HESI Practice Qs Flashcards
Which statement is an example of a correctly written nursing problem statement?
Altered tissue perfusion related to heart failure.
Altered urinary elimination related to urinary tract infection.
Risk for impaired tissue integrity related to the client’s refusal to turn.
Ineffective coping related to an inadequate level of perception of control.
Ineffective coping related to an inadequate level of perception of control.
A male client has a nursing problem of “spiritual distress.” Which intervention is best for the nurse to implement when caring for this client?
Use distraction techniques during times of spiritual stress and crisis.
Reassure the client that his faith will be regained with time and support.
Consult with the staff chaplain and ask that the chaplain visits with the client.
Use reflective listening techniques when the client expresses spiritual doubts.
Use reflective listening techniques when the client expresses spiritual doubts.
When the nurse enters a client’s room to do an initial assessment, the client shouts, “Get out of my room! I’m tired of being bothered!” How should the nurse respond?
“There is no reason to be so angry.”
“Why do I need to leave your room?”
“What is concerning you this morning?”
“Let me call the client advocate for you.”
“What is concerning you this morning?”
A male client with acquired immunodeficiency syndrome (AIDS) develops cryptococcal meningitis and tells the nurse he does not want to be resuscitated if his breathing stops. Which action should the nurse implement?
Document the client’s request in the medical record.
Ask the client if this decision has been discussed with his healthcare provider.
Inform the client that a written, notarized advance directive, is required to withhold resuscitation efforts.
Advise the client to designate a person to make healthcare decisions when the client is unable to do so.
Ask the client if this decision has been discussed with his healthcare provider.
Advance directives are written statements of a person’s wishes regarding medical care, and verbal directives may be given to a healthcare provider with specific instructions in the presence of two witnesses. To obtain this prescription, the client should discuss his choice with the healthcare provider (B). (A) is insufficient to implement the client’s request without legal consequences. Although (C and D) provide legal protection of the client’s wishes, the present request needs additional action.
The nurse formulates the nursing problem of, “Ineffective health maintenance related to lack of motivation” for a client with Type 2 diabetes. Which finding supports this nursing problem?
Does not check capillary blood glucose as directed.
Occasionally forgets to take daily prescribed medication.
Cannot identify signs or symptoms of high and low blood glucose.
Eats anything and does not think diet makes a difference in health.
Eats anything and does not think diet makes a difference in health.
When preparing to administer an intravenous medication through a central venous catheter, the nurse aspirates a blood return in one of the lumens of the triple lumen catheter. Which action should the nurse implement?
Flush the lumen with the saline solution and administer the medication through the lumen.
Determine if a PRN prescription for a thrombolytic agent is listed on the medication record.
Clamp the lumen and obtain a syringe of a dilute heparin solution to flush through the tubing.
Withdraw the aspirated blood into the syringe and use a new syringe to administer the medication.
Flush the lumen with the saline solution and administer the medication through the lumen.
Aspiration of a blood return in the lumen of a central venous catheter indicates that the catheter is in place and the medication can be administered. The nurse should flush the tubing with the saline solution, administer the medication, then flush the lumen with saline again. The aspirated blood can be flushed back through the closed system into the client’s bloodstream and does not need to be withdrawn.
The nurse is caring for a client who is weak from inactivity because of a 2-week hospitalization. In planning care for the client, the nurse should include which range of motion (ROM) exercises?
Passive ROM exercises to all joints on all extremities four times a day.
Active ROM exercises to both arms and legs two or three times a day.
Active ROM exercises with weights twice a day with 20 repetitions each.
Passive ROM exercises to the point of resistance and slightly beyond.
Active ROM exercises to both arms and legs two or three times a day.
Active, rather than passive, ROM is best to restore strength, and doing it two to three times a day is an effective schedule. ROM is not performed beyond the point of resistance or pain because of the risk of damage to underlying structures.
A client who has moderate, persistent, chronic neuropathic pain due to diabetic neuropathy takes gabapentin and ibuprofen daily. If Step 2 of the World Health Organization (WHO) pain relief ladder is prescribed, which drug protocol should be implemented?
Continue gabapentin.
Discontinue ibuprofen.
Add aspirin to the protocol.
Add oral methadone to the protocol.
Continue gabapentin.
Based on the WHO pain relief ladder, adjunct medications, such as gabapentin, an antiseizure medication, may be used at any step for anxiety and pain management, so continuing gabapentin should be implemented. Nonopioid analgesics, such as ibuprofen and aspirin are Step 1 drugs. Steps 2 and 3 include opioid narcotics, and to maintain freedom from pain, drugs should be given around the clock rather than by the client’s PRN requests.
The home health nurse visits an older female client who had a stroke three months ago and is now able to ambulate with the assistance of a quad cane. Which assessment finding has the greatest implications for this client’s care?
The husband, who is the caregiver, begins to weep when the nurse asks how he is doing.
The client tells the nurse that she does not have much of an appetite today.
The nurse notes that there are numerous scatter rugs throughout the house.
The client’s pulse rate is 10 beats higher than it was at the last visit one week ago.
The nurse notes that there are numerous scatter rugs throughout the house.
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. Which 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.
Reposition the client’s arm.
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. After other sources of occlusion are eliminated, the nurse may need to check for a blood return, remove the dressing, or flush the saline lock and then resume the intermittent infusion.
A 75-year-old client who has a history of end-stage renal failure and advanced lung cancer recently had a stroke. Two days ago the healthcare provider discontinued the client’s dialysis treatments, stating that death is inevitable, but the client is disoriented and will not sign a DNR directive. Which is the priority nursing intervention?
Review the client’s most recent laboratory reports.
