HESI RN FUNDAMENTALS NEWEST 2024-2025 ACTUAL EXAM VERSIO
COMPLETE 125 QUESTIONS AND CORRECT DETAILED ANSWERS (VE
FIED ANSWERS)
Study online at https://quizlet.com/_fpqegj
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.)
B, C, D
A.
Rationale: The fingers are placed at the
Compress the chest once between the
same location on an infant as chest com-
nipples with two fingers.
pressions for CPR; however, the nurse
B.
must deliver five chest thrusts, after the
Note any obstruction or absence of
five back slaps. Blind sweeps are not
breathing.
used as this action may push the ob-
C.
ject deeper into the throat. The remaining
Deliver five backslaps between the
steps are correct.
shoulder blades.
D.
Place the infant over the nurse's arm.
E.
Perform a blind finger sweep.
Which fluid will the nurse select to ad-
minister with the prescribed blood trans-
fusion?
A.
B
5% Dextrose and water
Rationale: Normal saline solution is the
B.
only solution that is compatible with
Normal saline
blood.
C.
Lactated Ringers solution
D.
5% Dextrose and lactated ringers
When assisting a client from the bed to
B
a chair, which procedure is best for the
Rationale: Option B describes the correct
nurse to follow?
positioning of the nurse and affords the
A.
nurse a wide base of support while sta-
Place the chair parallel to the bed, with
bilizing the client's knees when assisting
its back toward the head of the bed and
to a standing position. The chair should
assist the client in moving to the chair.
be placed at a 45-degree angle to the
B.
, HESI RN FUNDAMENTALS NEWEST 2024-2025 ACTUAL EXAM VERSIO
COMPLETE 125 QUESTIONS AND CORRECT DETAILED ANSWERS (VE
FIED ANSWERS)
Study online at https://quizlet.com/_fpqegj
With the nurse's feet spread apart and
bed, with the back of the chair toward the
knees aligned with the client's knees,
head of the bed. Clients should never be
stand and pivot the client into the chair.
lifted under the axillae; this could dam-
C.
age nerves and strain the nurse's back.
Assist the client to a standing position
The client should be instructed to use the
by gently lifting upward, underneath the
arms of the chair and should never place
axillae.
his or her arms around the nurse's neck;
D.
this places undue stress on the nurse's
Stand beside the client, place the client's
neck and back and increases the risk for
arms around the nurse's neck, and gen-
a fall.
tly move the client to the chair.
How many mL will the nurse document
on the client's intake and output record
from the items listed? _____ mL Answer: 2155
1200 mL water Rationale: 1200 + 240 (8 oz) + 240 (1
4 ounce container of gelatin cup) + 120 (4 oz) + 355 = 2155
8 ounces of orange juice
355 mL can of soda1 cup of soup
The nurse observes a UAP taking a
client's blood pressure in the lower ex-
tremity. Which observation of this proce- B
dure requires the nurse to intervene with Rationale: When obtaining the blood
the UAP's approach? pressure in the lower extremities, the
A. popliteal pulse is the site for auscultation
The cuff wraps around the girth of the when the blood pressure cuff is applied
leg. around the thigh. The nurse should inter-
B. vene with the UAP who has applied the
The UAP auscultates the popliteal pulse cuff on the lower leg. Option A ensures
with the cuff on the lower leg. an accurate assessment, and option C
C. provides the best access to the artery.
The client is placed in a prone position. Systolic pressure in the popliteal artery
D. is usually 10 to 40 mm Hg higher than in
The systolic reading is 20 mm Hg higher the brachial artery.
than the blood pressure in the client's
arm.
During a clinic visit, the mother of a
7-year-old reports to the nurse that her
, HESI RN FUNDAMENTALS NEWEST 2024-2025 ACTUAL EXAM VERSIO
COMPLETE 125 QUESTIONS AND CORRECT DETAILED ANSWERS (VE
FIED ANSWERS)
Study online at https://quizlet.com/_fpqegj
child is often awake until midnight play-
ing and is then very difficult to awaken
in the morning for school. Which assess-
ment data should the nurse obtain in re- D
sponse to the mother's concern? Rationale: School-age children often re-
A. sist bedtime. The nurse should begin by
The occurrence of any episodes of sleep assessing the environment of the home
apnea to determine factors that may not be con-
B. ducive to the establishment of bedtime
The child's blood pressure, pulse, and rituals that promote sleep. Option A of-
respirations ten causes daytime fatigue rather than
C. resistance to going to sleep. Option B is
Length of rapid eye movement (REM) unlikely to provide useful data. The nurse
sleep that the child is experiencing cannot determine option C.
D.
Description of the family's home environ-
ment
The nurse identifies a potential for infec-
tion in a client with partial-thickness (sec- B
ond-degree) and full-thickness (third-de- Rationale: Careful handwashing tech-
gree) burns. What action has the highest nique is the single most effective inter-
priority in decreasing the client's risk of vention for the prevention of contamina-
infection? tion to all clients. Option A reverses the
A. hypovolemia that initially accompanies
Administration of plasma expanders burn trauma but is not related to decreas-
B. ing the proliferation of infective organ-
Use of careful handwashing technique isms. Options C and D are recommend-
C. ed by various burn centers as possible
Application of a topical antibacterial ways to reduce the chance of infection.
cream Option B is a proven technique to prevent
D. infection.
Limiting visitors to the client with burns
The nurse assesses a 2-year-old who is B
admitted for dehydration and finds that Rationale: The nurse should first check
the peripheral IV rate by gravity has the tubing and height of the bag on the IV
slowed, even though the venous access pole, which are common factors that may
site is healthy. What should the nurse do slow the rate. Gravity infusion rates are
, HESI RN FUNDAMENTALS NEWEST 2024-2025 ACTUAL EXAM VERSIO
COMPLETE 125 QUESTIONS AND CORRECT DETAILED ANSWERS (VE
FIED ANSWERS)
Study online at https://quizlet.com/_fpqegj
next? influenced by the height of the bag, tub-
A. ing clamp closure or kinks, needle size or
Apply a warm compress proximal to the position, fluid viscosity, client blood pres-
site. sure (crying in the pediatric client), and
B. infiltration. Venospasm can slow the rate
Check for kinks in the tubing and raise and often responds to warmth over the
the IV pole. vessel, but the nurse should first adjust
C. the IV pole height. The nurse may need to
Adjust the tape that stabilizes the needle. adjust the stabilizing tape on a positional
D. needle or flush the venous access with
Flush with normal saline and recount the normal saline, but less invasive actions
drop rate. should be implemented first.
The nurse manager of a skilled nursing
(chronic care) unit is instructing UAPs on
ways to prevent complications of immo-
bility. Which action should be included in
this instruction?
A. A
Perform range-of-motion exercises to Rationale: Performing range-of-motion
prevent contractures. exercises is beneficial in reducing con-
B. tractures around joints. Options B, C, and
Decrease the client's fluid intake to pre- D are all potentially harmful practices
vent diarrhea. that place the immobile client at risk of
C. complications.
Massage the client's legs to reduce em-
bolism occurrence.
D.
Turn the client from side to back every
shift.
The nurse administered 10 mg of di-
azepam to the preoperative client. What
steps will the nurse take next? (Select all B, C, D
that apply.) Rationale: Diazepam is a common pre-
A. operative medication. Close observation
Place the client in the bed next to the by placing the client close to the nurse's
nurse's station.
B.
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