HESI RN FUNDAMENTALS EXAM
When turning an immobile bedridden client without assistance, which action by
the nurse best ensures client safety?
A,
... [Show More] Securely grasp the client's arm and leg.
B. Put bed rails up on the side of bed opposite from the nurse.
C. Correctly position and use a turn sheet.
D. Lower the head of the client's bed slowly.
(ANS- B.
Rationale: Because the nurse can only stand on one side of the bed, bed rails
should be up on the opposite side to ensure that the client does not fall out of bed.
Option A can cause client injury to the skin or joint. Options C and D are useful
techniques while turning a client but have less priority in terms of safety than use
of the bed r
The nurse identifies a potential for infection in a client with partial-thickness
(second-degree) and full-thickness (third-degree) burns. What action has the
highest priority in decreasing the client's risk of infection?
A. Administration of plasma expanders
B. Use of careful hand washing
technique
C. Use of careful hand washing technique
Application of a topical antibacterial cream
D. Limiting visitors to the client with burns
(ANS- B
Careful hand washing technique is the single most effective intervention for the
prevention of contamination to all clients. Option A reverses the hypovolemia that
initially accompanies burn trauma but is not related to decreasing the proliferation
of infective organisms. Options C and D are recommended by various burn centers
as possible ways to reduce the chance of infection. Option B is a proven technique
to prevent infection
The nurse is aware that malnutrition is a common problem among clients served by
a community health clinic for the homeless. Which laboratory value is the most
reliable indicator of chronic protein malnutrition?
A. Low serum albumin
level
B. Low serum transferrin level
C. High hemoglobin level
D. High cholesterol level
(ANS- A
Rationale:
Long-term protein deficiency is required to cause significantly lowered serum
albumin levels. Albumin is made by the liver only when adequate amounts of
amino acids (from protein breakdown) are available. Albumin has a long half-life,
so acute protein loss does not significantly alter serum levels. Option B is a serum
protein with a half-life of only 8 to 10 days, so it will drop with an acute protein
deficiency. Options C and D are not clinical measures of protein malnutrition.
In completing a client's preoperative routine, the nurse finds that the operative
permit is not signed. The client begins to ask more questions about the surgical
procedure. Which action should the nurse take next?
A. Witness the client's signature to the permit.
B. Answer the client's questions about the surgery.
C. Inform the surgeon the client has questions about the surgery.
D. Reassure the client that the surgeon will answer any questions before the
anesthesia is administered.
(ANS- C
Rationale:
It is the surgeon's responsibility to explain the procedure to the client and obtain
the client's signature on the permit. Although the nurse can witness an operative
permit, the procedure must first be explained by the health care provider or
surgeon, including answering the client's questions. The client's questions should
be addressed before the permit is signed.
The nurse is assessing several clients prior to surgery. Which factor in a client's
history poses the greatest threat for complications to occur during surgery?
A. Taking birth control pills for the past 2 years
B. Taking anticoagulants for the past year
C. Recently completing antibiotic therapy
D. Having taken laxatives PRN for the last 6 months
(ANS- B
Rationale:
Anticoagulants increase the risk for bleeding during surgery, which can pose a
threat for the development of surgical complications. The health care provider
should be informed that the client is taking these drugs. Although clients who take
birth control pills may be more susceptible to the development of thrombi, such
problems usually occur postoperatively. A client with option C or D is at less of a
surgical risk than with option B.
When assisting a client from the bed to a chair, which procedure is best for the
nurse to follow?
A. Place the chair parallel to the bed, with its back toward the head of the bed
and assist the client in moving to the chair.
B. With the nurse's feet spread apart and knees aligned with the client's knees,
stand and pivot the client into the chair.
C. Assist the client to a standing position by gently lifting upward, underneath
the axillae.
D.Stand beside the client, place the client's arms around the nurse's neck, and
gently move the client to the chair.
(ANS- B
Rationale:
Option B describes the correct positioning of the nurse and affords the nurse a wide
base of support while stabilizing the client's knees when assisting to a standing
position. The chair should be placed at a 45-degree angle to the bed, with the back
of the chair toward the head of the bed. Clients should never be lifted under the
axillae; this could damage nerves and strain the nurse's back. The client should be
instructed to use the arms of the chair and should never place his or her arms
around the nurse's neck; this places undue stress on the nurse's neck and back and
increases the risk for a fall.
