HESI
FUNDAMENTALS
PRACTICE TEST
B
HESI Fundamentals Practice Test B
What is the rationale for using the nursing process in planning care for
... [Show More] clients? A.
As a scientific process to identify nursing diagnoses of a clients' healthcare
problems.
B. To establish nursing theory that incorporates the biopsychosocial nature of humans.
C. As a tool to organize thinking and clinical decision making about clients'
healthcare needs.
D. To promote the management of client care in collaboration with other healthcare
professionals.
(ANS-: C)
What activity should the nurse use in the evaluation phase of the nursing process?
A. Ask a client to evaluate the nursing care provided.
B. Document the nursing care plan in the progress notes.
C. Determine whether a client's health problems have been alleviated.
D. Examine the effectiveness of nursing interventions toward meeting client
outcomes. (ANS-: D
Which statement is an example of a correctly written nursing diagnosis statement?
A. Altered tissue perfusion related to congestive heart failure.
B. Altered urinary elimination related to urinary tract infection.
C. Risk for impaired tissue integrity related to client's refusal to turn.
D. Ineffective coping related to response to positive biopsy test results.
(ANS-: D
What action by the nurse demonstrates culturally sensitive care? A.
Asks permission before touching a client.
B. Avoids questions about male-female relationships.
C. Explains the differences between Western medical care and cultural folk
remedies.
D. Applies knowledge of a cultural group unless a client embraces Western
customs. (ANS-: A
A nurse is becoming increasingly frustrated by the family members' efforts to
participate in the care of a hospitalized client. What action should the nurse
implement to cope with these feelings of frustration?
A. Suggest that other cultural practices be substituted by the family members.
B. Examine one's own culturally based values, beliefs, attitudes, and practices.
C. Explain to the family that multiple visitors are exhausting to the client.
D. Allow the situation to continue until a family member's action may harm the
client. (ANS-: B
Which technique is most important for the nurse to implement when performing a
physical assessment?
A. A head-to-toe approach.
B. The medical systems model.
C. A consistent, systematic approach.
D. An approach related to a nursing model. (ANS-: C
A 73-year-old Hispanic client is seen at the community health clinic with a history
of protein malnutrition. What information should the nurse obtain first? A. Amount
of liquid protein supplements consumed daily.
B. Foods and liquids consumed during the past 24 hours.
C. Usual weekly intake of milk products and red meats.
D. Grains and legume combinations used by the client. (ANS-: B
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?
A. Does not check capillary blood glucose as directed.
B. Occasionally forgets to take daily prescribed medication.
C. Cannot identify signs or symptoms of high and low blood glucose.
D. Eats anything and does not think diet makes a difference in health.
(ANS: D
Which statement correctly identifies a written learning objective for a client with
peripheral vascular disease?
A. The nurse will provide client instruction for daily foot care.
B. The client will demonstrate proper trimming toenail technique.
C. Upon discharge, the client will list three ways to protect the feet from injury.
D. After instruction, the nurse will ensure the client understands foot care rationale.
(ANS-: C
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 Erikson, she is involved in what developmental stage? A.
Generativity.
B. Ego integrity.
C. Identification.
D. Valuing wisdom
(ANS-: A
Which statement best describes durable power of attorney for health care?
A. The client signs a document that designates another person to make legally binding
healthcare decisions if client is unable to do so.
B. The healthcare decisions made by another person designated by the client are not
legally binding.
C. Instructions about actions to be taken in the event of a client's terminal or
irreversible condition are not legally binding.
D. Directions regarding care in the event of a terminal or irreversible condition must
be documented to ensure that they are legally binding.
(ANS- A
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?
A. Low fat and low sodium foods.
B. Combination of plant proteins to provide essential amino acids.
C. Limited complex carbohydrates and fiber.
D. Increased amount of vitamin C and beta carotene rich foods.
(ANS-: B
A client with Raynaud's disease asks the nurse about using biofeedback for
selfmanagement of symptoms. What response is best for the nurse to provide?
A. The responses to biofeedback have not been well established and may be a waste
of time and money.
B. Biofeedback requires extensive training to retrain voluntary muscles, not
involuntary responses.
C. Although biofeedback is easily learned, it is mostly often used to manage
exacerbation of symptoms.
D. Biofeedback allows the client to control involuntary responses to promote
peripheral vasodilation.
(ANS-: D
A female client informs the nurse that she uses herbal therapies to supplement her
diet and manage common ailments. What information should the nurse offer the
client about general use of herbal supplements?
