ALL HESI
FUNDAMENTALS
EXAM SPRING
SERIES QUIZBANK
Hesi Fundamentals 2022 exam. Correctly answered.
An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is
essential to the client's nursing care?
A. Massage any reddened areas for at least five minutes.
B. Encourage active range of motion exercises on extremities.
C. Position the client laterally, prone, and dorsally in sequence.
D. Gently lift the client when moving into a desired position.
✅- To avoid shearing forces when repositioning, the client should be lifted gently across a
surface (D). Reddened areas should not be massaged (A) since this may increase the
damage to already traumatized skin. To control pain and muscle spasms, active range of
motion (B) may be limited on the affected leg. The position described in (C) is
contraindicated for a client with a fractured left hip.
Correct Answer: D
The nurse is administering medications through a nasogastric tube (NGT) which is
connected to suction. After ensuring correct tube placement, what action should the nurse
take next?
A. Clamp the tube for 20 minutes.
B. Flush the tube with water.
C. Administer the medications as prescribed.
D. Crush the tablets and dissolve in sterile water.
✅- The NGT should be flushed before, after and in between each medication administered
(B). Once all medications are administered, the NGT should be clamped for 20 minutes (A).
(C and D) may be implemented only after the tubing has been flushed.
Correct Answer: B
A client who is in hospice care complains of increasing amounts of pain. The healthcare
provider prescribes an analgesic every four hours as needed. Which action should the
nurse implement?
A. Give an around-the-clock schedule for administration of analgesics.
B. Administer analgesic medication as needed when the pain is severe.
C. Provide medication to keep the client sedated and unaware of stimuli.
D. Offer a medication-free period so that the client can do daily activities. ✅- The most
effective management of pain is achieved using an around-the-clock schedule that
provides analgesic medications on a regular basis (A) and in a timely manner. Analgesics
are less effective if pain persists until it is severe, so an analgesic medication should be
administered before the client's pain peaks (B). Providing comfort is a priority for the
client who is dying, but sedation that impairs the client's ability to interact and
experience the time before life ends should be minimized (C). Offering a medication-free
period allows the serum drug level to fall, which is not an effective method to manage
chronic pain (D). Correct Answer: A
When assessing a client with wrist restraints, the nurse observes that the fingers on the
right hand are blue. What action should the nurse implement first? A. Loosen the right
wrist restraint.
B. Apply a pulse oximeter to the right hand.
C. Compare hand color bilaterally.
D. Palpate the right radial pulse.
✅- The priority nursing action is to restore circulation by loosening the restraint (A),
because blue fingers (cyanosis) indicates decreased circulation. (C and D) are also
important nursing interventions, but do not have the priority of (A). Pulse oximetry (B)
measures the saturation of hemoglobin with oxygen and is not indicated in situations
where the cyanosis is related to mechanical compression (the restraints). Correct
Answer: A
The nurse is assessing the nutritional status of several clients. Which client has the greatest
nutritional need for additional intake of protein?
A. A college-age track runner with a sprained ankle.
B. A lactating woman nursing her 3-day-old infant.
C. A school-aged child with Type 2 diabetes.
D. An elderly man being treated for a peptic ulcer.
✅- A lactating woman (B) has the greatest need for additional protein intake. (A, C, and D)
are all conditions that require protein, but do not have the increased metabolic protein
demands of lactation.
Correct Answer: B
A client is in the radiology department at 0900 when the prescription levofloxacin
(Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit
at 1300. What is the best intervention for the nurse to implement?
A. Contact the healthcare provider and complete a medication variance form.
B. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning.
C. Notify the charge nurse and complete an incident report to explain the missed dose.
D. Give the missed dose at 1300 and change the schedule to administer daily at 1300.
✅- To ensure that a therapeutic level of medication is maintained, the nurse should
administer the missed dose as soon as possible, and revise the administration schedule
accordingly to prevent dangerously increasing the level of the medication in the
bloodstream (D). The nurse should document the reason for the late dose, but (A and C) are
not warranted. (B) could result in increased blood levels of the drug.
Correct Answer: D
While instructing a male client's wife in the performance of passive range-of-motion
exercises to his contracted shoulder, the nurse observes that she is holding his arm above
and below the elbow. What nursing action should the nurse implement? A. Acknowledge
that she is supporting the arm correctly.
B. Encourage her to keep the joint covered to maintain warmth.
C. Reinforce the need to grip directly under the joint for better support.
D. Instruct her to grip directly over the joint for better motion.
✅- The wife is performing the passive ROM correctly, therefore the nurse should
acknowledge this fact (A). The joint that is being exercised should be uncovered (B) while
the rest of the body should remain covered for warmth and privacy. (C and D) do not
provide adequate support to the joint while still allowing for joint movement. Correct
Answer: A
What is the most important reason for starting intravenous infusions in the upper
extremities rather than the lower extremities of adults?
A. It is more difficult to find a superficial vein in the feet and ankles.
B. A decreased flow rate could result in the formation of a thrombosis.
C. A cannulated extremity is more difficult to move when the leg or foot is used.
D. Veins are located deep in the feet and ankles, resulting in a more painful procedure. ✅Venous return is usually better in the upper extremities. Cannulation of the veins in the
lower extremities increases the risk of thrombus formation (B) which, if dislodged, could
be life-threatening. Superficial veins are often very easy (A) to find in the feet and legs.