Refer the client and family members for hospice care.
Notify the hospital ethics committee of the client’s situation.
Determine who is legally empowered to make decisions.
Determine who is legally empowered to make decisions.
Rationale
When death is impending, it is essential for the nurse to determine who is legally empowered to make decisions regarding the use of life-saving measures for the client.
When making the bed of a client who needs a bed cradle, which action should the nurse include?
Teach the client to call for help before getting out of bed.
Keep both the upper and lower side rails in a raised position.
Keep the bed in the lowest position while changing the sheets.
Drape the top sheet and covers loosely over the bed cradle.
Drape the top sheet and covers loosely over the bed cradle.
Rationale
A bed cradle is used to keep the top bedclothes off the client, so the nurse should drape the top sheet and covers loosely over the cradle. A client using a bed cradle may still be able to ambulate independently and does not require raised side rails.
As the nurse prepares the equipment to be used to start an IV on a 4-year-old boy in the treatment room, he cries continuously. Which intervention should the nurse implement?
Take the child back to his room.
Recruit others to restrain the child.
Ask the mother to be present to soothe the child.
Show the child how to manipulate the equipment.
Ask the mother to be present to soothe the child.
Rationale
A 4-year-old typically has a vivid imagination and lacks concrete thinking abilities. The mother’s assistance can provide a stabilizing presence to help soothe the child, who may perceive the invasive procedure as mutilating. To preserve the child’s sense of security associated with the hospital room, it is best to perform difficult or painful procedures in another area.
The nurse overhears the healthcare provider explaining to the client that the tumor removed was nonmalignant and that the client will be fine. However, the nurse has read in the pathology report that the tumor was malignant and that there is extensive metastasis. Who should the nurse consult with first regarding the situation?
Healthcare provider.
Client’s family.
Case manager.
Chief of staff.
Healthcare provider.
Rationale
The nurse should address the healthcare provider with the written report and discuss why he/she did not tell the client the truth – this may be at the family’s request.
On the third postoperative day following thoracic surgery, a client reports feeling constipated. Which intervention should the nurse implement to promote bowel elimination?
Remind the client to turn every two hours while lying in bed.
Provide warm prune juice before the client goes to bed at night.
Teach the client to splint the incision while walking to the bathroom.
Administer an analgesic before the client attempts to defecate.
Provide warm prune juice before the client goes to bed at night.
Rationale
Prune juice is a natural laxative that stimulates peristalsis, and warming the prune juice facilitates peristalsis.
Which action by the nurse demonstrates culturally sensitive care?
Asks permission before touching a client.
Avoids questions about male-female relationships.
Explains the differences between Western medical care and cultural folk remedies.
Applies knowledge of a cultural group unless a client embraces Western customs.
Asks permission before touching a client.
Rationale
Physical contact, such as touching the head, in some cultures, is a sign of respect, whereas, in others, it is strictly forbidden. So asking permission before touching a client demonstrates culturally sensitive care.
When assessing a client with a nursing problem of fluid volume deficit, the nurse notes that the client’s skin over the sternum tents when gently pinched. Which action should the nurse implement?
Confirm the finding by further assessing the client for jugular vein distention.
Offer the client high-protein snacks between regularly scheduled mealtimes.
Continue the planned nursing interventions to restore the client’s fluid volume.
Change the plan of care to include a nursing diagnosis of impaired skin integrity.
Continue the planned nursing interventions to restore the client’s fluid volume.
Rationale
Skin turgor is assessed by pinching the skin and observing for tenting. This finding confirms the diagnosis of fluid volume deficit, so the nurse should continue interventions to restore the client’s fluid volume.
When caring for an immobile client, what nursing problem has the highest priority?
Risk for fluid volume deficit.
Impaired gas exchange.
Risk for impaired skin integrity.
Altered tissue perfusion.
Impaired gas exchange.
Rationale
The ABCs of caring for clients are airway, breathing, and circulation. Impaired gas exchange implies that the client is having trouble breathing, which has the highest priority of the nursing problems listed.
The nurse is completing the plan of care for a client who is admitted for benign prostatic hypertrophy. Which data should the nurse document as a subjective finding?
Reports inability to empty bladder.
Temperature of 99.8 °F (37.7 °C) and pulse of 108.
Postvoided residual volume of 750 mL.
Specimen collection for culture and sensitivity.
Reports inability to empty bladder.
Rationale
The nurse should document the client’s complaints of inability to empty bladder as subjective data – symptoms only the client can describe.
What is the rationale for using the nursing process in planning care for clients?
As a scientific process to identify nursing problems based on a clients’ healthcare diagnoses.
To establish a nursing theory that incorporates the biopsychosocial nature of humans.
As a tool to organize thinking and clinical decision-making about clients’ healthcare needs.
To promote the management of client care in collaboration with other healthcare professionals.
As a tool to organize thinking and clinical decision-making about clients’ healthcare needs.
The nurse removes the dressing on a client’s heel that is covering a pressure injury one inch in diameter and finds that there is straw-colored drainage seeping from the wound. Which description of this finding should the nurse include in the client’s record?
Stage 1 pressure injury draining serosanguineous drainage.
Pressure injury at bony prominence with exudate noted.
One-inch pressure injury draining serous fluid.
Pressure injury on the heel with a small amount of purulent drainage.
One-inch pressure injury draining serous fluid.
Which intervention should the nurse include in the plan of care for a client who is being treated with compression dressings for leg ulcers due to chronic venous insufficiency?
Check capillary refill of toes on the lower extremity with venous compression dressings.
Apply dressing to the wound area before applying the venous compression dressings.
Wrap the leg from the knee down towards the foot.