A. Most herbs are toxic or carcinogenic and should be used only when proven
effective.
B. There is no evidence that herbs are safe or effective as compared to conventional
supplements in maintaining health.
C. Herbs should be obtained from manufacturers with a history of quality control of
their supplements.
D. Herbal therapies may mask the symptoms of serious disease, so frequent medical
evaluation is required during use.
(ANS: C
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
(Percodan) and amitriptyline (Elavil) for pain control at home. During the
admission assessment, which information is most important for the nurse to obtain?
A. Sensory pattern, area, intensity, and nature of the pain.
B. Trigger points identified by palpation and manual pressure of painful areas.
C. Schedule and total dosages of drugs currently used for breakthrough pain.
D. Sympathetic responses consistent with onset of acute pain.
(ANS-: A
A client who has moderate, persistent, chronic neuropathic pain due to diabetic
neuropathy takes gabapentin (Neurontin) and ibuprofen (Motrin, Advil) daily. If
Step 2 of the World Health Organization (WHO) pain relief ladder is prescribed,
which drug protocol should be implemented? A. Continue gabapentin.
B. Discontinue ibuprofen.
C. Add aspirin to the protocol.
D. Add oral methadone to the protocol.
(ANS- Correct Answer: A
To obtain the most complete assessment data for a client with chronic pain, which
information should the nurse obtain?
A. Can you describe where your pain is the most severe?
B. What is your pain intensity on a scale of 1 to 10?
C. Is your pain best described as aching, throbbing, or sharp?
D. Which activities during a routine day are impacted by your pain?
(ANS- Correct Answer: D
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. What action should the nurse implement? A. Document the
client's request in the medical record.
B. Ask the client if this decision has been discussed with his healthcare provider. C.
Inform the client that a written, notarized advance directive, is required to withhold
resuscitation efforts.
D. Advise the client to designate a person to make healthcare decisions when the
client is unable to do so.
(ANS- 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.
Correct Answer: B
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 the
dietary plan? A. Fiber.
B. Folate.
C. Ascorbic acid.
D. Vitamin B12.
(ANS- : D
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. What action(s) should the nurse implement prior to assisting the client to
the chair? (Select all that apply.)
A. Pre-medicate the client with an analgesic.
B. Inform the client of the plan for moving to the chair.
C. Obtain and place a portable commode by the bed.
D. Ask the client to push the IV pole to the chair.
E. Clamp the indwelling catheter.
F. Assess the client's blood pressure.
(ANS- The nurse should plan to implement (A, B, D, and F). Pre-medicating the
client with an analgesic (A) reduces the client's pain during mobilization and
maximizes compliance. To ensure the client's cooperation and promote
independence, the nurse should inform the client about the plan for moving to the
chair (B) and encourage the client to participate by pushing the IV pole when
walking to the chair (D). The nurse should assess the client's blood pressure (F)
prior to mobilization, which can cause orthostatic hypotension. (C and E) are not
indicated.
Correct Answer: A, B, D, F
A client is demonstrating a positive Chvostek's sign. What action should the nurse
take?
A. Observe the client's pupil size and response to light.
B. Ask the client about numbness or tingling in the hands.
C. Assess the client's serum potassium level.
D. Restrict dietary intake of calcium-rich foods.
(ANS- A positive Chvostek's sign is an indication of hypocalcemia, so the client
should be assessed for the subjective symptoms of hypocalcemia, such as
numbness or tingling of the hands (B) or feet. (A and C) are unrelated assessment
data. (D) is contraindicated because the client is hypocalcemic and needs additional
dietary calcium.
Correct Answer: B
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?
A. Flush the lumen with the saline solution and administer the medication through the
lumen.
B. Determine if a PRN prescription for a thrombolytic agent is listed on the
medication record.
C. Clamp the lumen and obtain a syringe of a dilute heparin solution to flush through
the tubing.
D. Withdraw the aspirated blood into the syringe and use a new syringe to administer
the medication.
(ANS- 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
(A), then flush the lumen with saline again. (B and C) are not necessary. The
aspirated blood can be flushed back through the closed system into the client's
bloodstream, but does not need to be withdrawn (D).
Correct Answer: A
Which client assessment data is most important for the nurse to consider before
ambulating a postoperative client? A. Respiratory rate.
B. Wound location.
C. Pedal pulses.
D. Pain rating.
(ANS- 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).
Correct Answer: 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? A. Check for a blood return.
