice claims,regardlessoftheclientoutcome.AlthoughthePatient's Bill of Rights protects clients, this nurse is protected by the Good Samaritan Act.Thestate Board of Nursing has no reason to revoke a registered nurse's license unless therewasevidence thatactionstakenintheemergencywerenotdoneingoodfaithorthatreasonablecarewasnotprovided. Allfour elementsof malpracticewerenot shown.•When the health care provider diagnoses metastatic cancer and recommends agastrostomyforanolderfemaleclientinstablecondition, thesontells thenursethathismother mustnotbetold the reason for the surgery because she "can't handle" the cancerdiagnosis. Which legalprincipleisthecourtmostlikelytoupholdregardingthisclient'srighttoinformedconsent?•The family can provide the consent required in thissituation becausetheolderadultisinnoconditiontomakesuchdecisions.•Becausetheclientismentally incompetent, thesonhastherighttowaiveinformed consentforher.•Thecourtwillallow thehealthcareprovidertomakethedecisiontowithholdinformedconsentundertherapeuticprivilege.

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