Remove the venous compression dressings every 8 hours to assess wound healing.
Check capillary refill of toes on the lower extremity with venous compression dressings.
Venous compression dressings can be applied too tightly. Thus, it is important to check distally for adequate circulation.
Which action is most important for the nurse to implement when placing a client in the lateral recumbent position?
Raise the bed to a waist-high working level.
Elevate the head of the bed 45 degrees.
Place a pillow behind the client’s back.
Bring the client to one edge of the bed.
Raise the bed to a waist-high working level.
Rationale
A waist-high bed height is a comfortable and safe working height to maintain the nurse’s proper body mechanics and prevent back injury.
Which statement correctly identifies a written learning objective for a client with peripheral vascular disease?
The nurse will provide client instruction for daily foot care.
The client will demonstrate proper trimming toenail technique.
Upon discharge, the client will list three ways to protect the feet from injury.
After instruction, the nurse will ensure the client understands the foot care rationale.
Upon discharge, the client will list three ways to protect the feet from injury.
An objective should contain four elements: who will perform the activity or acquire the desired behavior, the actual behavior that the learner will exhibit, the condition under which the behavior is to be demonstrated, and the specific criteria to be used to measure success. “Upon discharge, the client will list three ways to protect the feet from injury” is a concise statement that is a learning objective that defines exactly how the client will demonstrate mastery of the content.
Which nursing intervention is most beneficial in reducing the risk of urosepsis in a hospitalized client with an indwelling urinary catheter?
Ensure that the client’s perineal area is cleansed twice a day.
Maintain accurate documentation of the fluid intake and output.
Encourage frequent ambulation if allowed or regular turning if on bedrest.
Obtain a prescription for removal of the catheter as soon as possible.
Obtain a prescription for removal of the catheter as soon as possible.
Rationale
The best intervention to reduce the risk of urosepsis (the spread of an infectious agent from the urinary tract to systemic circulation) is the removal of the urinary catheter as quickly as possible.
A male client with an infected wound tells the nurse that he follows a macrobiotic diet. Which type of foods should the nurse recommend that the client select from the hospital menu?
Low fat and low sodium foods.
Combination of plant proteins to provide essential amino acids.
Limited complex carbohydrates and fiber.
Increased amount of vitamin C and beta carotene-rich foods.
Combination of plant proteins to provide essential amino acids.
Rationale
A macrobiotic diet is high in whole-grain cereals, vegetables, sea vegetables, beans, and vegetarian soups, and the client needs essential amino acids to provide complete proteins to heal the infected wound. Although a macrobiotic diet contains no source of animal protein, essential amino acids should be obtained by combining plant (incomplete) proteins to provide complete (all essential amino acids) proteins for anabolic processes.
A client has a nursing problem of, “Spiritual distress related to a loss of hope, secondary to impending death.” Which intervention is best for the nurse to implement when caring for this client?
Help the client to accept the final stage of life.
Assist and support the client in establishing short-term goals.
Encourage the client to make future plans, even if they are unrealistic.
Instruct the client’s family to focus on positive aspects of the client’s life.
Assist and support the client in establishing short-term goals.
Hopefulness is necessary to sustain a meaningful existence, even close to death. The nurse should help the client set short-term goals, and recognize the achievement of immediate goals, such as seeing a family member or listening to music.
A 73-year-old Hispanic client is seen at the community health clinic with a history of protein malnutrition. Which information should the nurse obtain first?
Amount of liquid protein supplements consumed daily.
Foods and liquids consumed during the past 24 hours.
Usual weekly intake of milk products and red meats.
Grains and legume combinations used by the client.
Foods and liquids consumed during the past 24 hours.
The nurse is digitally removing a fecal impaction for a client. The nurse should stop the procedure and take corrective action if which client reaction is noted?
Temperature increases.
Pulse rate decreases from 78 to 52 beats/min.
Respiratory rate increases from 16 to 24 breaths/min.
Blood pressure increases from 110/84 to 118/88 mm/Hg.
Pulse rate decreases from 78 to 52 beats/min.
Rationale
Parasympathetic reaction can occur as a result of digital stimulation of the anal sphincter, which should be stopped if the client experiences a vagal response, such as bradycardia.
A client is demonstrating a positive Chvostek’s sign. Which action should the nurse take?
Observe the client’s pupil size and response to light.
Ask the client about numbness or tingling in the hands.
Assess the client’s serum potassium level.
Restrict dietary intake of calcium-rich foods.
Ask the client about numbness or tingling in the hands.
Which action should the nurse implement to mitigate the formation of a hip pressure injury for a client who is immobile?
Maintain in a lateral position using protective wrist and vest devices.
Partial side lying with hip elevated to 30 degrees (30-degree lateral position).
Raise the head and knee gatch when lying in a supine position.
Transfer into a wheelchair close to the nurse’s station for observation.
Partial side lying with hip elevated to 30 degrees (30-degree lateral position).
Rationale
The partial side-lying position with hip elevation maintains alignment and provides the best pressure relief over the hip bony prominence. Raising the head and bed gatch may reduce shearing forces due to sliding down in bed, but it interferes with venous return from the legs and places pressure on the sacrum, predisposing to pressure injury formation. Sitting in a wheelchair places the body weight over the ischial tuberosities and predisposes it to a potential pressure point.
Which client assessment data is most important for the nurse to consider before ambulating a postoperative client?
Respiratory rate.
Wound location.
Pedal pulses.
Pain rating.
Respiratory rate.
Mobilization and ambulation increase oxygen use, so it is most important to assess the client’s respiratory rate (A) before ambulation to determine tolerance for activity. (B, C, and D) are also important, but are of lower priority than (A).