Handling a leg or foot with an IV (C) is probably not any more difficult than handling an
arm or hand. Even if the nurse did believe moving a cannulated leg was more difficult,
this is not the most important reason for using the upper extremities. Pain (D) is not a
consideration.
Correct Answer: B
The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood
pressure with a cuff that is too small, but the blood pressure reading obtained is within the
client's usual range. What action is most important for the nurse to implement? A. Tell the
UAP to use a larger cuff at the next scheduled assessment.
B. Reassess the client's blood pressure using a larger cuff.
C. Have the unit educator review this procedure with the UAPs.
D. Teach the UAP the correct technique for assessing blood pressure.
✅- The most important action is to ensure that an accurate BP reading is obtained. The
nurse should reassess the BP with the correct size cuff (B). Reassessment should not be
postponed (A). Though (C and D) are likely indicated, these actions do not have the priority
of (B).
Correct Answer: B
A client is to receive cimetidine (Tagamet) 300 mg q6h IVPB. The preparation arrives from
the pharmacy diluted in 50 ml of 0.9% NaCl. The nurse plans to administer the IVPB dose
over 20 minutes. For how many ml/hr should the infusion pump be set to deliver the
secondary infusion?
✅- The infusion rate is calculated as a ratio proportion problem, i.e., 50 ml/ 20 min : x ml/
60 min. Multiply extremes and means 50 × 60 /20x 1= 300/20=150
Correct Answer: 150
Twenty minutes after beginning a heat application, the client states that the heating pad no
longer feels warm enough. What is the best response by the nurse?
A. That means you have derived the maximum benefit, and the heat can be removed.
B. Your blood vessels are becoming dilated and removing the heat from the site.
C. We will increase the temperature 5 degrees when the pad no longer feels warm.
D. The body's receptors adapt over time as they are exposed to heat. ✅- (D) describes
thermal adaptation, which occurs 20 to 30 minutes after heat application. (A and B)
provide false information. (C) is not based on a knowledge of physiology and is an unsafe
action that may harm the client.
Correct Answer: D
The nurse is instructing a client with high cholesterol about diet and life style modification.
What comment from the client indicates that the teaching has been effective?
A. If I exercise at least two times weekly for one hour, I will lower my cholesterol.
B. I need to avoid eating proteins, including red meat.
C. I will limit my intake of beef to 4 ounces per week.
D. My blood level of low density lipoproteins needs to increase. ✅- Limiting saturated fat
from animal food sources to no more than 4 ounces per week (C) is an important diet
modification for lowering cholesterol. To be effective in reducing cholesterol, the client
should exercise 30 minutes per day, or at least 4 to 6 times per week (A). Red meat and
all proteins do not need to be eliminated (B) to lower cholesterol, but should be
restricted to lean cuts of red meat and smaller portions (2-ounce servings). The low
density lipoproteins (D) need to decrease rather than increase.
Correct Answer: C
The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest
way to transfer an elderly client with left-sided weakness from the bed to the chair. What
method describes the correct transfer procedure for this client?
A. Place the chair at a right angle to the bed on the client's left side before moving.
B. Assist the client to a standing position, then place the right hand on the armrest.
C. Have the client place the left foot next to the chair and pivot to the left before sitting.
D. Move the chair parallel to the right side of the bed, and stand the client on the right foot.
✅- (D) uses the client's stronger side, the right side, for weight-bearing during the transfer,
and is the safest approach to take. (A, B, and C) are unsafe methods of transfer and include
the use of poor body mechanics by the caregiver.
Correct Answer: D
An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to
administering a soap suds enema. Which instruction should the nurse provide the UAP? A.
Position the client on the right side of the bed in reverse Trendelenburg.
B. Fill the enema container with 1000 ml of warm water and 5 ml of castile soap.
C. Reposition in a Sim's position with the client's weight on the anterior ilium.
D. Raise the side rails on both sides of the bed and elevate the bed to waist level. ✅- The
left sided Sims' position allows the enema solution to follow the anatomical course of the
intestines and allows the best overall results, so the UAP should reposition the client in
the Sims' position, which distributes the client's weight to the anterior ilium (C). (A) is
inaccurate. (B and D) should be implemented once the client is positioned. Correct
Answer: C
A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should
the nurse have for planning care in terms of the client's beliefs? A. Autopsy of the body is
prohibited.
B. Blood transfusions are forbidden.
C. Alcohol use in any form is not allowed.
D. A vegetarian diet must be followed. ✅- Blood transfusions are forbidden (B) in the
Jehovah's Witness religion. Judaism prohibits (A). Buddhism forbids the use of (C) and
drugs. Many of these sects are vegetarian (D), but the direct impact on nursing care is
(B). Correct Answer: B
The nurse observes that a male client has removed the covering from an ice pack applied to
his knee. What action should the nurse take first?
