HESI FUNDAMENTALS RN EXAM 2023 VERSION 5 2024 QUESTIONS AND DETAILED CORRECT ANSWERS INCLUDING RATIONALES (GRADED A+)

HESI FUNDAMENTALS RN EXAM 2023
VERSION 5 2024 QUESTIONS AND
DETAILED CORRECT ANSWERS
INCLUDING RATIONALES (GRADED A+)
The nurse is assessing several clients prior to surgery. Which factor in a client's history
poses the greatest threat for complications to occur during surgery? - ANSWER-Taking
anticoagulants for the past year
Rationale:
Anticoagulants (B) increase the risk for bleeding during surgery, which can pose a
threat for developing surgical complications. The healthcare provider should be
informed that the client is taking such drugs.
Urinary catheterization is prescribed for a postoperative female client who has been
unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen in the
tubing. What action will the nurse take next? - ANSWER-Leave the catheter in place
and reattempt with another catheter.
Rationale:
It is likely that the first catheter is in the vagina, rather than the bladder. Leaving the first
catheter in place will help locate the meatus when attempting the second catheterization
The nurse is instructing a male client in the proper use of a metered-dose inhaler.
Which instruction should the nurse provide the client to ensure the optimal benefits from
the drug? - ANSWER-Compress the inhaler while slowly breathing in through your
mouth.
Rationale:
The medication should be inhaled through the mouth simultaneously with compression
of the inhaler
The nurse is assisting a male client to the bathroom. When 5 feet from the bathroom
door, the client states, "I feel faint." Before the nurse can get him to a chair, he starts to
fall. What is the priority action for the nurse to take? - ANSWER-Gently lower the client
to the floor.
Rationale:
(D) is the most prudent intervention and is the priority nursing action to prevent injury to
the client and the nurse. Lowering the client to the floor should be done when the client
cannot support his own weight. The client should be placed in a bed or chair only when
sufficient help is available to prevent injury.
Which nursing diagnosis has the highest priority when planning care for a client with an
indwelling urinary catheter? - ANSWER-High risk for infection
Rationale:
Indwelling urinary catheters are a major source of infection
A nurse is working in an occupational health clinic when a male employee walks in and
states that he was struck by lightning while working on his truck bed. He is alert but
reports feeling faint. What assessment will the nurse perform first? - ANSWER-Pulse
characteristics
Rationale:
Lightning is a jolt of electrical current and can produce a "natural" defibrillation, so
assessment of the pulse rate and regularity (A) is a priority. Since the client is talking,
he has an open airway
The nurse makes the nursing diagnosis of Potential for infection related to partialthickness (second-degree) and full-thickness (third-degree) burns. What intervention
has the highest priority in decreasing the client's risk of infection? - ANSWER-Use of
careful handwashing technique
Rationale:
Careful handwashing technique (B) is the single most effective intervention for
prevention of contamination to all clients.
When taking a client's blood pressure, the nurse is unable to distinguish the point at
which the first sound was heard. What is the best action for the nurse to take? -
ANSWER-Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the
reading.
Rationale:
Deflating the cuff for 30 to 60 seconds (C) allows blood flow to return to the extremity so
that an accurate reading can be obtained on that extremity a second time.