The nurse determines a client’s IV solution is infusing at 250 mL/hr. The prescribed rate is 125 mL/hr. Which action should the nurse take first?
Determine when the IV solution was started.
Slow the IV infusion to keep vein open rate.
Assess the IV insertion site for swelling.
Report the finding to the healthcare provider.
Slow the IV infusion to keep vein open rate.
Rationale
The nurse should first slow the IV flow rate to keep vein open (KVO) rate to prevent further risk of fluid volume overload, then gather additional assessment data, such as when the IV solution was started and the appearance of the IV insertion site before contacting the healthcare provider for further instructions.
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.
Inform the family that death is imminent.
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.
The nurse is preparing to irrigate a client’s indwelling urinary catheter using an open technique. Which action should the nurse take after applying gloves?
Empty the client’s urinary drainage bag.
Draw up the irrigating solution into the syringe.
Secure the client’s catheter to the drainage tubing.
Use aseptic technique to instill the irrigating solution.
Draw up the irrigating solution into the syringe.
Rationale
To irrigate an indwelling urinary catheter, the nurse should first apply gloves, then draw up the irrigating solution into the syringe. The syringe is then attached to the catheter and the fluid is instilled, using aseptic technique. Once the irrigating solution is instilled, the client’s catheter should be secured to the drainage tubing. The urinary drainage bag can be emptied whenever intake and output measurement is indicated, and the instilled irrigating fluid can be subtracted from the output at that time
A healthcare provider is performing a sterile procedure at a client’s bedside. Near the end of the procedure, the nurse observes the healthcare provider contaminating a sterile glove and the sterile field. Which is the best action for the nurse to implement?
Report the healthcare provider for the violation in aseptic technique.
Allow the completion of the procedure.
Ask if the glove and sterile field are contaminated.
Identify the break in surgical asepsis and provide another set of sterile supplies.
Identify the break in surgical asepsis and provide another set of sterile supplies.
A female nurse who sometimes tries to save time by putting medications in her uniform pocket to deliver to clients confides that after arriving home she found a hydrocodone (Vicodin) tablet in her pocket. Which possible outcome of this situation should be the nurse’s greatest concern?
Accused of diversion.
Reported for stealing.
Reported for a HIPAA violation.
Accused of unprofessional conduct.
Accused of diversion.
Rationale
Even if this is only one incident, the nurse may be suspected of taking medications on a regular basis and the incident could be interpreted as diversion, or diverting narcotics for her own use, which should be reported to the peer review committee and to the State Board of Nursing.
The nurse is preparing to give a dehydrated client IV fluid delivered at a continuous rate of 175 mL/hour. Which infusion device should the nurse use?
Portable syringe pump.
Electronic infusion device/smart pump.
Volumetric controller.
Nonvolumetric controller.
Electronic infusion device/smart pump.
Rationale
An electronic infusion device/smart pump should be used to accurately deliver large volumes of fluid over longer periods of time with extreme precision, such as mL/hour. A syringe pump is accurate for low-dose continuous infusion of low-dose medication at a basal rate, but not large fluid volume replacement. Volumetric and nonvolumetric controllers count drops/minute to administer fluid volume and are inherently inaccurate because of variations in drop size.
Which client statement indicates to the nurse that the client requires assistance with bathing?
“I wasn’t able to pack a bag before I left for the hospital.”
“I don’t understand why I’m so weak and tired.”
“I only bathe every other day.”
“I left my eyeglasses at home.”
“I don’t understand why I’m so weak and tired.”
Rationale
Bathing often makes a client feel weak, and if a client is already feeling weak, assistance is required during the bathing process to ensure the client’s safety.
The daughter of an older woman who became depressed following the death of her husband asks, “My mother was always well-adjusted until my father died. Will she tend to be sick from now on?” Which response is best for the nurse to provide?
“She is almost sure to be less able to adapt than before.”
“It’s highly likely that she will recover and return to her pre-illness state.”
“If you can interest her in something besides religion, it will help her stay well.”
“Cultural strains contribute to each woman’s tendencies for recurrences of depression.”
“It’s highly likely that she will recover and return to her pre-illness state.”
Rationale
Analysis of behavior patterns using Erikson’s framework can identify age-appropriate or arrested development of normal interpersonal skills. Erikson describes the successful resolution of a developmental crisis in the later years (older than 65 years) to include the achievement of a sense of integrity and fulfillment, wisdom, and a willingness to face one’s own mortality and accept the death of others.
While caring for a child and mother from an Asian culture, which action should the nurse implement to accommodate the clients’ cultural needs?
Speak initially with the oldest family member to show respect.
Realize that Southeast Asians may not take Western medications.
Ask the husband to step out during the mother’s pelvic examination.
Tell the family that planning health care is provided in private with the client.
Speak initially with the oldest family member to show respect.
A male nurse is assigned to care for a female Muslim client. When the nurse offers to bathe the client, the client requests that a female nurse perform this task. How should the male nurse respond?
“May I ask your daughter to help you with your personal hygiene?”
“I will ask one of the female nursing techs to bathe you.”
“A staff member on the next shift will help you.”
“I will keep you draped and hand you the supplies as you need them.”
“I will ask one of the female nursing techs to bathe you.”
The nurse is providing passive range of motion (ROM) exercises to the hip and knee for a client who is unconscious. After supporting the client’s knee with one hand, which action should the nurse take next?
Raise the bed to a comfortable working level.
Bend the client’s knee.
Move the knee toward the chest as far as it will go.
Cradle the client’s heel.
Cradle the client’s heel.