A. Observe the appearance of the skin under the ice pack.
B. Instruct the client regarding the need for the covering.
C. Reapply the covering after filling with fresh ice.
D. Ask the client how long the ice was applied to the skin. ✅- The first action taken by the
nurse should be to assess the skin for any possible thermal injury (A). If no injury to the
skin has occurred, the nurse can take the other actions (B, C, and D) as needed. Correct
Answer: A
The nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at
a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml,
how many drops per minute should the client receive? A. 31 gtt/min. B. 62 gtt/min.
C. 93 gtt/min.
D. 124 gtt/min. ✅- (D) is the correct calculation: Convert lbs to kg: 182/2.2 = 82.73 kg.
Determine the dosage for this client: 5 mcg × 82.73 = 413.65 mcg/min. Determine how
many mcg are contained in 1 ml: 250/50,000 mcg = 200 mcg per ml. The client is to
receive 413.65 mcg/min, and there are 200 mcg/ml; so the client is to receive 2.07ml per
minute. With a drip factor of 60 gtt/ml, then 60 × 2.07 = 124.28 gtt/min (D) OR, using
dimensional analysis: gtt/min = 60 gtt/ml X 250 ml/50 mg X 1 mg/1,000 mcg X 5
mcg/kg/min X 1 kg/2.2 lbs X 182 lbs.
Correct Answer: D
A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a
continuous pump infusion. He reports that he had a bad bout of severe coughing a few
minutes ago, but feels fine now. What action is best for the nurse to take?
A. Record the coughing incident. No further action is required at this time.
B. Stop the feeding, explain to the family why it is being stopped, and notify the healthcare
provider.
C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube.
D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling. ✅Coughing, vomiting, and suctioning can precipitate displacement of the tip of the small
bore feeding tube upward into the esophagus, placing the client at increased risk for
aspiration. Checking the sample of fluid withdrawn from the tube (after clearing the tube
with 30 ml of air) for acidic (stomach) or alkaline (intestine) values is a more sensitive
method for these tubes, and the nurse should assess tube placement in this way prior to
taking any other action (C). (A and B) are not indicated. The auscultating method (D) has
been found to be unreliable for small-bore feeding tubes.
Correct Answer: C
A male client being discharged with a prescription for the bronchodilator theophylline tells
the nurse that he understands he is to take three doses of the medication each day. Since, at
the time of discharge, timed-release capsules are not available, which dosing schedule
should the nurse advise the client to follow? A. 9 a.m., 1 p.m., and 5 p.m.
B. 8 a.m., 4 p.m., and midnight.
C. Before breakfast, before lunch and before dinner.
D. With breakfast, with lunch, and with dinner. ✅- Theophylline should be administered on
a regular around-the-clock schedule (B) to provide the best bronchodilating effect and
reduce the potential for adverse effects. (A, C, and D) do not provide around-the-clock
dosing. Food may alter absorption of the medication (D).
Correct Answer: B
A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what
rate should the nurse set the client's intravenous infusion pump? A. 13 ml/hour. B. 63
ml/hour.
C. 80 ml/hour.
D. 125 ml/hour. ✅- (B) is the correct calculation: To calculate this problem correctly,
remember that the dose of KCl is not used in the calculation. 250 ml/4 hours = 63
ml/hour. Correct Answer: B
A.
B.
C.
D.
An obese male client discusses with the nurse his plans to begin a long-term weight loss
regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise
program 3 to 4 times a week and to take stress management classes. After praising the
client for his decision, which instruction is most important for the nurse to provide?
Be sure to have a complete physical examination before beginning your planned exercise
program.
Be careful that the exercise program doesn't simply add to your stress level, making you
want to eat more.
Increased exercise helps to reduce stress, so you may not need to spend money on a stress
management class.
Make sure to monitor your weight loss regularly to provide a sense of accomplishment and
motivation. ✅- The most important teaching is (A), so that the client will not begin a
dangerous level of exercise when he is not sufficiently fit. This might result in chest pain, a
heart attack, or stroke. (B, C, and D) are important instructions, but are of less priority than
(A).
Correct Answer: A
The nurse is teaching a client proper use of an inhaler. When should the client administer
the inhaler-delivered medication to demonstrate correct use of the inhaler? A.
Immediately after exhalation.
B. During the inhalation.
C. At the end of three inhalations.
D. Immediately after inhalation. ✅- The client should be instructed to deliver the
medication during the last part of inhalation (B). After the medication is delivered, the
client should remove the mouthpiece, keeping his/her lips closed and breath held for
several seconds to allow for distribution of the medication. The client should not deliver
the dose as stated in (A or D), and should deliver no more than two inhalations at a time
(C).
Correct Answer: B
The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO.
Zaroxolyn is available in 5 mg tablets. How much should the nurse plan to administer? A.
½ tablet.
B. 1 tablet.
C. 1½ tablets.
D. 2 tablets. ✅- (C) is the correct calculation: D/H × Q = 7.5/5 × 1 tablet = 1½ tablets.
Correct Answer: C
The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix 20
mg/2 ml. How many milliliters should the nurse administer? A. 1 ml.
B. 1.5 ml.
C. 1.75 ml.
D. 2 ml. ✅- (B) is the correct calculation: Dosage on hand/amount on hand = Dosage
desired/x amount. 20 mg : 2 ml = 15 mg : x . 20x = 30. x = 30/20; = 1½ or 1.5 ml. Correct
Answer: B
Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5½ hours. How
much heparin has the client received? A. 11,000 units. B. 13,000 units.
