HESI RN FUNDAMENTALS EXIT EXAM LATEST ACTUAL EXAM 100 QUESTIONS AND CORRECT ANSWERS WITH RATIOANLES (VERIFIED ANSWERS) |ALREADY GRADED A+

HESI RN FUNDAMENTALS EXIT EXAM LATEST

2023-2024 ACTUAL EXAM 100 QUESTIONS AND

CORRECT ANSWERS WITH RATIOANLES

(VERIFIED ANSWERS) |ALREADY GRADED A+

The nurse is administering an intermittent infusion of an antibiotic to a

client whose intravenous (IV) access is an antecubital saline lock. After

the nurse opens the roller clamp on the IV tubing, the alarm on the

infusion pump indicates an obstruction. What action should the nurse

take first?

Check for a blood return.

Reposition the client's arm.

Remove the IV site dressing.

Flush the lock with saline. - ANSWER- B

Rationale: If the client's elbow is bent, the IV may be unable to

infuse, resulting in an obstruction alarm, so the nurse should first

attempt to reposition the client's arm to alleviate any obstruction

(B). After other sources of occlusion are eliminated, the nurse may

need to check for a blood return (A), remove the dressing (C), or

flush the saline lock (D) and then resume the intermittent infusion.

A 35-year-old female client with cancer refuses to allow the nurse to

insert an IV for a scheduled chemotherapy treatment, and states that she

is ready to go home to die. What intervention should the nurse initiate?

Review the client's medical record for an advance directive.

Determine if a do-not-resuscitate prescription has been obtained.

Document that the client is being discharged against medical advice.

Evaluate the client's mental status for competence to refuse treatment. -

ANSWER- D

Rationale: Competent clients have the right to refuse treatment, so

the nurse should first ensure that the client is competent (D). (A and

C) are not necessary for a competent client to refuse treatment. The

nurse cannot document (C) until the healthcare provider is notified

of the client's wishes and a discharge prescription is obtained.

A client in hospice care develops audible gurgling sounds on inspiration.

Which nursing action has the highest priority?

Ensure cultural customs are observed.

Increase oxygen flow to 4L/minute.

Auscultate bilateral lung fields.

Inform the family that death is imminent. - ANSWER- D

Rationale: An audible gurgling sound produced by a dying client is

characteristic of ineffective clearance of secretions from the lungs or

upper airways, causing a "rattling" sound as air moves through the

accumulated fluid. The nursing priority in this situation is to convey

to the family that the client's death is imminent (D). Although

culturally sensitive care should be observed throughout the client's

plan of care (A), this is not the priority at this time. Administration

of oxygen may be expected care, but a flow rate greater than 2

L/minute (B) is not palliative care. (C) may provide additional

information, but is not necessary as death approaches.

A signed consent form indicated a client should have an

electromyogram, but a myelogram was performed instead. Though the

myelogram revealed the cause of the client's back pain, which was

subsequently treated, the client filed a lawsuit against the nurse and

healthcare provider for performing the incorrect procedure. The court is

likely to rule in favor of the plaintiff because these events represent what

infraction?

A quasi-intentional tort because a similar mistake can happen to anyone.

Failure to respect client autonomy to choose based on intentional tort

law.

Assault and battery with deliberate intent to deviate from the consent

form.

An unintentional tort because the client benefited from having the

myelogram. - ANSWER- C

Rationale: The client was not properly informed of the procedure,

and failure to obtain informed consent constitutes assault and

battery (C). (A) is injury to economics and dignity, such as invasion

of privacy or defamation of character. This is not an incident of

failure to respect the client's autonomy (B). An unintentional tort

(D) is an act in which the outcome was not expected, such as

negligence or malpractice.

The nurse formulates the nursing diagnosis of, "Ineffective health

maintenance related to lack of motivation" for a client with Type 2

diabetes. Which finding supports this nursing diagnosis?

Does not check capillary blood glucose as directed.

Occasionally forgets to take daily prescribed medication.