Rationale
Passive ROM exercise for the hip and knee is provided by supporting the joints of the knee and ankle and gently moving the limb in a slow, smooth, firm but gentle manner. Raising the bed should be done before the exercises are begun to prevent injury to the nurse and client. Bending the knee is carried out after both joints are supported. After the knee is bent, the knee is moved toward the chest to the point of resistance two or three times.
The nurse working in the emergency department is assessing four clients’ ability to tolerate pain. Which client is likely to tolerate a higher level of pain?
A 10-year-old who was burned by a camp fire earlier today.
A 70-year-old who has a postoperative infection from a surgery one week ago.
A 23-year-old woman who sprained her knee while bicycling.
A 55-year-old woman who has had moderate low back pain for three months.
A 55-year-old woman who has had moderate low back pain for three months.
A single mother of two teenagers, ages 16 and 18, was just told that she has advanced cancer. She is devastated by the news and expresses her concern about who will care for her children. Which statement by the nurse is likely to be most helpful at this time?
“Your children are old enough to help you make decisions about their futures.”
“The social worker can tell you about placement alternatives for your children.”
“Tell me what you would like to see happen with your children in the future.”
“You have just received bad news, and you need some time to adjust to it.”
“Tell me what you would like to see happen with your children in the future.”
Rationale
The nurse should first assess what the client desires. Though a referral to the social worker may be indicated, the nurse should first offer support. Time is likely to help the client cope with this news, but the nurse should first provide support and assess what the client wants to see happen with her children.
A female client informs the nurse that she uses herbal therapies to supplement her diet and manage common ailments. Which information should the nurse offer the client about the general use of herbal supplements?
Most herbs are toxic or carcinogenic and should be used only when proven effective.
There is no evidence that herbs are safe or effective as compared to conventional supplements in maintaining health.
Herbs should be obtained from manufacturers with a history of quality control of their supplements.
Herbal therapies may mask the symptoms of serious diseases, so frequent medical evaluation is required during use.
Herbs should be obtained from manufacturers with a history of quality control of their supplements.
When assessing a client with an indwelling urinary catheter, which observation requires immediate intervention by the nurse?
The drainage tubing is secured over the side rail.
The clamp on the urinary drainage bag is open.
There are no dependent loops in the drainage tubing.
The urinary drainage bag is attached to the bed frame.
The clamp on the urinary drainage bag is open.
Rationale
Maintaining a closed urinary drainage system is important to prevent infection, so the most immediate priority is to close the clamp to reduce the risk of ascending microorganisms.
A nurse observes a student nurse taking a copy of a client’s medication administration record. When questioned, the student states, “Another student is scheduled to administer medications for this client tomorrow, so I am going to make a copy to help my friend prepare for tomorrow’s clinical.” Which response should the nurse provide first?
Ask the nursing supervisor to meet with the students.
Notify the student’s clinical instructor of the situation.
Ask the student if permission was obtained from the client.
Explain that the records are hospital property and may not be removed.
Explain that the records are hospital property and may not be removed.
Rationale
The nurse should deal with the issue immediately and explain that a client’s records are the property of the hospital and cannot be removed, even with the client’s permission. Next, the clinical instructor should be notified so that all students can be educated regarding copying and removing clinical records from the healthcare agency. The nursing supervisor should also be alerted to ensure appropriate supervision of students as well as the protection of client information.
An older client who is able to stand but not ambulate receives a prescription to be mobilized into a chair as tolerated during each day. Which is the best action for the nurse to implement when assisting the client from the bed to the chair?
Use a mechanical lift to transfer from the bed to a chair.
Place a roller board under the client who is sitting on the side of the bed and slide the client to the chair.
Lift the client out of bed to the chair with another staff member using a coordinated effort on the count of three.
Place a transfer belt around the client, assist them to stand, and pivot to a chair that is placed at a right angle to the bed.
Place a transfer belt around the client, assist them to stand, and pivot to a chair that is placed at a right angle to the bed.
In providing care for a terminally ill resident of a long-term care facility, the nurse determines that the resident is exhibiting signs of impending death and has a do not resuscitate or DNR status. Which intervention should the nurse implement first?
Request hospice care for the client.
Report the client’s acuity level to the nursing supervisor.
Notify family members of the client’s condition.
Inform the chaplain that the client’s death is imminent.
Notify family members of the client’s condition
Rationale
The nurse’s first priority is to notify the family of the resident’s impending death.
After a client has been premedicated for surgery with an opioid analgesic, the nurse discovers that the operative permit has not been signed. Which action should the nurse implement?
Notify the surgeon that the consent form has not been signed.
Read the consent form to the client before witnessing the client’s signature.
Determine if the client’s spouse is willing to sign the consent form.
Administer an opioid antagonist prior to obtaining the client’s signature.
Notify the surgeon that the consent form has not been signed.
The home health nurse visits an older client who lives at home with her husband. The client is experiencing frequent episodes of diarrhea and bowel incontinence. Which problem, for which the client is at risk, has the greatest priority when planning the client’s care?
Disturbed sleep pattern.
Caregiver role strain.
Impaired skin integrity.
Fluid volume imbalance.
Fluid volume imbalance.
Rationale
Diarrhea can lead to fluid volume loss, which is potentially life-threatening, so the highest priority is to prevent a fluid volume imbalance.
Which activity should the nurse use in the evaluation phase of the nursing process?
Ask a client to evaluate the nursing care provided.
Document the nursing care plan in the progress notes.
Determine whether a client’s health problems have been alleviated.
Examine the effectiveness of nursing interventions toward meeting client outcomes.
Examine the effectiveness of nursing interventions toward meeting client outcomes.