C. 15,000 units.
D. 17,000 units. ✅- (A) is the correct calculation: 20,000 units/500 ml = 40 units (the
amount of units in one ml of fluid). 40 units/ml x 50 ml/hr = 2,000 units/hour (1,000
units in 1/2 hour). 5.5 x 2,000 = 11,000 (A). OR, multiply 5 x 2,000 and add the 1/2 hour
amount of 1,000 to reach the same conclusion = 11,000 units.
Correct Answer: A
The healthcare provider prescribes morphine sulfate 4mg IM STAT. Morphine comes in 8
mg per ml. How many ml should the nurse administer?
A. 0.5 ml.
B. 1 ml.
C. 1.5 ml.
D. 2 ml. ✅- Using ratio and proportion:
8mg: 1ml :: 4mg:Xml
8X=4
X=0.5
Correct Answer: A
The nurse prepares a 1,000 ml IV of 5% dextrose and water to be infused over 8 hours. The
infusion set delivers 10 drops per milliliter. The nurse should regulate the IV to administer
approximately how many drops per minute?
A. 80
B. 8
C. 21
D. 25 ✅- The accepted formula for figuring drops per minute is: amount to be infused in
one hour × drop factor/time for infusion (min)= drops per minute. Using this formula:
1,000/8 hours = 125 ml/ hour 125 × 10 (drip factor) = 1,250 drops in one hour. 1,250/
60 (number of minutes in one hour) = 20.8 or 21 gtt/min (C).
Correct Answer: C
Which action is most important for the nurse to implement when donning sterile gloves? A.
Maintain thumb at a ninety degree angle.
B. Hold hands with fingers down while gloving.
C. Keep gloved hands above the elbows.
D. Put the glove on the dominant hand first. ✅- Gloved hands held below waist level are
considered unsterile (C). (A and B) are not essential to maintaining asepsis. While it may
be helpful to put the glove on the dominant hand first, it is not necessary to ensure
asepsis (D). Correct Answer: C
A client's infusion of normal saline infiltrated earlier today, and approximately 500 ml of
saline infused into the subcutaneous tissue. The client is now complaining of excruciating
arm pain and demanding "stronger pain medications." What initial action is most important
for the nurse to take?
A. Ask about any past history of drug abuse or addiction.
B. Measure the pulse volume and capillary refill distal to the infiltration.
C. Compress the infiltrated tissue to measure the degree of edema.
D. Evaluate the extent of ecchymosis over the forearm area. ✅- Pain and diminished pulse
volume (B) are signs of compartment syndrome, which can progress to complete loss of
the peripheral pulse in the extremity. Compartment syndrome occurs when external
pressure (usually from a cast), or internal pressure (usually from subcutaneous infused
fluid), exceeds capillary perfusion pressure resulting in decreased blood flow to the
extremity. (A) should not be pursued until physical causes of the pain are ruled out. (C) is
of less priority than determining the effects of the edema on circulation and nerve
function. Further assessment of the client's ecchymosis can be delayed until the signs of
edema and compression that suggest compartment syndrome have been examined (D).
Correct Answer: B
An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is
receiving bolus enteral feedings though a gastrostomy tube. What is the best client position
for administration of the bolus tube feedings? A. Prone.
B. Fowler's.
C. Sims'.
D. Supine. ✅- The client should be positioned in a semi-sitting (Fowler's) (B) position
during feeding to decrease the occurrence of aspiration. A gastrostomy tube, known as a
PEG tube, due to placement by a percutaneous endoscopic gastrostomy procedure, is
inserted directly into the stomach through an incision in the abdomen for long-term
administration of nutrition and hydration in the debilitated client. In (A and/or C), the
client is placed on the abdomen, an unsafe position for feeding. Placing the client in (D)
increases the risk of aspiration.
Correct Answer: B
A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due to a
fracture resulting from a fall. In reviewing hip precautions with the client, which instruction
should the nurse include in this client's teaching plan?
A. In 8 weeks you will be able to bend at the waist to reach items on the floor.
B. Place a pillow between your knees while lying in bed to prevent hip dislocation.
C. It is safe to use a walker to get out of bed, but you need assistance when walking.
D. Take pain medication 30 minutes after your physical therapy sessions. ✅- The client's
affected hip joint following a hemiarthroplasty (partial hip replacement) is at risk of
dislocation for 6 months to a year following the procedure. Hip precautions to prevent
dislocation include placing a pillow between the knees to maintain abduction of the hips
(B). Clients should be instructed to avoid bending at the waist (A), to seek assistance for
both standing and walking until they are stable on a walker or cane (C), and to take pain
medication 20 to 30 minutes prior to physical therapy sessions, rather than waiting until
the pain level is high after their therapy.
Correct Answer: B
A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while
ambulating. Based on these findings, which intervention should the nurse implement first?
