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HESI -RN FUNDAMENTAL WITH NGN ACTUAL EXAM 2023 WITH 125 QUESTION AND LATEST ANSWERS WITH RATIONALES. 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. 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 aroun d 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 mot her'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 proliferati on 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.
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