Which steps should the nurse take when administering ear drops to an adult client?
(Select all that apply.)
A. Place the client in a side-lying position.
B. Pull the auricle upward and outward.
C. Hold the dropper 6 cm above the ear canal.
D. Place a cotton ball into the inner
canal.
E. Pull the auricle down and back.
(ANS- A B Rationale:
The correct answers (A and B) are the appropriate administration of ear drops. The
dropper should be held 1 cm (½ inch) above the ear canal (C). A cotton ball should
be placed in the outermost canal (D). The auricle is pulled down and back for a
child younger than 3 years of age, but not an adult (E).
The nurse is instructing a client in the proper use of a metered-dose inhaler. Which
instruction should the nurse provide the client to ensure the optimal benefits from
the drug?
A.
"Fill your lungs with air through your mouth and then compress the inhaler."
B.
"Compress the inhaler while slowly breathing in through your mouth."
C.
"Compress the inhaler while inhaling quickly through your nose."
D.
"Exhale completely after compressing the inhaler and then inhale."
(ANS- B
Rationale:
The medication should be inhaled through the mouth simultaneously with
compression of the inhaler. This will facilitate the desired destination of the aerosol
medication deep in the lungs for an optimal bronchodilation effect. Options A, C,
and D do not allow for deep lung penetration.
A 20-year-old female client with a noticeable body odor has refused to shower for
the last 3 days. She states, "I have been told that it is harmful to bathe during my
period." Which action should the nurse take first?
A.
Accept and document the client's wish to refrain from bathing.
B.
Offer to give the client a bed bath, avoiding the perineal area. C.
Obtain written brochures about menstruation to give to the client.
D.
Teach the importance of personal hygiene during menstruation with the client.
(ANS- D
Rationale:
Because a shower is most beneficial for the client in terms of hygiene, the client
should receive teaching first, respecting any personal beliefs such as cultural or
spiritual values. After client teaching, the client may still choose option A or B.
Brochures reinforce the teaching.
While reviewing the side effects of a newly prescribed medication, a 72-year-old
client notes that one of the side effects is a reduction in sexual drive. Which is the
best response by the nurse?
A.
"How will this affect your present sexual activity?"
B.
"How active is your current sex life?"
C.
"How has your sex life changed as you have become older?"
D.
"Tell me about your sexual needs as an older adult."
(ANS- A
Rationale:
Option A offers an open-ended question most relevant to the client's statement.
Option B does not offer the client the opportunity to express concerns. Options C
and D are even less relevant to the client's statement.
The nurse is using the Glasgow Coma Scale to perform a neurologic assessment. A
comatose client winces and pulls away from a painful stimulus. Which action
should the nurse take next?
A.
Document that the client responds to painful stimulus. B.
Observe the client's response to verbal stimulation.
C.
Place the client on seizure precautions for 24 hours.
D.
Report decorticate posturing to the health care provider.
(ANS- A
Rationale:
The client has demonstrated a purposeful response to pain, which should be
documented as such. Response to painful stimulus is assessed after response to
verbal stimulus, not before. There is no indication for placing the client on seizure
precautions. Reporting decorticate posturing to the health care provider is a
nonpurposeful movement.
The nurse plans to administer diazepam, 4 mg IV push, to a client with severe
anxiety. How many milliliters should the nurse administer? _____ mL (Round to
the nearest tenth.) 10mg/2ml (5mg/ml) (ANS- Rationale:
(1 mL × 4 mg)/5 mg = 0.8 mL
The nurse prepares to insert a nasogastric tube in a client with hyperemesis who is
awake and alert. Which nursing actions are correct? (Select all that apply.)
A.
Place the client in a high Fowler position.
B.
Explain that placement of the tube is painless.
C.
Measure the tube from the tip of the nose to the umbilicus.
D.
Instruct the client to swallow after the tube has passed the pharynx.
E.
Assist the client in extending the neck back so the tube may enter the larynx.
(ANS- A D
Rationale:
(A and D) are the correct steps to follow during nasogastric intubation. Placement
of an NG tube can be uncomfortable and can induce gagging. The tube should be
measured from the tip of the nose to behind the ear and then from behind the ear to
the xiphoid process (C). The neck should only be extended back prior to the tube
passing the pharynx and then the client should be instructed to position the neck
forward (E).