A. Assist the ambulating client back to the bed.
B. Encourage the client to ambulate to resolve pneumonia.
C. Obtain a prescription for portable oxygen while ambulating.
D. Move the oximetry probe from the finger to the earlobe. ✅- An oxygen saturation below
90% indicates inadequate oxygenation. First, the client should be assisted to return to
bed (A) to minimize oxygen demands. Ambulation increases aeration of the lungs to
prevent pooling of respiratory secretions, but the client's activity at this time is depleting
oxygen saturation of the blood, so (B) is contraindicated. Increased activity increases
respiratory effort, and oxygen may be necessary to continue ambulation (C), but first the
client should return to bed to rest. Oxygen saturation levels at different sites should be
evaluated after the client returns to bed (D).
Correct Answer: A
A client with chronic renal failure selects a scrambled egg for his breakfast. What action
should the nurse take?
A. Commend the client for selecting a high biologic value protein.
B. Remind the client that protein in the diet should be avoided.
C. Suggest that the client also select orange juice, to promote absorption.
D. Encourage the client to attend classes on dietary management of CRF. ✅- Foods such as
eggs and milk (A) are high biologic proteins which are allowed because they are
complete proteins and supply the essential amino acids that are necessary for growth
and cell repair. Although a low-protein diet is followed (B), some protein is essential.
Orange juice is rich in potassium, and should not be encouraged (C). The client has made
a good diet choice, so (D) is not necessary.
Correct Answer: A
A client who is 5' 5" tall and weighs 200 pounds is scheduled for surgery the next day. What
question is most important for the nurse to include during the preoperative assessment? A.
What is your daily calorie consumption?
B. What vitamin and mineral supplements do you take?
C. Do you feel that you are overweight?
D. Will a clear liquid diet be okay after surgery? ✅- Vitamin and mineral supplements (B)
may impact medications used during the operative period. (A and C) are appropriate
questions for long-term dietary counseling. The nature of the surgery and anesthesia will
determine the need for a clear liquid diet (D), rather than the client's preference. Correct
Answer: B
During the initial morning assessment, a male client denies dysuria but reports that his
urine appears dark amber. Which intervention should the nurse implement? A. Provide
additional coffee on the client's breakfast tray.
B. Exchange the client's grape juice for cranberry juice.
C. Bring the client additional fruit at mid-morning.
D. Encourage additional oral intake of juices and water. ✅- Dark amber urine is
characteristic of fluid volume deficit, and the client should be encouraged to increase
fluid intake (D). Caffeine, however, is a diuretic (A), and may worsen the fluid volume
deficit. Any type of juice will be beneficial (B), since the client is not dysuric, a sign of an
urinary tract infection. The client needs to restore fluid volume more than solid foods
(C). Correct Answer: D
Which intervention is most important for the nurse to implement for a male client who is
experiencing urinary retention? A. Apply a condom catheter.
B. Apply a skin protectant.
C. Encourage increased fluid intake.
D. Assess for bladder distention. ✅- Urinary retention is the inability to void all urine
collected in the bladder, which leads to uncomfortable bladder distention (D). (A and B)
are useful actions to protect the skin of a client with urinary incontinence. (C) may
worsen the bladder distention.
Correct Answer: D
A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood
cells) as rapidly as possible. Which intervention is most important for the nurse to
implement?
A. Obtain the pre-transfusion hemoglobin level.
B. Prime the tubing and prepare a blood pump set-up.
C. Monitor vital signs q15 minutes for the first hour.
D. Ensure the accuracy of the blood type match. ✅- All interventions should be
implemented prior to administering blood, but (D) has the highest priority. Any time
blood is administered, the nurse should ensure the accuracy of the blood type match in
order to prevent a possible hemolytic reaction.
Correct Answer: D
Which snack food is best for the nurse to provide a client with myasthenia gravis who is at
risk for altered nutritional status? A. Chocolate pudding.
B. Graham crackers.
C. Sugar free gelatin.
D. Apple slices. ✅- The client with myasthenia gravis is at high risk for altered nutrition
because of fatigue and muscle weakness resulting in dysphagia. Snacks that are
semisolid, such as pudding (A) are easy to swallow and require minimal chewing effort,
and provide calories and protein. (C) does not provide any nutritional value. (B and D)
require energy to chew and are more difficult to swallow than pudding.
Correct Answer: A
The nurse is evaluating client learning about a low-sodium diet. Selection of which meal
would indicate to the nurse that this client understands the dietary restrictions? A.
Tossed salad, low-sodium dressing, bacon and tomato sandwich.
B. New England clam chowder, no-salt crackers, fresh fruit salad.
C. Skim milk, turkey salad, roll, and vanilla ice cream.
D. Macaroni and cheese, diet Coke, a slice of cherry pie. ✅- Skim milk, turkey, bread, and
ice cream (C), while containing some sodium, are considered low-sodium foods. Bacon
(A), canned soups (B), especially those with seafood, hard cheeses, macaroni, and most
diet drinks (D) are very high in sodium.
Correct Answer: C
Which nutritional assessment data should the nurse collect to best reflect total muscle
mass in an adolescent?