B. Reposition the client's arm.
C. Remove the IV site dressing.
D. Flush the lock with saline.
(ANS- 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.
Correct Answer: B
Which nursing intervention is most beneficial in reducing the risk of urosepsis in a
hospitalized client with an indwelling urinary catheter?
A. Ensure that the client's perineal area is cleansed twice a day.
B. Maintain accurate documentation of the fluid intake and output.
C. Encourage frequent ambulation if allowed or regular turning if on bedrest.
D. Obtain a prescription for removal of the catheter as soon as possible. (ANSThe best intervention to reduce the risk for urosepsis (spread of an infectious
agent from the urinary tract to systemic circulation) is removal of the urinary
catheter as quickly as possible (D). (A, B, and C) are helpful to reduce the risk
of infection, but are of less priority than (D) in reducing the risk of urosepsis.
Correct Answer: D
In evaluating client care, which action should the nurse take first? A.
Determine if the expected outcomes of care were achieved.
B. Review the rationales used as the basis of nursing actions.
C. Document the care plan goals that were successfully met.
D. Prioritize interventions to be added to the client's plan of care. (ANS- In
evaluating care, the nurse should first determine if the expected outcomes of the
plan of care were achieved (A). As indicated, the nurse may then review the
initial nursing actions and the rationales for those actions (B), document
successful completion of the care plan goals (C), and revise the plan of care (D).
Correct Answer: A
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? A. Assessment.
B. Analysis.
C. Implementation.
D. Evaluation.
(ANS- The nurse is analyzing (B) data to establish an individualized nursing
diagnosis, such as, "Risk for injury related to side effects of drugs." This analysis is
based on assessment (A) and guides the planning and implementation (C) of care,
such as the decision to monitor the client frequently. (D) provides the nurse with
information about the effectiveness of the plan of care.
Correct Answer: B
The nurses determines a client's IV solution is infusing at 250 ml/hr. The
prescribed rate is 125 ml/hr. What action should the nurse take first? A.
Determine when the IV solution was started.
B. Slow the IV infusion to keep vein open rate.
C. Assess the IV insertion site for swelling.
D. Report the finding to the healthcare provider.
(ANS- The nurse should first slow the IV flow rate to keep vein open (KVO) rate
(B) to prevent further risk of fluid volume overload, then gather additional
assessment data, such as when the IV solution was started (A) and the appearance
of the IV insertion site (C) before contacting the healthcare provider (D) for further
instructions.
Correct Answer: B
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?
A. May I ask your daughter to help you with your personal hygiene?
B. I will ask one of the female nurses to bathe you.
C. A staff member on the next shift will help you.
D. I will keep you draped and hand you the supplies as you need them. (ANSMany female Muslim clients are very modest and prefer to receive personal
care from another female because of their religious and cultural beliefs. The
most culturally sensitive response is for the male nurse to ask a female
colleague to perform this task (B). (A and D) are less respectful of the client's
cultural and spiritual preferences. (C) delays the client's care.
Correct Answer: B
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. What intervention should the nurse
implement?
A. Take the child back to his room.
B. Recruit others to restrain the child.
C. Ask the mother to be present to soothe the child.
D. Show the child how to manipulate the equipment.
(ANS- A 4-year-old typically has a vivid imagination and lacks concrete thinking
abilities. The mother's assistance (C) can provide a stabilizing presence to help
soothe the preschooler, 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 (A). (B) may be necessary
to prevent injury if the child is unable to cooperate with the mother's coaxing. (D)
is best done before going to the treatment room when the child feels less
threatened. Correct Answer: C
When making the bed of a client who needs a bed cradle, which action should the
nurse include?
A. Teach the client to call for help before getting out of bed.
B. Keep both the upper and lower side rails in a raised position.
C. Keep the bed in the lowest position while changing the sheets.
D. Drape the top sheet and covers loosely over the bed cradle.
(ANS- 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 (D). A client using a
bed cradle may still be able to ambulate independently (A) and does not require
raised side rails (B). (C) causes the nurse to use poor body mechanics.
Correct Answer: D
A male client has a nursing diagnosis of "spiritual distress." What intervention is
best for the nurse to implement when caring for this client?
