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HESI FUNDAMENTALS EXAM 2024 WITH 300 ACTUAL
EXAM QUESTIONS AND CORRECT ANSWERS (100%
CORRECT ANSWERS) WITH RATIONALES/ EVOLVE
HESI FUNDAMENTALS EXAM 2024/2025 (NEWEST!)
The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement?
- Tell the UAP to use a larger cuff at the next scheduled assessment.
- Reassess the client's blood pressure using a larger cuff.
- Have the unit educator review this procedure with the UAPs.
- Teach the UAP the correct technique for assessing blood pressure. - ANSWER-
The most important action is to ensure that an accurate BP reading is obtained. The nurse should reassess the BP with the correct size cuff (B). Reassessment should not be postponed (A). Though (C and D) are likely indicated, these actions do not have the priority of (B).
Correct Answer: B
An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care?
- Massage any reddened areas for at least five minutes.
- Encourage active range of motion exercises on extremities.
- Position the client laterally, prone, and dorsally in sequence.
- Gently lift the client when moving into a desired position. - ANSWER-To avoid
shearing forces when repositioning, the client should be lifted gently across a surface (D). Reddened areas should not be massaged (A) since this may increase 1 / 4
pg. 2 the damage to already traumatized skin. To control pain and muscle spasms, active range of motion (B) may be limited on the affected leg. The position described in (C) is contraindicated for a client with a fractured left hip.
Correct Answer: D
The nurse witnesses the signature of a client who has signed an informed consent.Which statement best explains this nursing responsibility?
- The client voluntarily signed the form.
- The client fully understands the procedure.
- The client agrees with the procedure to be done.
- The client authorizes continued treatment. - ANSWER-The nurse signs the
consent form to witness that the client voluntarily signs the consent (A), that the client's signature is authentic, and that the client is otherwise competent to give consent. It is the healthcare provider's responsibility to ensure the client fully understands the procedure (B). The nurse's signature does not indicate (C or D).
Correct Answer: A
A Sub-Saharan African widowed immigrant woman lives with her deceased husband's brother and his family, which includes the brother-in-law's children and the widow's adult children. Each family member speaks fluent English. Surgery was recommended for the client. What is the best plan to obtain consent for surgery for this client?
- Obtain an interpreter to explain the procedure to the client.
- Encourage the client to make her own decision regarding surgery.
- Ask the family members to provide a clarification of the surgeon's explanation
to the client. 2 / 4
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- Tell the surgeon that the brother-in-law will decide after explanation of the
proposed surgery is provided to him and the widow. - ANSWER-Customary law in some rural sub-Saharan countries encompasses wife inheritance and polygamy; the widow becomes the inherited wife of her husband's brother. In those rural areas women live in a patriarchal family where decisions are made by men. Most likely, the brother-in-law will make the decision for his inherited wife, so (D) provides the surgeon with culturally sensitive information. (A) all family members speak fluent English therefore there is no need for translation. It is culturally insensitive to encourage the woman to go against her wishes and her cultural worldview, as in (B). Family members are more likely to misinterpret medical information (C).
Correct Answer: D
The nurse is administering medications through a nasogastric tube (NGT) which is connected to suction. After ensuring correct tube placement, what action should the nurse take next?
- Clamp the tube for 20 minutes.
- Flush the tube with water.
- Administer the medications as prescribed.
- Crush the tablets and dissolve in sterile water. - ANSWER-The NGT should be
flushed before, after and in between each medication administered (B). Once all medications are administered, the NGT should be clamped for 20 minutes (A). (C and D) may be implemented only after the tubing has been flushed.
Correct Answer: B
A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement?
- Give an around-the-clock schedule for administration of analgesics. 3 / 4
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- Administer analgesic medication as needed when the pain is severe.
- Provide medication to keep the client sedated and unaware of stimuli.
- Offer a medication-free period so that the client can do daily activities. -
ANSWER-The most effective management of pain is achieved using an around- the-clock schedule that provides analgesic medications on a regular basis (A) and in a timely manner. Analgesics are less effective if pain persists until it is severe, so an analgesic medication should be administered before the client's pain peaks (B). Providing comfort is a priority for the client who is dying, but sedation that impairs the client's ability to interact and experience the time before life ends should be minimized (C). Offering a medication-free period allows the serum drug level to fall, which is not an effective method to manage chronic pain (D).
Correct Answer: A
When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first?
- Loosen the right wrist restraint.
- Apply a pulse oximeter to the right hand.
- Compare hand color bilaterally.
- Palpate the right radial pulse. - ANSWER-The priority nursing action is to
restore circulation by loosening the restraint (A), because blue fingers (cyanosis) indicates decreased circulation. (C and D) are also important nursing interventions, but do not have the priority of (A). Pulse oximetry (B) measures the saturation of hemoglobin with oxygen and is not indicated in situations where the cyanosis is related to mechanical compression (the restraints).
Correct Answer: A
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