HESI RN FUNDAMENTAL EXAM LATEST TESTBANK 2024/2025 WITH
ACTUAL QUESTIONS AND CORRECT VERIFIED (DETAILED)
ANSWERS/ALREADY GRADED A
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 - ANSWER-B
Rationale: Normal saline solution is the only solution that is compatible with
blood.
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. - ANSWER-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.
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. - ANSWER-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 - ANSWER-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. - ANSWER-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.
During a clinic visit, the mother of a 7-year-old reports to the nurse that her
child is often awake until midnight playing and is then very difficult to awaken
in the morning for school. Which assessment data should the nurse obtain in
response to the mother's concern?
A.
The occurrence of any episodes of sleep apnea
B.
The child's blood pressure, pulse, and respirations
C.
Length of rapid eye movement (REM) sleep that the child is experiencing
D.
Description of the family's home environment - ANSWER-D
Rationale: School-age children often resist bedtime. The nurse should begin by
assessing the environment of the home to determine factors that may not be
conducive to the establishment of bedtime rituals that promote sleep. Option
A often causes daytime fatigue rather than resistance to going to sleep. Option
B is unlikely to provide useful data. The nurse cannot determine option C.
The nurse identifies a potential for infection in a client with partial-thickness
(second-degree) and full-thickness (third-degree) burns. What action has the
highest priority in decreasing the client's risk of infection?
A.
Administration of plasma expanders
B.
Use of careful handwashing technique
C.
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