The nurse teaches the use of a gait belt to a caregiver whose spouse has right-sided
weakness and needs assistance with ambulation. The caregiver performs a return
demonstration of the skill. Which observation indicates that the caregiver has
learned how to use the belt?
A.
Standing on the spouse's strong side, the caregiver is ready to hold the gait belt if
any evidence of weakness is observed. B.
Standing on the spouse's weak side, the caregiver provides security by holding the
gait belt from the back. C.
Standing behind the spouse, the caregiver provides balance by holding both sides
of the gait belt. D.
Standing slightly in front and to the right of the spouse, the caregiver guides the
client forward by gently pulling on the gait belt.
(ANS- B
Rationale:
The spouse is most likely to lean toward the weak side and needs extra support on
that side and from the back to prevent falling. Options A, C, and D provide less
security.
The nurse is planning care for a client with an indwelling urinary catheter. Which
nursing action has the highest priority?
A.
Assist the client with daily cleansing.
B.
Tell the client that incontinence happens with aging.
C.
Offer 200 mL of fluid every 2 hours while awake.
D.
Take the client's temperature every 4 hours.
(ANS- D
Rationale:
Indwelling urinary catheters are a major source of infection. Option A is a problem
that may develop from having an indwelling catheter. Option B may or may not be
true for the client. Option C is not affected by an indwelling catheter.
The nurse notes in the client's plan of care altered sleep patterns related to nocturia.
Which nursing actions are important for the nurse to provide? (Select all that
apply.)
A.
Decrease intake of fluids after the evening meal.
B.
Drink a glass of cranberry juice every day.
C.
Drink a glass of warm decaffeinated beverage at bedtime.
D.
Consult the health care provider about a sleeping pill.
E.
Assess the client's usual sleep pattern.
(ANS- A E Rationale:
Nocturia is urination during the night. Option A is helpful to decrease the
production of urine, thus decreasing the need to void at night. Option E gives the
nurse the client's baseline sleep pattern. Option B helps prevent bladder infections.
Option C may promote sleep, but the fluid will contribute to nocturia. Option D
may result in urinary incontinence if the client is sedated and does not awaken to
void.
When performing sterile wound care in the acute care setting, the nurse obtains a
bottle of normal saline from the bedside table that is labeled "opened" and dated 48
hours prior to the current date. Which is the best action for the nurse to take?
A.
Use the normal saline solution once more and then discard.
B.
Obtain a new sterile syringe to draw up the labeled saline solution.
C.
Use the saline solution and then relabel the bottle with the current date.
D.
Discard the saline solution and obtain a new unopened bottle.
(ANS- D
Rationale:
Solutions labeled as opened within 24 hours may be used for clean procedures, but
only newly opened solutions are considered sterile. This solution is not newly
opened and is out of date, so it should be discarded. Options A, B, and C describe
incorrect procedures.
The nurse is concerned the client will develop a nosocomial infection. Which
nursing action is best for the nurse to take when providing care for an incontinent
client?
A.
Maintain standard precautions.
B.
Initiate contact isolation measures.
C.
Insert an indwelling urinary catheter.
D.
Instruct client in the use of adult diapers.
(ANS- A
Rationale:
The best action to decrease the risk of infection in vulnerable clients is hand
washing. Option B is not necessary unless the client has an infection. Option C
increases the risk of infection. Option D does not reduce the risk of infection.
When taking a client's blood pressure, the nurse is unable to distinguish the point at
which the first sound was heard. Which is the best action for the nurse to take?
A.
Deflate the cuff completely and immediately reattempt the reading.
B.
Reinflate the cuff completely and leave it inflated for 90 to 110 seconds before
taking the second reading. C.
Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading.
D.
Document the exact level visualized on the sphygmomanometer where the first
fluctuation was seen. (ANS- C Rationale:
Deflating the cuff for 30 to 60 seconds allows blood flow to return to the extremity
so that an accurate reading can be obtained on that extremity a second time. Option
A could result in a falsely high reading. Option B reduces circulation, causes pain,
and could alter the reading. Option D is not an accurate method of assessing blood
pressure.
A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse
take first?
A.
Tell the client that the blood pressure is high and that the reading needs to be
verified by another nurse. B.