When teaching a female client to perform intermittent self-catheterization, the nurse should ensure the client’s ability to perform which action?
Locate the perineum.
Transfer to a commode.
Attach the catheter to a drainage bag.
Manipulate a syringe to inflate the balloon.
Locate the perineum.
Rationale
Adequate visualization or palpation of the perineum is essential to ensure the correct placement of the catheter. During a self-catheterization, the client typically allows the urine to drain into an open collection device, rather than a drainage bag and uses a straight catheter without a balloon.
While the nurse is administering a bolus feeding to a client via a nasogastric tube, the client begins to vomit. Which action should the nurse implement first?
Discontinue the administration of the bolus feeding.
Auscultate the client’s breath sounds bilaterally.
Elevate the head of the bed to a high Fowler’s position.
Administer a PRN dose of a prescribed antiemetic.
Discontinue the administration of the bolus feeding.
When a client receiving a tube feeding begins to vomit, the nurse should first stop the feeding to prevent further vomiting.
The charge nurse assigns a nursing procedure to a new staff nurse who has not previously performed the procedure. Which action is most important for the new staff nurse to take?
Review the steps in the procedure manual.
Ask another nurse to assist while implementing the procedure.
Follow the agency’s policy and procedure.
Inform the charge nurse that they have never done this procedure.
Inform the charge nurse that they have never done this procedure.
In evaluating client care, which action should the nurse take first?
Determine if the expected outcomes of care were achieved.
Review the rationales used as the basis of nursing actions.
Document the care plan goals that were successfully met.
Prioritize interventions to be added to the client’s plan of care.
Determine if the expected outcomes of care were achieved.
To obtain the most complete assessment data for a client with chronic pain, which information should the nurse obtain?
Can you describe where your pain is the most severe?
What is your pain intensity on a scale of 1 to 10?
Is your pain best described as aching, throbbing, or sharp?
Which activities during a routine day are impacted by your pain?
Which activities during a routine day are impacted by your pain?
Rationale
A client with chronic pain is more likely to have adapted physiologically to vital sign changes, localization, or intensity, so pain assessment should focus on any interference with daily activities, such as sleep, relationships with others, physical activity, and emotional well-being. Exacerbation of acute symptoms, such as pain distribution, patterns, intensity, and descriptors elicit specific assessment findings.
A female client who has breast cancer with metastasis to the liver and spine is admitted with constant, severe pain despite around-the-clock use of oxycodone and amitriptyline for pain control at home. During the admission assessment, which information is most important for the nurse to obtain?
Sensory pattern, area, intensity, and nature of the pain.
Trigger points identified by palpation and manual pressure of painful areas.
Schedule and total dosages of drugs currently used for breakthrough pain.
Sympathetic responses consistent with the onset of acute pain.
Sensory pattern, area, intensity, and nature of the pain.
The nurse is preparing a male client who has an indwelling catheter and an IV infusion to ambulate from the bed to a chair for the first time following abdominal surgery. Which action(s) should the nurse implement prior to assisting the client to the chair? (Select all that apply.)
Select all that apply
Premedicate the client with an analgesic.
Inform the client of the plan for moving to the chair.
Obtain and place a portable commode by the bed.
Ask the client to push the IV pole to the chair.
Clamp the indwelling catheter.
Assess the client’s blood pressure.
Premedicate the client with an analgesic.
Inform the client of the plan for moving to the chair.
Ask the client to push the IV pole to the chair.
Assess the client’s blood pressure.
A middle-aged woman who enjoys being a teacher and mentor feels that she should pass down her legacy of knowledge and skills to the younger generation. According to Erickson’s psychosocial developmental theory, she is involved in which developmental stage?
Generativity.
Ego integrity.
Identification.
Valuing wisdom.
Generativity.
Rationale
Healthy middle-aged adults focus on establishing the next generation by nurturing and guiding, which is described by Erikson as the developmental stage of generativity, and is characteristic of middle adulthood.
Which statement best describes durable power of attorney for health care?
The client signs a document that designates another person to make legally binding healthcare decisions if the client is unable to do so.
The healthcare decisions made by another person designated by the client are not legally binding.
Instructions about actions to be taken in the event of a client’s terminal or irreversible condition are not legally binding.
Directions regarding care in the event of a terminal or irreversible condition must be documented to ensure that they are legally binding.
The client signs a document that designates another person to make legally binding healthcare decisions if the client is unable to do so.
A client who has been on bed rest for several days now has a prescription to progress activity as tolerated. When the nurse assists the client out of bed for the first time, the client becomes dizzy. Which action should the nurse implement?
Encourage the client to take several slow, deep breaths while ambulating.
Help the client to remain standing by the bedside until the dizziness is relieved.
Instruct the client to remain on bedrest until the healthcare provider is contacted.
Advise the client to sit on the side of the bed for a few minutes before standing again.
Advise the client to sit on the side of the bed for a few minutes before standing again.
A male client with venous incompetence stands up and his blood pressure subsequently drops. Which finding should the nurse identify as a compensatory response?
Bradycardia.
Increase in pulse rate.
Peripheral vasodilation.
Increase in cardiac output.
Increase in pulse rate.
Rationale
When postural hypotension occurs, the body attempts to restore arterial pressure by stimulating the baroreceptors to increase the heart rate, not decrease it. Peripheral vasoconstriction of the veins and arterioles occurs with venous incompetence through the baroreceptor reflex. A decrease in cardiac output occurs when orthostatic hypotension occurs.
The nurse encounters a slight resistance when inserting the tubing into a client’s rectum for a tap water enema. Which action should the nurse implement?
Withdraw the tube and apply additional lubricant to the tip of the tube.