A. Height in inches or centimeters.
B. Weight in kilograms or pounds.
C. Triceps skin fold thickness.
D. Upper arm circumference. ✅- Upper arm circumference (D) is an indirect measure of
muscle mass. (A and B) do not distinguish between fat (adipose) and muscularity. (C) is a
measure of body fat. Correct Answer: D
An elderly resident of a long-term care facility is no longer able to perform self-care and is
becoming progressively weaker. The resident previously requested that no resuscitative
efforts be performed, and the family requests hospice care. What action should the nurse
implement first?
A. Reaffirm the client's desire for no resuscitative efforts.
B. Transfer the client to a hospice inpatient facility.
C. Prepare the family for the client's impending death.
D. Notify the healthcare provider of the family's request. ✅- The nurse should first
communicate with the healthcare provider (D). Hospice care is provided for clients with
a limited life expectancy, which must be identified by the healthcare provider. (A) is not
necessary at this time. Once the healthcare provider supports the transfer to hospice
care, the nurse can collaborate with the hospice staff and healthcare provider to
determine when (B and C) should be implemented.
Correct Answer: D
After completing an assessment and determining that a client has a problem, which action
should the nurse perform next?
A. Determine the etiology of the problem.
B. Prioritize nursing care interventions.
C. Plan appropriate interventions.
D. Collaborate with the client to set goals. ✅- Before planning care, the nurse should
determine the etiology, or cause, of the problem (A), because this will help determine (B,
C, and D).
Correct Answer: A
An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse is
at greatest risk for a malpractice judgment?
A. A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes.
B. The nurse assigned to care for the client who was at lunch at the time of the fall.
C. The nurse who transferred the client to the chair when the fall occurred.
D. The charge nurse who completed rounds 30 minutes before the fall occurred. ✅- The
four elements of malpractice are: breach of duty owed, failure to adhere to the
recognized standard of care, direct causation of injury, and evidence of actual injury. The
hip fracture is the actual injury and the standard of care was "frequent monitoring." (C)
implies that duty was owed and the injury occurred while the nurse was in charge of the
client's care. There is no evidence of negligence in (A, B, and D).
Correct Answer: C
A postoperative client will need to perform daily dressing changes after discharge. Which
outcome statement best demonstrates the client's readiness to manage his wound care
after discharge? The client
A. asks relevant questions regarding the dressing change.
B. states he will be able to complete the wound care regimen.
C. demonstrates the wound care procedure correctly.
D. has all the necessary supplies for wound care. ✅- A return demonstration of a
procedure (C) provides an objective assessment of the client's ability to perform a task,
while (A and B) are subjective measures. (D) is important, but is less of a priority prior to
discharge than the nurse's assessment of the client's ability to complete the wound care.
Correct Answer: C
When evaluating a client's plan of care, the nurse determines that a desired outcome was
not achieved. Which action will the nurse implement first? A. Establish a new nursing
diagnosis.
B. Note which actions were not implemented.
C. Add additional nursing orders to the plan.
D. Collaborate with the healthcare provider to make changes. ✅- First, the nurse reviews
which actions in the original plan were not implemented (B) in order to determine why
the original plan did not produce the desired outcome. Appropriate revisions can then be
made, which may include revising the expected outcome, or identifying a new nursing
diagnosis (A). (C) may be needed if the nursing actions were unsuccessful, or were
unable to be implemented. (D) other members of the healthcare team may be necessary
to collaborate changes once the nurse determines why the original plan did not produce
the desired outcome.
Correct Answer: B
The healthcare provider prescribes 1,000 ml of Ringer's Lactate with 30 Units of Pitocin to
run in over 4 hours for a client who has just delivered a 10 pound infant by cesarean
section. The tubing has been changed to a 20 gtt/ml administration set. The nurse plans to
set the flow rate at how many gtt/min? A. 42 gtt/min. B. 83 gtt/min.
C. 125 gtt/min.
D. 250 gtt/min. ✅- gtt/min = 20gtts/ml X 1000 ml/4hrs X 1 hr/60 min
Correct Answer: B
Seconal 0.1 gram PRN at bedtime is prescribed to a client for rest. The scored tablets are
labeled grain 1.5 per tablet. How many tablets should the nurse plan to administer?
A. 0.5 tablet.
B. 1 tablet.
C. 1.5 tablets.
D. 2 tablets. ✅- 15 gr=1 Gm. Converting the prescribed dose of 0.1 grams to grains requires
multiplying 0.1 × 15 = 1.5 grains. The tablets come in 1.5 grains, so the nurse should plan
to administer 1 tablet (B).
Correct Answer: B
Which assessment data would provide the most accurate determination of proper
placement of a nasogastric tube?
A. Aspirating gastric contents to assure a pH value of 4 or less.
B. Hearing air pass in the stomach after injecting air into the tubing.
C. Examining a chest x-ray obtained after the tubing was inserted.
D. Checking the remaining length of tubing to ensure that the correct length was inserted.
✅- Both (A and B) are methods used to determine proper placement of the NG tubing.
However, the best indicator that the tubing is properly placed is (C). (D) is not an indicator
of proper placement.
Correct Answer: C
The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via
a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN
solution has run out and the next TPN solution is not available. What immediate action
should the nurse take?