A. Use distraction techniques during times of spiritual stress and crisis.
B. Reassure the client that his faith will be regained with time and support.
C. Consult with the staff chaplain and ask that the chaplain visit with the client.
D. Use reflective listening techniques when the client expresses spiritual doubts.
(ANS- The most beneficial nursing intervention is to use nonjudgmental
reflective listening techniques, to allow the client to feel comfortable expressing
his concerns (D). (A and B) are not therapeutic. The client should be consulted
before implementing (C). Correct Answer: D
A client has a nursing diagnosis of, "Spiritual distress related to a loss of hope,
secondary to impending death." What intervention is best for the nurse to
implement when caring for this client?
A. Help the client to accept the final stage of life.
B. Assist and support the client in establishing short-term goals.
C. Encourage the client to make future plans, even if they are unrealistic.
D. Instruct the client's family to focus on positive aspects of the client's life.
(ANS- 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 (B), such as seeing a family member, or
listening to music. (A) is too vague to be a helpful intervention. (C) does not
help the client deal with this nursing diagnosis. (D) might be implemented, but
does not have the priority of (B).
Correct Answer: B
The nurse overhears the healthcare provider explaining to the client that the tumor
removed was non-malignant 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?
A. Healthcare provider.
B. Client's family.
C. Case manager.
D. Chief of staff.
(ANS- 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 (A). (B, C, and D) may be indicated, but first the nurse should confer with
the healthcare provider to obtain all needed information.
Correct Answer: A
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?
A. Your children are old enough to help you make decisions about their futures.
B. The social worker can tell you about placement alternatives for your children.
C. Tell me what you would like to see happen with your children in the future.
D. You have just received bad news, and you need some time to adjust to it.
(ANS- The nurse should first assess what the client desires (C). (A) is somewhat
judgmental and attempts to solve the problem for the client without eliciting the
client's feelings. Though a referral to the social worker (B) may be indicated,
the nurse should first offer support. Time is likely to help the client cope with
this news (D), but the nurse should first provide support and assess what the
client wants to see happen with her children.
Correct Answer: C
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. What intervention should the nurse implement
first?
A. Request hospice care for the client.
B. Report the client's acuity level to the nursing supervisor.
C. Notify family members of the client's condition.
D. Inform the chaplain that the client's death is imminent.
(ANS- The nurse's first priority is to notify the family of the resident's impending
death (C). The family may request that hospice care is initiated (A). Reporting the
client's acuity level (B) does not have the priority of informing the family of the
client's condition. Once the family is contacted, the nurse can also contact the
chaplain (D). Correct Answer: C
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?
A. There is no reason to be so angry.
B. Why do I need to leave your room?
C. What is concerning you this morning?
D. Let me call the client advocate for you.
(ANS- (C) is an open-ended question that encourages the client to discuss personal
feelings. (A) devalues the client and hinders further communication. Acting
defensively and asking why questions such as (B) are likely to elicit more anger
and block communication. By deferring to the client advocate (D), the nurse fails
to even address the client's feelings of anger and exasperation.
Correct Answer: C
The nurse encounters resistance when inserting the tubing into a client's rectum for
a tap water enema. What action should the nurse implement?
A. Withdraw the tube and apply additional lubricant to the tube.
B. Encourage the client to bear down and continue to insert the tube.
C. Remove the tube and check the client for a fecal impaction.
D. Ask the client to relax and run a small amount of fluid into the rectum. (ANSIf resistance is encountered during the initial insertion of an enema tube, the
client should be instructed to relax while a small amount of solution runs
through the tube into the rectum (D) to promote dilation. (A) is unlikely to
resolve the problem. (B) may cause injury. (C) should not be implemented until
other, less invasive actions, such as (D) have been taken.
Correct Answer: D
When assessing a client with a nursing diagnosis 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?
A. Confirm the finding by further assessing the client for jugular vein distention.
B. Offer the client high protein snacks between regularly scheduled mealtimes.
C. Continue the planned nursing interventions to restore the client's fluid volume.
D. Change the plan of care to include a nursing diagnosis of impaired skin
integrity.
(ANS- 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 (C). Jugular vein distention (A) is
a sign of fluid volume overload. High protein snacks (B) will not resolve the fluid
volume deficit. Changes in the client's skin integrity are not evident (D).
Correct Answer: C
When teaching a female client to perform intermittent self-catheterization, the
nurse should ensure the client's ability to perform which action?
A. Locate the perineum.
B. Transfer to a commode.
C. Attach the catheter to a drainage bag.
D. Manipulate a syringe to inflate the balloon.
(ANS- Adequate visualization or palpation of the perineum (A) is essential to
ensure correct placement of the catheter. (B) is not necessary to perform
selfcatheterization. During a self-catheterization, the client typically allows the
urine to drain into an open collection device, rather than a drainage bag (C), and
uses a straight catheter without a balloon (D).
