HESI RN Fundamentals Practice Exam With Answers (75 Solved Questions)

Name: HESI RN Fundamentals Practice Exam With Answers (75 Solved Questions)
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HESI RN FUNDAMENTALS EXAM QUESTIONS WITH
ANSWERS AND EXPLANATIONS UPDATED
• When turning an immobile bedridden client without assistance, which action by the
nurse 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 nurse.
C. Correctly position and use a turn sheet.
D Lower the head of the client's bed slowly.
.
Rationale:
Because the nurse can only stand on one side of the bed, bed rails should be up on the
opposite side to ensure that the client does not fall out of bed. Option A can cause client injury
to the skinor 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 nurse identifies a potential for infection in a client with partial-thickness (second-
degree) and full-thickness (third-degree) burns. What intervention has the highest
priorityin 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
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 is aware that malnutrition is a common problem among clients served by
a community health clinic for the homeless. Which laboratory value is the most
reliable indicator of chronic protein malnutrition?
• Low serum albumin level
• Low serum transferrin level
• High hemoglobin level
• High cholesterol level
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 nurse finds that the operative permit
is not signed. The client begins to ask more questions about the surgical procedure.
Whichaction should the nurse take next?
• Witness the client's signature to the permit.
• Answer the client's questions about the surgery.
• Inform the surgeon that the operative permit is not signed
and the client has questions about the surgery.
• Reassure the client that the surgeon will answer any
questions before the anesthesia is administered.
Rationale:
The surgeon should be informed immediately that the permit is not signed. It is the surgeon's
responsibility to explain the procedure to the client and obtain the client's signature on the
permit. Although the nurse can witness an operative permit, the procedure 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 the permit is signed.

• The nurse is assessing several clients prior to surgery. Which factor in a client's
historyposes the greatest threat for complications to occur during surgery?
• Taking birth control pills for the past 2 years
• Taking anticoagulants for the past year
• Recently completing antibiotic therapy
• Having taken laxatives PRN for the last 6 months
Rationale:
Anticoagulants increase the risk for bleeding during surgery, which can pose a threat for the
development of surgical complications. The health care provider should be informed that 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 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.
Rationale:
Option B describes the correct positioning of the nurse and affords the nurse a wide base
ofsupport 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.
• Which step(s) should the nurse 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.
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 ball should 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 nurse is instructing a client in the proper use of a metered-dose inhaler. Which
instructionshould the nurse provide the client to ensure the optimal benefits from the drug?
• "Fill your lungs with air through your mouth and then
compress the inhaler."
• "Compress the inhaler while slowly breathing in through
your mouth."
• "Compress the inhaler while inhaling quickly through your
nose."
• "Exhale completely after compressing the inhaler and then
inhale."
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
foran optimal bronchodilation effect. Options A, C, and D do not allow for deep lung
penetration

• A 20-year-old female client with a noticeable body odor has refused to shower for the
last 3days. She states, "I have been told that it is harmful to bathe during my period." Which
action should the nurse take first?
• Accept and document the client's wish to refrain
frombathing.
• Offer to give the client a bed bath, avoiding the perineal
area.
• Obtain written brochures about menstruation to give to the
client.
• Teach the importance of personal hygiene during
menstruation with the client.
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 or spiritual 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 client
notesthat one of the side effects is a reduction in sexual drive. Which is the best response by
the nurse?
A "How will this affect your present sexual activity?"
.
B. "How active is your current

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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
tothe client's statement.
• The nurse is using the Glasgow Coma Scale to perform a neurologic assessment. A
comatoseclient winces and pulls away from a painful stimulus. Which action should the nurse
take next?
• Document that the client responds to painful stimulus.
• Observe the client's response to verbal stimulation.
• Place the client on seizure precautions for 24 hours.
• Report decorticate posturing to the health care provider.
Rationale:
The client has demonstrated a purposeful response to pain, which should be documented as
such. Response to painful stimulus is assessed after response to verbal stimulus, 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 nurse plans to administer diazepam, 4 mg IV push, to a client with severe anxiety.
Howmany milliliters should the nurse administer? (Round

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• The nurse prepares to insert a nasogastric tube in a client with hyperemesis who is awake
andalert. 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.
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 prior to the tube passing the pharynx and
then the client should be instructed to position the neck forward (E).
• The nurse teaches the use of a gait belt to a male caregiver whose wife has right-sided
weakness and needs assistance with ambulation. The caregiver performs a return
demonstrationof the skill. Which observation indicates that the caregiver has learned how to
perform this procedure correctly?
A Standing on his wife's strong side, the caregiver is ready to
. hold the gait belt if any evidence of weakness is observed.
B. Standing

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Rationale:
His wife is most likely to lean toward the weak side and needs extra support on that side and
from the back to prevent falling. Options A, C, and D provide less security for her.
• Which nursing diagnosis has the highest priority when planning care for a client with
anindwelling urinary catheter?.
• Self-care deficit
• Functional incontinence
• Fluid volume deficit
• High risk for infection
Rationale:
Indwelling urinary catheters are a major source of infection. Options A and B are both problems
that may require an indwelling catheter. Option C is not affected by an indwelling catheter
• A

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solution.
C. Use the saline solution and then relabel the bottle with the
current date.
D Discard the saline solution and obtain a new unopened
. bottle.
Rationale:
Solutions labeled as opened within 24 hours may be used for clean procedures, but only newly
opened solutions are considered sterile. This solution is not newly opened and is out of date, so
it should be discarded. Options A, B, and C describe incorrect procedures.
• Based on the nursing diagnosis of risk for infection, which intervention is best for the
nurseto implement when providing care for an older incontinent client?
• Maintain standard precautions.
• Initiate contact isolation measures.
• Insert an indwelling urinary catheter.
• Instruct client in the use of adult diapers.
Rationale:
The best action to decrease the risk of infection in vulnerable clients is handwashing. Option B
is not necessary unless the client has an infection. Option C increases the risk of infection.
Option D does not reduce the risk of infection.
• When taking a client's blood pressure, the nurse is unable to distinguish the point at
whichthe first

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• Document the exact level visualized on the
sphygmomanometer where the first fluctuation was
seen.
Rationale:
Deflating the cuff for 30 to 60 seconds allows blood flow to return to the extremity so that an
accurate reading can be obtained on that extremity a second time. Option A could result in a
falsely high reading. Option B reduces circulation, causes pain, and could alter the reading.
Option D is not an accurate method of assessing blood pressure.
• A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take
first?
• Tell the client that the blood pressure is high and that
thereading needs to be verified by another nurse.
• Contact the health care provider to report the reading and
obtain a prescription for an antihypertensive medication.
• Replace the cuff with a

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A The Patient's Bill of Rights protects clients from malicious
. intents, so the nurse could lose the case.
B. The lawsuit may be settled out of court, but the nurse's
license is likely to be revoked.
C. There will be no judgment against the nurse, whose
actions were protected under the Good Samaritan Act.
D The client will win because the four elements of
. negligence (duty, breach, causation, and damages) can
beproved.
Rationale:
The Good Samaritan Act protects health care professionals who practice in good faith and
provide reasonable care from malpractice claims, regardless of the client outcome. Although
thePatient's Bill of Rights protects clients, this nurse is protected by the Good Samaritan Act.
The state Board of Nursing has no reason to revoke a registered nurse's license unless there
was evidence that actions taken in the emergency were not done in

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HESI RN Fundamentals Practice Exam With Answers (75 Solved Questions)

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