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HESI RN FUNDAMENTAL EXAM QUESTIONS WITH CORRECT ANSWERS LATEST SELF ASSESSMENT TEST BANK 2024
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HESI RN FUNDAMENTAL EXAM QUESTIONS WITH CORRECT ANSWERS LATEST SELF ASSESSMENT TEST BANK 2024
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HESI RN FUNDAMENTAL | HESI RN FUNDAMENTAL EXAMQUESTIONS WITH CORRECT ANSWERS LATEST SELF ASSESSMENT
TEST BANK 2024
When turning an immobile bedridden client without assistance, which action by the nərs best
ensures client safety?
A. Securely grasp the client's arm and leg.
B. Put bed rails up on the side of bed opposite from the nərs.
C. Correctly position and use a turn sheet.
D. Lower the head of the client's bed slowly. - Correct answer-B
Rationale: Because the nərs can only stand on one side of the bed, bed rails should beup on the
opposite side to ensure that the client does not fall out of bed. Option A can cause client injury to
the skin or joint. Options C and D are useful techniques while turning a client but have less
priority in terms of safety than use of the bed rails.
The nərs identifies a potential for infection in a client with partial-thickness (second-degree) and
full-thickness (third-degree) burns. What intervention 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 - Correct answer-B
Rationale: Careful handwashing technique is the single most effective intervention forthe
prevention of contamination to all clients. Option A reverses the hypovolemia thatinitially
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 nərs is aware that malnutrition is a common problem among clients served by acommunity
health clinic for the homeless. Which laboratory value is the most reliableindicator of chronic
protein malnutrition?
A. Low serum albumin level B.
Low serum transferrin levelC.
High hemoglobin level
D. High cholesterol level - Correct answer-A
Rationale: 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
protein breakdown) are available. Albumin has a long half-life, so acute protein loss does not
significantly alter serum levels. Option B is a serum protein with a half-life of only 8 to 10 days,
so it will drop with an acute protein deficiency. Options C and D are not clinical measures of
protein malnutrition.
,In completing a client's preoperative routine, the nərs finds that the operative permit isnot
signed. The client begins to ask more questions about the surgical procedure.
Which action should the nərs take next?
A. Witness the client's signature to the permit.
B. Answer the client's questions about the surgery.
C. Inform the surgeon that the operative permit is not signed and the client has
questions about the surgery.
D. Reassure the client that the surgeon will answer any questions before the anesthesiais
administered. - Correct answer-C
Rationale: The surgeon should be informed immediately that the permit is not signed. Itis the
surgeon's responsibility to explain the procedure to the client and obtain the client's signature on
the permit. Although the nərs can witness an operative permit, theprocedure must first be
explained by the health care provider or surgeon, including answering the client's questions. The
client's questions should be addressed before thepermit is signed.
The nərs is assessing several clients prior to surgery. Which factor in a client's historyposes the
greatest threat for complications to occur during surgery?
A. Taking birth control pills for the past 2 yearsB.
Taking anticoagulants for the past year
C. Recently completing antibiotic therapy
D. Having taken laxatives PRN for the last 6 months - Correct answer-BRationale:
Anticoagulants increase the risk for bleeding during surgery, which can pose a threat forthe
development of surgical complications. The health care provider should be informedthat the
client is taking these drugs. Although clients who take birth control pills may be more
susceptible to the development of thrombi, such problems usually occur postoperatively. A client
with option C or D is at less of a surgical risk than with option B.
When assisting a client from the bed to a chair, which procedure is best for the nərs tofollow?
A. Place the chair parallel to the bed, with its back toward the head of the bed andassist
the client in moving to the chair.
B. With the nərs's feet spread apart and knees aligned with the client's knees, standand pivot
the client into the chair.
C. Assist the client to a standing position by gently lifting upward, underneath theaxillae.
D. Stand beside the client, place the client's arms around the nərs's neck, and gentlymove the
client to the chair. - Correct answer-B
Rationale: Option B describes the correct positioning of the nərs and affords the nərsa 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
nərs's back. The client should be instructed touse the arms of the chair and should never place his
or her arms around the nərs's
,neck; this places undue stress on the nərs's neck and back and increases the risk for afall.
Which step(s) should the nərs take when administering ear drops to an adult client?(Select all
that apply.)
A. Place the client in a side-lying position.B.
Pull the auricle upward and outward.