Encourage the client to bear down and continue to insert the tube.
Remove the tube and re-position the client to reinsert the tube.
Ask the client to relax and twist the tube gently through the sphincter.
Ask the client to relax and twist the tube gently through the sphincter.
A client is admitted to the hospital with intractable pain. Which instruction should the nurse provide the unlicensed assistive personnel (UAP) who is preparing to assist this client with a bed bath?
Take measures to promote as much comfort as possible.
Report any signs of drug addiction to the nurse immediately.
Wait until the client’s pain is gone before assisting with personal care.
This client’s pain will be difficult to manage since the cause is unknown.
Take measures to promote as much comfort as possible.
The nurse notes that a client consistently coughs while eating and drinking. Which nursing problem is most important for the nurse to include in this client’s plan of care?
Ineffective breathing pattern.
Impaired gas exchange.
Risk for aspiration.
Ineffective airway clearance.
Risk for aspiration.
Rationale
Coughing during or after meals is a manifestation of dysphagia, or difficulty swallowing, which places the client at risk for aspiration. Dysphagia can lead to aspiration pneumonia, but the client is not currently exhibiting any symptoms of breathing difficulty or impaired gas exchange.
A client with chronic renal disease is admitted to the hospital for evaluation prior to a surgical procedure. Which laboratory test indicates the client’s protein status for the longest length of time?
Transferrin.
Prealbumin.
Serum albumin.
Urine urea nitrogen.
Serum albumin.
Rationale
Serum albumin has a long half-life and is the best long-term indicator of the body’s entry into a catabolic state following protein depletion from malnutrition or stress of chronic illness.
A client is admitted with a stage four pressure injury that has a black, hardened surface (eschar) that is stable. Which dressing is best for the nurse to use first?
Hydrogel.
Exudate absorber.
No dressing.
Transparent adhesive film.
No dressing.
Rationale
If eschar is dry and intact and debridement is not part of the plan of care, no dressing is used, allowing eschar to act as physiological cover.
While preparing to insert a rectal suppository in a male adult client, the nurse observes that the client is holding his breath while bearing down. Which action should the nurse implement?
Advise the client to continue to bear down without holding his breath.
Gently insert the lubricated suppository four inches into the rectum.
Perform a digital exam to determine if a fecal impaction is present.
Instruct the client to take slow deep breaths and stop bearing down.
Instruct the client to take slow deep breaths and stop bearing down.
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. Which 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.
Evaluate the client’s mental status for competence to refuse treatment.
Rationale
Competent clients have the right to refuse treatment, so the nurse should first ensure that the client is competent.
An older female client with rheumatoid arthritis is reporting severe joint pain that is caused by the weight of the linen on her legs. Which action should the nurse implement first?
Apply flannel pajamas to provide warmth.
Administer a PRN dose of ibuprofen.
Perform range of motion exercises in a warm tub.
Drape the sheets over the footboard of the bed.
Drape the sheets over the footboard of the bed.
Rationale
The nurse should first provide an immediate comfort measure to address the client’s complaint about the linens and drape the linens over the footboard of the bed instead of tucking them under the mattress, which can add pressure perceived by the client as the source of her pain.
The nurse is discussing dietary preferences with a client who adheres to a vegan diet. Which dietary supplement should the nurse encourage the client to include in the dietary plan?
Fiber.
Folate.
Ascorbic acid.
Vitamin B12.
Vitamin B12.
Rationale
Vitamin B12 is normally found in liver, kidney, meat, fish, and dairy products. A vegan who consumes only vegetables without careful dietary planning and supplementation may develop peripheral neuropathy due to a deficiency in vitamin B12.
How should the nurse handle linens that are soiled with incontinent feces?
Put the soiled linens in an isolation bag, then place it in the dirty linen hamper.
Place an isolation hamper in the client’s room and discard the linens in it.
Place the soiled linens in the designated fluid-resistant dirty linen bag and deposit them in the dirty linen hamper.
Ask the housekeeping staff to pick up the soiled linen from the dirty utility room.
Place the soiled linens in the designated fluid-resistant dirty linen bag and deposit them in the dirty linen hamper.
Which action should the nurse implement when adding sterile liquids to a sterile field?
Use an outdated sterile liquid if the bottle is sealed and has not been opened.
Consider the sterile field contaminated if it becomes wet during the procedure.
Remove the container cap and lay it with the inside facing down on the sterile field.
Hold the container high and pour the solution into a receptacle at the back of the sterile field.
Consider the sterile field contaminated if it becomes wet during the procedure.
A nurse is becoming increasingly frustrated by the family members’ efforts to participate in the care of a hospitalized client. Which action should the nurse implement to cope with these feelings of frustration?
Suggest that other cultural practices be substituted by the family members.
Examine one’s own culturally based values, beliefs, attitudes, and practices.
Explain to the family that multiple visitors are exhausting to the client.
Allow the situation to continue until a family member’s action may harm the client.
Examine one’s own culturally based values, beliefs, attitudes, and practices.
A nurse is preparing to insert a rectal suppository and observes a small amount of rectal bleeding. Which action should the nurse implement?
Administer the medication as scheduled after assessing the client’s vital signs.
Ask the pharmacist to send an alternate form of the prescribed medication to the unit.
Withhold the administration of the suppository until contacting the healthcare provider.
Insert the suppository very gently being careful not to further injure the rectal mucosa.
Withhold the administration of the suppository until contacting the healthcare provider.
The nurse assesses an immobile, older male client and determines that his blood pressure is 138/60 mmHg, his temperature is 95.8 °F (35.4 °C), and his output is 100 mL of concentrated urine during the last hour. He has wet-sounding lung sounds, and increased respiratory secretions. Based on these assessment findings, which nursing action is most important for the nurse to implement?