A. Infuse normal saline at a keep vein open rate.
B. Discontinue the IV and flush the port with heparin.
C. Infuse 10 percent dextrose and water at 54 ml/hr.
D. Obtain a stat blood glucose level and notify the healthcare provider. ✅- TPN is
discontinued gradually to allow the client to adjust to decreased levels of glucose.
Administering 10% dextrose in water at the prescribed rate (C) will keep the client from
experiencing hypoglycemia until the next TPN solution is available. The client could
experience a hypoglycemic reaction if the current level of glucose (A) is not maintained
or if the TPN is discontinued abruptly (B). There is no reason to obtain a stat blood
glucose level (D) and the healthcare provider cannot do anything about this situation.
Correct Answer: C
When assisting an 82-year-old client to ambulate, it is important for the nurse to realize
that the center of gravity for an elderly person is the A. Arms.
B. Upper torso.
C. Head.
D. Feet. ✅- The center of gravity for adults is the hips. However, as the person grows older,
a stooped posture is common because of the changes from osteoporosis and normal
bone degeneration, and the knees, hips, and elbows flex. This stooped posture results in
the upper torso (B) becoming the center of gravity for older persons. Although (A) is a
part, or an extension of the upper torso, this is not the best and most complete answer.
Correct Answer: B
In developing a plan of care for a client with dementia, the nurse should remember that
confusion in the elderly
A. is to be expected, and progresses with age.
B. often follows relocation to new surroundings.
C. is a result of irreversible brain pathology.
D. can be prevented with adequate sleep. ✅- Relocation (B) often results in confusion
among elderly clients--moving is stressful for anyone. (A) is a stereotypical judgment.
Stress in the elderly often manifests itself as confusion, so (C) is wrong. Adequate sleep is
not a prevention (D) for confusion.
Correct Answer: B
An elderly male client who suffered a cerebral vascular accident is receiving tube feedings
via a gastrostomy tube. The nurse knows that the best position for this client during
administration of the feedings is A. prone.
B. Fowler's.
C. Sims'.
D. supine. ✅- The client should be positioned in a semi-sitting or Fowler's (B) position
during feeding, in order to decrease the chance of aspiration. A gastrostomy tube, often
referred to as a PEG tube, is inserted directly into the stomach through an incision in the
abdomen and is used when long-term tube feedings are needed. In (A and/or C)
positions, the client would be lying on his abdomen and on the tubing. In (D), the client
would be lying flat on his back which would increase the chance of aspiration.
Correct Answer: B
The nurse notices that the mother a 9-year-old Vietnamese child always looks at the floor
when she talks to the nurse. What action should the nurse take? A. Talk directly to the
child instead of the mother.
B. Continue asking the mother questions about the child.
C. Ask another nurse to interview the mother now.
D. Tell the mother politely to look at you when answering. ✅- Eye contact is a
culturallyinfluenced form of non-verbal communication. In some non-Western cultures,
such as the Vietnamese culture, a client or family member may avoid eye contact as a
form of respect, so the nurse should continue to ask the mother questions about the child
(B). (A, C, and D) are not indicated. Correct Answer: B
When conducting an admission assessment, the nurse should ask the client about the use of
complimentary healing practices. Which statement is accurate regarding the use of these
practices?
A. Complimentary healing practices interfere with the efficacy of the medical model of
treatment.
B. Conventional medications are likely to interact with folk remedies and cause adverse
effects.
C. Many complimentary healing practices can be used in conjunction with conventional
practices.
D. Conventional medical practices will ultimately replace the use of complimentary healing
practices. ✅- Conventional approaches to health care can be depersonalizing and often fail
to take into consideration all aspects of an individual, including body, mind, and spirit.
Often complimentary healing practices can be used in conjunction with conventional
medical practices (C), rather than interfering (A) with conventional practices, causing
adverse effects (B), or replacing conventional medical care (D).
Correct Answer: C
A young mother of three children complains of increased anxiety during her annual
physical exam. What information should the nurse obtain first? A. Sexual activity
patterns.
B. Nutritional history.
C. Leisure activities.
D. Financial stressors. ✅- Caffeine, sugars, and alcohol can lead to increased levels of
anxiety, so a nutritional history (C) should be obtained first so that health teaching can
be initiated if indicated. (A and C) can be used for stress management. Though (D) can be
a source of anxiety, a nutritional history should be obtained first.
Correct Answer: B
Three days following surgery, a male client observes his colostomy for the first time. He
becomes quite upset and tells the nurse that it is much bigger than he expected. What is the
best response by the nurse?
A. Reassure the client that he will become accustomed to the stoma appearance in time.
B. Instruct the client that the stoma will become smaller when the initial swelling
diminishes.
C. Offer to contact a member of the local ostomy support group to help him with his
concerns.
D. Encourage the client to handle the stoma equipment to gain confidence with the
procedure. ✅- Postoperative swelling causes enlargement of the stoma. The nurse can
teach the client that the stoma will become smaller when the swelling is diminished (B).
This will help reduce the client's anxiety and promote acceptance of the colostomy. (A)
does not provide helpful teaching or support. (C) is a useful action, and may be taken
after the nurse provides pertinent teaching. The client is not yet demonstrating
readiness to learn colostomy care (D).