Correct Answer: A
A client in hospice care develops audible gurgling sounds on inspiration. Which
nursing action has the highest priority?
A. Ensure cultural customs are observed.
B. Increase oxygen flow to 4L/minute.
C. Auscultate bilateral lung fields.
D. Inform the family that death is imminent.
(ANS- 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.
Correct Answer: D
The nurse notes that a client consistently coughs while eating and drinking. Which
nursing diagnosis is most important for the nurse include in this client's plan of
care?
A. Ineffective breathing pattern.
B. Impaired gas exchange.
C. Risk for aspiration.
D. Ineffective airway clearance.
(ANS- Coughing during or after meals is a manifestation of dysphagia, or
difficulty swallowing, which places the client at risk for aspiration (C). Dysphagia
can lead to aspiration pneumonia, but the client is not currently exhibiting any
symptoms of breathing difficulty (A) or impaired gas exchange (B). Although (D)
may be related to an ineffective cough, the client's coughing is an effective
response when solids or liquids are taken orally.
Correct Answer: C
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? A.
Temperature increases from 98.8° to 99.0° F.
B. Pulse rate decreases from 78 to 52 beats/min.
C. Respiratory rate increases from 16 to 24 breaths/min.
D. Blood pressure increases from 110/84 to 118/88 mm/Hg.
(ANS- 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 (B). (A, C, and D) do not warrant stopping the procedure.
Correct Answer: B
A client is admitted with a stage four pressure ulcer that has a black, hardened
surface and a light-pink wound bed with a malodorous green drainage. Which
dressing is best for the nurse to use first? A. Hydrogel.
B. Exudate absorber.
C. Wet to moist dressing.
D. Transparent adhesive film.
(ANS- To provide moisture and loosen the necrotic tissue, the eschar should be
covered first with wet to moist dressings (C), which are discontinued and then a
hydrogel alginate can be placed in the prepared wound bed to prevent further
damage of granulating any surrounding tissue. Although a hydrogel (A) liquefies
necrotic tissue of slough and rehydrates the wound bed, it does not address wicking
the purulent drainage from the wound. Exudate absorbers (B) provide a moist
wound surface, absorb exudate, and support debridement, but do not prepare the
wound bed for proper healing. Transparent dressings (D) are used to protect against
contamination and friction while maintaining a clean moist surface. Correct
Answer: C
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?
A. Review the client's medical record for an advance directive.
B. Determine if a do-not-resuscitate prescription has been obtained.
C. Document that the client is being discharged against medical advice.
D. Evaluate the client's mental status for competence to refuse treatment. (ANSCompetent 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. Correct Answer: D
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? A. Transferrin.
B. Prealbumin.
C. Serum albumin.
D. Urine urea nitrogen.
(ANS- 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 (C). While (A) is a good indicator of iron-binding capacity
in a healthy adult, it is an unreliable measure in the client with a chronic illness.
(B) has a short half-life, and is a sensitive indicator of recent catabolic changes, but
it is not as effective as (C) in indicating long-term protein depletion. While (D) is a
good indicator of a negative nitrogen balance, it is not as good an indicator of
longterm protein catabolism as is (C).
Correct Answer: C
What client statement indicates to the nurse that the client requires assistance with
bathing?
A. I wasn't able to pack a bag before I left for the hospital.
B. I don't understand why I'm so weak and tired.
C. I only bathe every other day.
D. I left my eyeglasses at home.
(ANS- Bathing often makes a client feel weak, and if a client is already feeling
weak (B), assistance is required during the bathing process to ensure the client's
safety. (A and C) do not pose safety issues. Although (D) may pose a safety issue,
further assessment is needed to determine if this in fact poses a safety issue for the
client.
Correct Answer: B
How should the nurse handle linens that are soiled with incontinent feces?
A. Put the soiled linens in an isolation bag, then place it in the dirty linen hamper.
B. Place an isolation hamper in the client's room and discard the linens in it.
C. Place the soiled linens in a pillow case and deposit them in the dirty linen
hamper.
D. Ask the housekeeping staff to pick up the soiled linen from the dirty utility
room.
(ANS- The nurse should be careful to keep the soiled linens from contaminating
the fresh linens, and should handle the soiled linens like any other dirty linen (C).
(A, B, and D) are not indicated. [Show Less]