Administer a PRN antihypertensive prescription.
Provide the client with an additional blanket.
Encourage additional fluid intake.
Encourage the client to cough and deep breathe every 2 hours.
Encourage the client to cough and deep breathe every 2 hours.
Rationale
Coughing and deep breathing every 2 hours will help to move and drain respiratory secretions and prevent pneumonia from occurring, so this intervention has the highest priority. Older adults often have an increased BP, and a PRN antihypertensive medication is usually prescribed for a BP over 140 systolic and 90 diastolic.
In assessing a client’s femoral pulse, the nurse must use deep palpation to feel the pulsation while the client is in a supine position. Which action should the nurse implement?
Elevate the head of the bed and attempt to palpate the site again.
Document the presence and volume of the pulse palpated.
Use a thigh cuff to measure the blood pressure in the leg.
Record the presence of pitting edema in the inguinal area.
Document the presence and volume of the pulse palpated.
Which client care activity requires the nurse to wear barrier gloves as required by the protocol for standard precautions?
Removing the empty food tray from a client with a urinary catheter.
Washing and combing the hair of a client with a fractured leg in traction.
Administering oral medications to a cooperative client with a wound infection.
Emptying the urinary catheter drainage bag for a client with Alzheimer’s disease.
Emptying the urinary catheter drainage bag for a client with Alzheimer’s disease.
Rationale
Possible contact with body secretions, excretions, or broken skin is an indication of wearing barrier (nonsterile) gloves. Emptying a urine drainage bag requires the use of gloves.
A medication is prescribed to be given QID. Which schedule should the nurse use to administer this prescription?
0800, 1200, 1600, 2000.
0800.
Every other day at 0800.
0800, 1200, 1600, 2000, 0000, 0400.
0800, 1200, 1600, 2000.
Which technique is most important for the nurse to implement when performing a physical assessment?
A head-to-toe approach.
The medical systems model.
A consistent, systematic approach.
An approach related to a nursing model.
A consistent, systematic approach.
Prior to administering a newly prescribed medication to a client, the nurse reviews the adverse effects of the medication listed in a drug reference guide and determines the priority risks to the client. While performing this action, the nurse is engaged in which step of the nursing process?
Assessment.
Analysis.
Implementation.
Evaluation.
Analysis.
Rationale
The nurse is analyzing data to establish an individualized nursing problem, such as, “Risk for injury related to side effects of drugs.” This analysis is based on assessment and guides the planning and implementation of care, such as the decision to monitor the client frequently. Evaluation provides the nurse with information about the effectiveness of the plan of care.
A client with Raynaud’s phenomenon asks the nurse about using biofeedback for self-management of symptoms. Which response is best for the nurse to provide?
The responses to biofeedback have not been well established and may be a waste of time and money.
Biofeedback requires extensive training to retrain voluntary muscles, not involuntary responses.
Although biofeedback is easily learned, it is most often used to manage the exacerbation of symptoms.
Biofeedback allows the client to control involuntary responses to promote peripheral vasodilation
Biofeedback allows the client to control involuntary responses to promote peripheral vasodilation.
A client provides the nurse with information about the reason for seeking care. The nurse realizes that some information about past hospitalizations is missing. How should the nurse obtain this information?
Solicit information on hospitalization from the insurance company.
Look up previous medical records from archived hospital documents.
Ask the client to discuss previous hospitalizations in the last 5 years.
Elicit specific facts about past hospitalizations with direct questions.
Elicit specific facts about past hospitalizations with direct questions.
The charge nurse observes an unlicensed assistive personnel (UAP) bending at the waist to lift a 20-pound box of medical supplies off the treatment room floor. Which instruction should the charge nurse provide to the UAP?
Ask another staff member for assistance.
Request that supplies are delivered in smaller containers.
Push the box against the wall to provide support while lifting.
Bend at the knees when lifting heavy objects.
Bend at the knees when lifting heavy objects.
Before administering a client’s medication, the nurse assesses a change in the client’s condition and decides to withhold the medication until consulting with the healthcare provider. After consultation with the healthcare provider, the dose of the medication is changed and the nurse administers the newly prescribed dose an hour later than the originally scheduled time. Which action should the nurse implement in response to this situation?
Notify the charge nurse that a medication error occurred.
Submit a medication variance report to the supervisor.
Document the events that occurred in the nurses’ notes.
Discard the original medication administration record.
Document the events that occurred in the nurses’ notes.
A 4-year-old boy who is scheduled for a tonsillectomy and adenoidectomy asks the nurse, “Will it hurt to have my tonsils and adenoids taken out?” Which response is best for the nurse to provide?
“It may hurt a little because of the incision made in your throat.”
“It won’t hurt because you’re such a big boy.”
“It won’t hurt because we put you to sleep.”
“It may hurt but we’ll give you medicine to help you feel better.”
“It may hurt but we’ll give you medicine to help you feel better.”
Rationale
Answering questions simply and directly provides comfort for the preschool-age child and builds confidence in the healthcare team.
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 which 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.
Assault and battery with deliberate intent to deviate from the consent form.
A male client arrives at the outpatient surgery center for a scheduled needle aspiration of the knee. He tells the nurse that he has already given verbal consent for the procedure to the healthcare provider. Which action should the nurse pursue next?
Witness the client’s signature on the consent form.
Verify the client’s consent with the healthcare provider.
Notify the healthcare provider that the client is ready for the procedure.
Document that the client has given consent for the needle aspiration.
Verify the client’s consent with the healthcare provider.