Contact the health care provider to report the reading and obtain a prescription for
an antihypertensive medication. C.
Replace the cuff with a larger one to ensure an ample fit for the client to increase
arm comfort. D.
Compare the current reading with the client's previously documented blood
pressure readings. (ANS- D
Rationale:Comparing this reading with previous readings will provide information
about what is normal for this client; this action should be taken first. Option A
might unnecessarily alarm the client. Option B is premature. Further assessment is
needed to determine if the reading is abnormal for this client. Option C could
falsely decrease the reading and is not the correct procedure for obtaining a blood
pressure reading.
A nurse stops at a motor vehicle collision site to render aid until the emergency
personnel arrive and applies pressure to a groin wound that is bleeding profusely.
Later the client has to have the leg amputated and sues the nurse for malpractice.
Which statement reflects the likely outcome for the nurse?
A.
The Patient's Bill of Rights protects clients from malicious intents, so the nurse
could lose the case. B.
The lawsuit may be settled out of court, but the nurse's license is likely to be
revoked. C.
There will be no judgment against the nurse, whose actions are protected under the
Good Samaritan Act. D.
The client will win because the four elements of negligence (duty, breach,
causation, and damages) can be proved. (ANS- C
Rationale:The Good Samaritan Act protects health care professionals who practice
in good faith and provide reasonable care from malpractice claims, regardless of
the client outcome. Although the Patient's Bill of Rights protects clients, this nurse
is protected by the Good Samaritan Act. The state Board of Nursing has no reason
to revoke a registered nurse's license unless there was evidence that actions taken
in the emergency were not done in good faith or that reasonable care was not
provided. All four elements of malpractice were not shown.
The health care provider diagnoses metastatic cancer and recommends a
gastrostomy for an elderly client in stable condition. The client's adult child is
concerned and states to the nurse, "I don't think my parent 'can handle' the cancer
diagnosis." What information will guide the nurse's response?
A.
The family can provide the consent required in this situation because the older
adult is in no condition to make such decisions. B.
Because the client is mentally incompetent, the adult child has the right to waive
informed consent for the parent. C.
The court will allow the health care provider to make the decision to withhold
informed consent under therapeutic privilege. D.
If informed consent is withheld from a client, health care providers could be found
guilty of negligence. (ANS- D
Rationale:
Health care providers may be found guilty of negligence, specifically assault and
battery, if they carry out a treatment without the client's consent. The client's
condition is stable, so option A is not a valid rationale. Advanced age does not
automatically authorize the son to make all decisions for his mother, and there is
no evidence that the client is mentally incompetent. Although option C may have
been upheld in the past, when paternalistic medical practice was common, today's
courts are unlikely to accept it.
The nurse is obtaining a lie-sit-stand blood pressure reading on a client. Which
action is most important for the nurse to take for this client?
A.
Stay with the client while the client is standing.
B.
Record the findings on the graphic sheet in the chart.
C.
Keep the blood pressure cuff on the same arm.
D.
Record changes in the client's pulse rate.
(ANS- A
Rationale:
Although all these measures are important, option A is most important because it
helps ensure client safety. Option B is necessary but does not have the priority of
option A. Options C and D are important measures to ensure accuracy of the
recording but are of less importance than providing client safety.
A client becomes angry while waiting for a supervised break to smoke a cigarette
outside and states, "I want to go outside now and smoke. It takes forever to get
anything done here!" Which nursing action is best for this client?
A.
Encourage the client to use a nicotine patch.
B.
Reassure the client that it is almost time for another break.
C.
Have the client leave the unit with another staff member.
D.
Review the schedule of outdoor breaks with the client. (ANS- D Rationale:
The best nursing action is to review the schedule of outdoor breaks and provide
concrete information about the schedule. Option A is contraindicated if the client
wants to continue smoking. Option B is insufficient to encourage a trusting
relationship with the client. Option C is preferential for this client only and is
inconsistent with unit rules.
Which serum laboratory value should the nurse monitor carefully for a client who
has a nasogastric (NG) tube to suction for the past week?
A.
White blood cell count
B.
Albumin
C.
Calcium
D.
Sodium (ANS- D Rationale:
Monitoring serum sodium levels for hyponatremia is indicated during prolonged
NG suctioning because of loss of fluids. Changes in levels of option A, B, or C are
not typically associated with prolonged NG suctioning.
