HESI-RN Fundamentals Actual Exam Updated

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HESI-RN Fundamentals Actual Exam/ Updated 2024- 2025/ Latest Practice Questions with Correct Verified Answers.

Which fluid will the nurse select to administer with the prescribed blood transfusion?

• 5% Dextrose and water
• Normal saline
• Lactated Ringers solution
• 5% Dextrose and lactated ringers - ANSWER - B

Rationale: Normal saline solution is the only solution that is compatible with blood.

How many mL will the nurse document on the client's intake and output record from the items listed?_____ mL 1200 mL water

• ounce container of gelatin
• 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?

• The cuff wraps around the girth of the leg.
• The UAP auscultates the popliteal pulse with the cuff on the lower leg.
• The client is placed in a prone position.
• The systolic reading is 20 mm Hg higher than the blood pressure in the client's arm. - ANSWER - B 1 / 4

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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.

The nurse identifies a potential for infection in a client with partial-thickness (second-degree) and fullthickness (third-degree) burns. What action has the highest priority in decreasing the client's risk of infection?

• Administration of plasma expanders
• Use of careful handwashing technique
• Application of a topical antibacterial cream
• 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?

• Apply a warm compress proximal to the site.
• Check for kinks in the tubing and raise the IV pole.
• Adjust the tape that stabilizes the needle.
• 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.

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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?

• Perform range-of-motion exercises to prevent contractures.
• Decrease the client's fluid intake to prevent diarrhea.
• Massage the client's legs to reduce embolism occurrence.
• 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.)

• Place the client in the bed next to the nurse's station.
• Instruct the client not to get out of bed.
• Place the call bell within the client's reach.
• Place the side rails up, according to institutional policy.
• 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?

• Administer the prescribed maximum dose of pain medication.
• Talk with the client about thoughts and feelings about death.
• Collaborate with the health care provider about initiating antidepressant therapy.
• 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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The nurse selects the best site for insertion of an IV catheter in the client's right arm. Which documentation should the nurse use to identify placement of the IV access?

• Left brachial vein
• Right cephalic vein
• Dorsal side of the right wrist

D.Right upper extremity - ANSWER - B Rationale: The cephalic vein is large and superficial and identifies the anatomic name of the vein that is accessed, which should be included in the documentation. The basilic vein of the arm is used for IV access, not the brachial vein, which is too deep to be accessed for IV infusion. Although veins on the dorsal side of the right wrist are visible, they are fragile and using them would be painful, so they are not recommended for IV access. Option D is not specific enough for documenting the location of the IV access.

The nurse transcribes the postoperative prescriptions for a client who returns to the unit following surgery and notes that an antihypertensive medication that was prescribed preoperatively is not listed.Which action should the nurse take?

• Consult with the pharmacist

aboutthe need to continue the medication.

• Administer the antihypertensive medication as prescribed preoperatively.
• Withhold the medication until the client is fully alert and vital signs are stable.
• Contact the health care provider to renew the prescription for the medication. - ANSWER - D

Rationale: Medications prescribed preoperatively must be renewed postoperatively, so the nurse should contact the health care provider if the antihypertensive medication is not included in the postoperative prescriptions. The pharmacist does not prescribe medications or renew prescriptions. The nurse must have a current prescription before administering any medications.

When emptying 350 mL of pale yellow urine from a client's urinal, the nurse notes that this is the first time the client has voided in 4 hours. Which action should the nurse take next?

• Record the amount on the client's fluid output record.
• Encourage the client to increase oral fluid intake.
• Notify the health care provider of the findings.
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