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HESI RN FUNDAMENTALS EXAM
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HESI RN FUNDAMENTALS EXAM
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HESI RN FUNDAMENTALS EXAMThe 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.
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.
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.
Application of a topical antibacterial cream
D.
Limiting visitors to the client with burns - ANSWER: B
Rationale: Careful handwashing technique is the single most effective intervention
for the prevention of contamination to all clients. Option A reverses the hypovolemia
that initially accompanies burn trauma but is not related to decreasing the
proliferation of infective organisms. Options C and D are recommended by various
burn centers as possible ways to reduce the chance of infection. Option B is a proven
technique to prevent infection.
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. - ANSWER: 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. - ANSWER: 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 administered 10 mg of diazepam to the preoperative client. What steps
will the nurse take next? (Select all that apply.)
A.
Place the client in the bed next to the nurse's station.
B.
Instruct the client not to get out of bed.
C.
Place the call bell within the client's reach.
D.
Place the side rails up, according to institutional policy.
E.
Assist the client to the bathroom - ANSWER: B, C, D
Rationale: Diazepam is a common preoperative medication. Close observation by
placing the client close to the nurse's station is not necessary. The medication has a
sedative effect and the client should not get out of bed, even with assistance. The
remaining selections are correct.
A terminally ill client tells the nurse, "I am so tired and in so much pain! Please help
me to die." Which is the best response for the nurse to provide?
A.
Administer the prescribed maximum dose of pain medication.
B.
Talk with the client about thoughts and feelings about death.
C.
Collaborate with the health care provider about initiating antidepressant therapy.
D.
Refer the client to the ethics committee of her local health care facility. - ANSWER: B
Rationale: The nurse should first assess the client's feelings about death and
determine the extent to which this statement expresses the client's true feelings.
The client may need additional pain management, but further assessment is needed
before implementing option A. Options C and D are both premature interventions
and should not be implemented until further assessment is obtained.
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