C. Hold the dropper 6 cm above the ear canal.D.
Place a cotton ball into the inner canal.
E. Pull the auricle down and back. - Correct answer-A, B
Rationale: The correct answers (A and B) are the appropriate administration of ear drops. The
dropper should be held 1 cm (½ inch) above the ear canal (C). A cotton ballshould be placed in
the outermost canal (D). The auricle is pulled down and back for a child younger than 3 years of
age, but not an adult (E).
The nərs is instructing a client in the proper use of a metered-dose inhaler. Which instruction
should the nərs provide the client to ensure the optimal benefits from thedrug?
A. "Fill your lungs with air through your mouth and then compress the inhaler."B.
"Compress the inhaler while slowly breathing in through your mouth."
C. "Compress the inhaler while inhaling quickly through your nose."
D. "Exhale completely after compressing the inhaler and then inhale." - Correct answer-B
Rationale: The medication should be inhaled through the mouth simultaneously with
compression of the inhaler. This will facilitate the desired destination of the aerosol medication
deep in the lungs for an optimal bronchodilation effect. Options A, C, and Ddo not allow for
deep lung penetration.
A 20-year-old female client with a noticeable body odor has refused to shower for thelast 3
days. She states, "I have been told that it is harmful to bathe during my period."Which action
should the nərs take first?
A. Accept and document the client's wish to refrain from bathing.B.
Offer to give the client a bed bath, avoiding the perineal area.
C. Obtain written brochures about menstruation to give to the client.
D. Teach the importance of personal hygiene during menstruation with the client. -Correct
answer-D
Rationale: Because a shower is most beneficial for the client in terms of hygiene, the client
should receive teaching first, respecting any personal beliefs such as cultural orspiritual values.
After client teaching, the client may still choose option A or B. Brochures reinforce the
teaching.
While reviewing the side effects of a newly prescribed medication, a 72-year-old clientnotes that
one of the side effects is a reduction in sexual drive. Which is the best response by the nərs?
A. "How will this affect your present sexual activity?"B.
"How active is your current sex life?"
, C. "How has your sex life changed as you have become older?"
D. "Tell me about your sexual needs as an older adult." - Correct answer-A Rationale:
Option A offers an open-ended question most relevant to the client's statement. Option B
does not offer the client the opportunity to express concerns.Options C and D are even less
relevant to the client's statement.
The nərs is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose
client winces and pulls away from a painful stimulus. Which action should thenərs take next?
A. Document that the client responds to painful stimulus.B.
Observe the client's response to verbal stimulation.
C. Place the client on seizure precautions for 24 hours.
D. Report decorticate posturing to the health care provider - Correct answer-.A Rationale: The
client has demonstrated a purposeful response to pain, which should bedocumented as such.
Response to painful stimulus is assessed after response to verbalstimulus, not before. There is no
indication for placing the client on seizure precautions.Reporting decorticate posturing to the
health care provider is nonpurposeful movement.
The nərs plans to administer diazepam, 4 mg IV push, to a client with severe anxiety.How many
milliliters should the nərs administer? (Round to the nearest tenth.)
A. 0.2 mL
B. 0.8 mL
C. 1.25 mL
D. 2.0 mL - Correct answer-B Rationale:
(1 mL × 4 mg)/5 mg = 0.8 mL
The nərs prepares to insert a nasogastric tube in a client with hyperemesis who isawake and
alert. Which intervention(s) is(are) correct? (Select all that apply.)
A. Place the client in a high Fowler position.
B. Help the client assume a left side-lying position.
C. Measure the tube from the tip of the nose to the umbilicus.
D. Instruct the client to swallow after the tube has passed the pharynx.
E. Assist the client in extending the neck back so the tube may enter the larynx. -Correct
answer-A, D
Rationale:
(A and D) are the correct steps to follow during nasogastric intubation. Only the unconscious or
obtunded client should be placed in a left side-lying position (B). The tube should be measured
from the tip of the nose to behind the ear and then from behind the ear to the xiphoid process
(C). The neck should only be extended back priorto the tube passing the pharynx and then the
client should be instructed to position the neck forward (E).
The nərs teaches the use of a gait belt to a male caregiver whose wife has right-sidedweakness
and needs assistance with ambulation. The caregiver performs a return demonstration of the
skill. Which observation indicates that the caregiver has learned how to perform this procedure
correctly?
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