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HESI RN FUNDAMENTALS EXIT EXAM VERSION 4 / RN FUNDAMENTALS HESI EXIT EXAM VERSION 5 ACTUAL EXAM ALL 75 QUESTIONS AND CORRECT DETAILED ANSWERS$15.99
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A 20-year-old female client with a notice-
able body odor has refused to shower for
the
last 3 days. She states, "I have been
D
told that it is harmful to bathe during my
period."
Because a shower is most beneficial for
Which action should the nurse take first?
the client in terms of hygiene, the client
should receive teaching first, respecting
A.Accept and document the client's wish
any personal beliefs such as cultural or
to refrain from bathing.
spiritual values. After client teaching, the
B.Offer to give the client a bed bath,
client may still choose option A or B.
avoiding the perineal area.
Brochures reinforce the teaching
C.Obtain written brochures about men-
struation to give to the client.
D.Teach the importance of personal hy-
giene during menstruation with the client
A 65-year-old client who attends an adult
daycare program and is wheelchair-mo-
B
bile
has redness in the sacral area. Which in-
The most important teaching is to
struction is most important for the nurse
change positions frequently because
to
pressure is the most significant factor
provide?
related to the development of pressure
ulcers. Increased vitamin and fluid
A.Take a vitamin supplement tablet once
intake may also be beneficial and pro-
a day.
mote healing and reduce further risk. Op-
B.Change positions in the chair at least
tion D is an intervention of last resort
every hour.
because this will be very expensive for
C.Increase daily intake of water or other
the client.
oral fluids.
D.Purchase a newer model wheelchair.
B
After a needle stick occurs while remov-
ing the cap from a sterile needle, which After a needle stick, the needle is consid-
action should the nurse implement? ered used, so the nurse should discard it
and select another needle. Because the
A.Complete an incident report. needle was sterile when the nurse was
stuck and the needle
, HESI RN Fundamentals
was not in contact with any other per-
B.Select another sterile needle. son's body fluids, the nurse does not
C.Disinfect the needle with an alcohol need to complete an incident report or
swab. notify the occupational health nurse. Dis-
D.Notify the supervisor of the depart- infecting a needle with an alcohol
ment immediately swab is not in accordance with standards
for safe practice and infection control.
After receiving written and verbal instruc-
tions from a clinic nurse about a newly
prescribed medication, a client asks the
nurse what to do if questions arise about
the medication after getting home. How
D
should the nurse respond?
To ensure safe medication use, the nurse
A.Provide the client with a list of Internet
should encourage the client to call the
sites that answer frequently asked
nurse or health care provider if any ques-
questions about medications.
tions arise. Options A, B, and C may
B.Advise the client to obtain a current
all include useful information, but these
edition of a drug reference book from a
sources of information cannot evaluate
local bookstore or library.
the nature of the client's questions and
C.Reassure the client that information
the follow-up needed.
about the medication is included in the
written instructions.
D.Encourage the client to call the clinic
nurse or health care provider if any
questions arise.
After the nurse tells an older client that
an IV line needs to be inserted, the client
becomes very apprehensive, loudly ver- C
balizing a dislike for all health care
providers and nurses. How should the The nurse should respond with a calm
nurse respond? demeanor to help reduce the client's ap-
prehension. After responding calmly to
A.Ask the client to remain quiet so the the client's apprehension, the nurse may
procedure can be performed safely. implement to
B.Concentrate on completing the inser- ensure safe completion of the procedure.
tion as efficiently as possible.
C.Calmly reassure the client that the dis-
, HESI RN Fundamentals
comfort will be temporary.
D.Tell the client a joke as a means of
distraction from the procedure
Based on the nursing diagnosis of risk
for infection, which intervention is best
A
for the
nurse to implement when providing care
The best action to decrease the risk of
for an older incontinent client?
infection in vulnerable clients is hand-
washing. Option B is not necessary un-
A.Maintain standard precautions.
less the client has an infection. Option C
B.Initiate contact isolation measures.
increases the risk of infection. Option D
C.Insert an indwelling urinary catheter
does not reduce the risk of infection.
D. Instruct client in the use of adult dia-
pers
By rolling contaminated gloves in-
side-out, the nurse is affecting which
step in the chain A
of infection?
The contaminated gloves serve as the
A.Mode of transmission mode of transmission from the portal of
B.Portal of entry exit of the reservoir to a portal of entry
C.Reservoir
D.Portal of exit:
A client becomes angry while waiting for
a supervised break to smoke a cigarette
outside and states, "I want to go outside D
now and smoke. It takes forever to get
anything done here!" Which intervention The best nursing action is to review the
is best for the nurse to implement? schedule of outdoor breaks and provide
concrete information about the schedule.
A.Encourage the client to use a nicotine Option A is contraindicated if the client
patch. wants to continue smoking. Option B is
B.Reassure the client that it is almost insufficient to encourage a trusting rela-
time for another break. tionship with the client.
C.Have the client leave the unit with an- Option C is preferential for this client only
other staff member. and is inconsistent with unit rules.
D.Review the schedule of outdoor
breaks with the client.
, HESI RN Fundamentals
A client has a nasogastric tube connect- D
ed to low intermittent suction. When
administering medications through the The nurse should 1) turn off the suction
nasogastric tube, which action should and then
the nurse do first? 2) confirm placement of the tube in the
stomach before
A.Clamp the nasogastric tube. 3) instilling the medications. To prevent
B.Confirm placement of the tube. immediate removal of the instilled med-
C.Use a syringe to instill the medica- ications and allow absorption, the tube
tions. should be clamped for a period of time
D.Turn off the intermittent suction device. before reconnecting the suction.
A client has a nursing diagnosis of Al-
tered sleep patterns related to nocturia. A
Which
client instruction is important for the Nocturia is urination during the night. Op-
nurse to provide? tion A is helpful to decrease the produc-
tion
A.Decrease intake of fluids after the of urine, thus decreasing the need to void
evening meal. at night. Option B helps prevent bladder
B.Drink a glass of cranberry juice every infections. Option C may promote sleep,
day. but the fluid will contribute to nocturia.
C.Drink a glass of warm decaffeinated Option D may result in
beverage at bedtime. urinary incontinence if the client is sedat-
D.Consult the health care provider about ed and does not awaken to void.
a sleeping pill.
A client in a long-term care facility re-
ports to the nurse that he has not had a
bowel movement in 2 days. Which in-
C
tervention should the nurse implement
first?
This client may not routinely have a daily
bowel movement, so the nurse should
A.Instruct the caregiver to offer a glass of
first assess this client's normal bowel
warm prune juice at mealtimes.
habits before attempting any interven-
B.Notify the health care provider and re-
tion. Option A, B, or D
quest a prescription for a large-volume
may then be implemented, if warranted.
enema.
C.Assess the client's medical record to
determine the client's normal bowel pat-
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