A client with frequent urinary tract infections (UTIs) asks the nurse to explain a
friend's advice about drinking a glass of juice daily to prevent future UTIs. Which
response is best for the nurse to provide?
A.
"Orange juice has vitamin C that deters bacterial growth."
B.
"Apple juice is the most useful in acidifying the urine."
C.
"Cranberry juice stops pathogens' adherence to the bladder."
D.
"Grapefruit juice increases absorption of most antibiotics." (ANS- C
Rationale:Cranberry juice maintains urinary tract health by reducing the adherence
of Escherichia coli bacteria to cells within the bladder. Options A, B, and D have
not been shown to be as effective as cranberry juice in preventing UTIs.
The nurse is counting a client's respiratory rate. During a 30-second interval, the
nurse counts six respirations and the client coughs three times. In repeating the
count for a second 30-second interval, the nurse counts eight respirations. Which
respiratory rate will the nurse document?
A.
14
B.
16
C.
17
D.
28
(ANS- B
Rationale:
The most accurate respiratory rate is the second count obtained by the nurse, which
was not interrupted by coughing. Because it was counted for 30 seconds, the rate
should be doubled. Options A, C, and D are inaccurate recordings.
The nurse is teaching an obese client, newly diagnosed with arteriosclerosis, about
reducing the risk of a heart attack or stroke. Which health promotion brochure is
most important for the nurse to provide to this client?
A.
"Monitoring Your Blood Pressure at Home"
B.
"Smoking Cessation as a Lifelong Commitment"
C.
"Decreasing Cholesterol Levels Through Diet"
D.
"Stress Management for a Healthier You" (ANS- C
Rationale:A health promotion brochure about decreasing cholesterol is most
important to provide this client, because the most significant risk factor
contributing to development of arteriosclerosis is excess dietary fat, particularly
saturated fat and cholesterol. Option A does not address the underlying causes of
arteriosclerosis. Options B and D are also important factors for reversing
arteriosclerosis but are not as important as lowering cholesterol.
The nurse finds a client crying behind a locked bathroom door. The client will not
open the door. Which action should the nurse take first?
A.
Instruct an unlicensed assistive personnel (UAP) to stay and keep talking to the
client. B.
Sit quietly in the client's room until the client leaves the bathroom.
C.
Allow the client to cry alone and leave the client in the bathroom.
D.
Talk to the client and attempt to find out why the client is crying. (ANS- D
Rationale:The nurse's first concern should be for the client's safety, so an
immediate assessment of the client's situation is needed. Option A is incorrect; the
nurse should implement the intervention. The nurse may offer to stay nearby after
first assessing the situation more fully. Although option C may be correct, the
nurse should determine if the client's safety is compromised and offer assistance,
even if it is refused.
A client in a long-term care facility reports to the nurse, "I have not had a bowel
movement in 2 days." What is the nurse's first action?
A.
Instruct the caregiver to offer a glass of warm prune juice at mealtimes.
B.
Notify the health care provider and request a prescription for a large-volume
enema.
C.
Assess the client's medical record to determine the client's normal bowel pattern.
D.
Instruct the caregiver to increase the client's fluids to five 8-ounce glasses per day
(ANS- C
Rationale:This client may not routinely have a daily bowel movement, so the nurse
should first assess this client's normal bowel habits before attempting any
intervention. Options A, B, or D may then be implemented, if warranted.
A 65-year-old client who attends an adult daycare program and is wheelchair
mobile has redness in the sacral area. Which instruction is most important for the
nurse to provide?
A.
"Take a vitamin supplement tablet once a day."
B.
"Change positions in the chair frequently"
C.
"Increase daily intake of water or other oral fluids."
D.
"Purchase a newer model wheelchair." (ANS- B
Rationale:The most important teaching is to change positions frequently because
pressure is the most significant factor related to the development of pressure
ulcers. Increased vitamin and fluid intake may also be beneficial and promote
healing and reduce further risk. Option D is an intervention of last resort because
this will be very expensive for the client.
Urinary catheterization is prescribed for a postoperative female client who has
been unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen
in the tubing. Which action will the nurse take next?
A.
Clamp the catheter and recheck it in 60 minutes.
B.
Pull the catheter back 3 inches and redirect upward.
C.
Leave the catheter in place and reattempt with another catheter.
D.
Notify the health care provider of a possible obstruction. (ANS- C
Rationale:It is likely that the first catheter is in the vagina, rather than the bladder.
Leaving the first catheter in place will help locate the meatus when attempting the
second catheterization. The client should have at least 240 mL of urine after 8
hours. Option A does not resolve the problem. Option B will not change the
location of the catheter unless it is completely removed, in which case a new
catheter must be used. There is no evidence of a urinary tract obstruction if the
catheter could be easily inserted.
The mental health nurse plans to discuss a client's depression with the health care
provider in the emergency department. There are two clients sitting across from the
emergency department desk. Which nursing action is best?
A.
Only refer to the client by gender.
B.
Identify the client only by age.
C.
Avoid using the client's name.
D.
Discuss the client another time. (ANS- D
Rationale:The best nursing action is to discuss the client another time.
Confidentiality must be observed at all times, so the nurse should not discuss the
client when the conversation can be overheard by others. Details of the client can
be identified when referring to the client by gender or age, even when not using the
client's name.
The nurse is teaching a client how to perform progressive muscle relaxation
techniques to relieve insomnia. A week later the client reports, "I am still unable to
sleep, despite following the same routine every night." Which action should the
nurse take next?
A.
Instruct the client to add regular exercise as a daily routine.
B.
Determine if the client has been keeping a sleep diary.
C.
Encourage the client to continue the routine until sleep is achieved.
D.
Ask the client to describe the routine he is currently following. (ANS- D
Rationale:The nurse should first evaluate whether the client has been adhering to
the original instructions. A verbal report of the client's routine will provide more
specific information than the client's written diary. The nurse can then determine
which changes need to be made. The routine practiced by the client is clearly
unsuccessful, so encouragement alone is insufficient.
Ten minutes after signing an operative permit for a fractured hip, an older client
states, "The aliens will be coming to get me soon!" and falls asleep. Which action
should the nurse take next?
A.
Make the client comfortable and allow the client to sleep.
B.
Assess the client's neurologic status.
C.
Notify the surgeon about the comment.
D.
Ask the client's family to co-sign the operative permit. (ANS- C
Rationale:This statement may indicate that the client is confused. Informed consent
must be provided by a mentally competent individual, so the nurse should further
assess the client's neurologic status to be sure that the client understands and can
legally provide consent for surgery. Option A does not provide sufficient followup.
If the nurse determines that the client is confused, the surgeon must be notified and
permission obtained from the next of kin.
A nurse is working in an occupational health clinic when an employee walks in and
states, "I was walking outside and I believe I was just struck by lightning." The
client is alert but reports feeling faint. Which assessment will the nurse perform
first?
A.
Pulse characteristics
B. Open airway
C.
Entrance and exit wounds
D.
Cervical spine injury (ANS- A
Rationale:Lightning is a jolt of electrical current and can produce a "natural"
defibrillation, so assessment of the pulse rate and regularity is a priority. Because
the client is talking, he has an open airway so that assessment is not necessary.
Assessing for options C and D should occur after assessing for adequate
circulation.
The nurse who is preparing to give a 14-year-old client a prescribed antipsychotic
medication notes that parental consent has not been obtained. Which action should
the nurse take?
A.
Review the chart for a signed consent for hospitalization.
B.
Get the health care provider's permission to give the medication.
C.
Do not give the medication and document the reason.
D.
Complete an incident report and notify the parents. (ANS- C
Rationale:The nurse should not give the medication and should document the
reason because the client is a minor and needs a guardian's permission to receive
medications. Permission to give medications is not granted by a signed hospital
consent or a health care provider's permission, unless conditions are met to justify
coerced treatment. Option D is not necessary unless the medication had previously
been administered.
A hospitalized client has had difficulty falling asleep for two nights, and is
becoming irritable and restless. Which action by the nurse is best?
A.
Determine the client's usual bedtime routine and include these rituals in the plan of
care as safety allows. B.
Instruct the UAP not to wake the client under any circumstances during the night.
C.
Place a "Do Not Disturb" sign on the door and change assessments from every 4 to
8 hours. D.
Encourage the client to avoid pain medication during the day, which might increase
daytime napping. (ANS- A
Rationale:Including habitual rituals that do not interfere with the client's care or
safety may allow the client to go to sleep faster and increase the quality of care.
Options B, C, and D decrease the client's standard of care and compromise safety.
The nurse is assisting a client to the bathroom. When the client is 5 feet from the
bathroom door, he states, "I feel faint." Before the nurse can get the client to a
chair, the client starts to fall. Which is the priority action for the nurse to take?
A.
Check the client's carotid pulse.
B.
Encourage the client to get to the toilet.
C.
In a loud voice, call for help.
D.
Gently lower the client to the floor. (ANS- D
Rationale:Option D is the most prudent intervention and is the priority nursing
action to prevent injury to the client and the nurse. Lowering the client to the floor
should be done when the client cannot support his own weight. The client should
be placed in a bed or chair only when sufficient help is available to prevent injury.
Option A is important but should be done after the client is in a safe position.
Because the client is not supporting himself, option B is impractical. Option C is
likely to cause chaos on the unit and might alarm the other clients.
A client is laughing at a television program when the evening nurse enters the
room. The client states, "My foot is hurting. I would like a pain pill." How should
the nurse respond?
A.
Ask the client to rate the pain using a 1 to 10 scale.
B.
Encourage the client to wait until bedtime for the pill.
C.
Attend to an acutely ill client's needs first because this client is laughing.
D.
Instruct the client in the use of deep breathing exercises for pain control. (ANS- A
Rationale:Obtaining a subjective estimate of the pain experience by asking the
client to rate his pain helps the nurse determine which pain medication should be
administered and also provides a baseline for evaluating the effectiveness of the
medication. Medicating for pain should not be delayed so that it can be used as a
sleep medication. Option C is judgmental. Option D should be used as an adjunct
to pain medication, not instead of medication.
During a routine assessment, an obese 50-year-old client states, "I feel so unlovable
because of my weight." Which is the best response by the nurse?
A.
Reassure the client that many obese people have concerns about sex.
B.
Remind the client that sexual relationships need not be affected by obesity.
C.
Determine the frequency of sexual intercourse.
D.
Ask the client to talk about specific concerns. (ANS- D
Rationale:Option D provides an opportunity for the client to verbalize concerns
and provides the nurse with more assessment data. Options A and B may not be
related to the current concern, assume that obesity is the problem, and are
communication blocks. Option C may be appropriate after discussing the stated
concerns.
The nurse determines that a postoperative client's respiratory rate has increased
from 18 to 24 breaths/min. Based on this assessment finding, what is the priority
nursing action?
A.
Encourage the client to increase ambulation in the room.
B.
Offer the client a high-carbohydrate snack for energy.
C.
Force fluids to thin the client's pulmonary secretions.
D.
Determine if pain is causing the client's tachypnea. (ANS- D
Rationale:Pain, anxiety, and increasing fluid accumulation in the lungs can cause
tachypnea (increased respiratory rate). Encouraging the client to increase
ambulation when the respiratory rate is rising above normal limits puts the client at
risk for further oxygen desaturation. Option B can increase the client's carbon
metabolism, so an alternative source of energy, such as Pulmocare liquid
supplement, should be offered instead. Option C could increase respiratory
congestion in a client with a poorly functioning cardiopulmonary system, placing
the client at risk of fluid overload.
A nurse is assigned to care for a close friend in the hospital setting. Which action
should the nurse take first when given the assignment?
A.
Notify the friend that all medical information will be kept confidential.
B.
Explain the relationship to the charge nurse and ask for reassignment.
C.
Approach the client and ask if the assignment is uncomfortable.
D.
Accept the assignment but protect the client's confidentiality. (ANS- B
Rationale:Caring for a close friend can violate boundaries for nurses and should be
avoided when possible (B). If the assignment is unavoidable (there are no other
nurses to care for the client) then C, A, and D should be addressed.
The nurse manager of a skilled nursing (chronic care) unit is instructing UAPs on
ways to prevent complications of immobility. Which action should be included in
this instruction?
A.
Perform range-of-motion exercises to prevent contractures.
B.
Decrease the client's fluid intake to prevent diarrhea.
C.
Massage the client's legs to reduce embolism occurrence.
D.
Turn the client from side to back every shift (ANS- A [Show Less]