Correct Answer: B
At the time of the first dressing change, the client refuses to look at her mastectomy
incision. The nurse tells the client that the incision is healing well, but the client refuses to
talk about it. What would be an appropriate response to this client's silence?
A. It is normal to feel angry and depressed, but the sooner you deal with this surgery, the
better you will feel.
B. Looking at your incision can be frightening, but facing this fear is a necessary part of your
recovery.
C. It is OK if you don't want to talk about your surgery. I will be available when you are ready.
D. I will ask a woman who has had a mastectomy to come by and share her experiences with
you. ✅- (C) displays sensitivity and understanding without judging the client. (A) is
judgmental in that it is telling the client how she feels and is also insensitive. (B) would give
the client a chance to talk, but is also demanding and demeaning. (D) displays a positive
action, but, because the nurse's personal support is not offered, this response could be
interpreted as dismissing the client and avoiding the problem.
Correct Answer: C
The nurse witnesses the signature of a client who has signed an informed consent. Which
statement best explains this nursing responsibility? A. The client voluntarily signed the
form.
B. The client fully understands the procedure.
C. The client agrees with the procedure to be done.
D. The client authorizes continued treatment. ✅- The nurse signs the consent form to
witness that the client voluntarily signs the consent (A), that the client's signature is
authentic, and that the client is otherwise competent to give consent. It is the healthcare
provider's responsibility to ensure the client fully understands the procedure (B). The
nurse's signature does not indicate (C or D).
Correct Answer: A
The nurse assigns a UAP to obtain vital signs from a very anxious client. What instructions
should the nurse give the UAP?
A. Remain calm with the client and record abnormal results in the chart.
B. Notify the medication nurse immediately if the pulse or blood pressure is low.
C. Report the results of the vital signs to the nurse.
D. Reassure the client that the vital signs are normal. ✅- Interpretation of vital signs is the
responsibility of the nurse, so the UAP should report vital sign measurements to the
nurse (C). (A, B, and D) require the UAP to interpret the vital signs, which is beyond the
scope of the UAP's authority.
Correct Answer: C
An adult male client with a history of hypertension tells the nurse that he is tired of taking
antihypertensive medications and is going to try spiritual meditation instead. What should
be the nurse's first response?
A. It is important that you continue your medication while learning to meditate.
B. Spiritual meditation requires a time commitment of 15 to 20 minutes daily.
C. Obtain your healthcare provider's permission before starting meditation.
D. Complementary therapy and western medicine can be effective for you. ✅- The
prolonged practice of meditation may lead to a reduced need for antihypertensive
medications. However, the medications must be continued (A) while the physiologic
response to meditation is monitored. (B) is not as important as continuing the
medication. The healthcare provider should be informed, but permission is not required
to meditate (C). Although it is true that this complimentary therapy might be effective
(D), it is essential that the client continue with antihypertensive medications until the
effect of meditation can be measured.
Correct Answer: A
Examination of a client complaining of itching on his right arm reveals a rash made up of
multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the
nurse record this finding?
A. Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm.
B. Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter.
C. Several areas of red, papular lesions from pinpoint to 0.5 cm in size.
D. Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter. ✅Macules are localized flat skin discolorations less than 1 cm in diameter. However, when
recording such a finding the nurse should describe the appearance (B) rather than
simply naming the condition. (A) identifies vesicles -- fluid filled blisters -- an incorrect
description given the symptoms listed. (C) identifies papules -- solid elevated lesions,
again not correctly identifying the symptoms. (D) identifies petechiae -- pinpoint red to
purple skin discolorations that do not itch, again an incorrect identification.
Correct Answer: B
The nurse is completing a mental assessment for a client who is demonstrating slow
thought processes, personality changes, and emotional lability. Which area of the brain
controls these neuro-cognitive functions? A. Thalamus.
B. Hypothalamus.
C. Frontal lobe.
D. Parietal lobe. ✅- The frontal lobe (C) of the cerebrum controls higher mental activities,
such as memory, intellect, language, emotions, and personality. (A) is an afferent relay
center in the brain that directs impulses to the cerebral cortex. (B) regulates body
temperature, appetite, maintains a wakeful state, and links higher centers with the
autonomic nervous and endocrine systems, such as the pituitary. (D) is the location of
sensory and motor functions.
Correct Answer: C
A male client tells the nurse that he does not know where he is or what year it is. What data
should the nurse document that is most accurate? A. demonstrates loss of remote memory.
B. exhibits expressive dysphasia.
C. has a diminished attention span.
D. is disoriented to place and time. ✅- The client is exhibiting disorientation (D). (A) refers
to memory of the distant past. The client is able to express himself without difficulty (B),
and does not demonstrate a diminished attention span (C).
Correct Answer: D
An IV infusion terbutaline sulfate 5 mg in 500 ml of D5W, is infusing at a rate of 30 mcg/min
prescribed for a client in premature labor. How many ml/hr should the nurse set the
infusion pump?
A. 30
B. 60
C. 120
D. 180 ✅- (D) is correct calculation: 180 ml/hr = 500 ml/5 mg × 1mg/1000 mcg × 30
mcg/min × 60 min/hr.
Correct Answer: D
An African-American grandmother tells the nurse that her 4-year-old grandson is suffering
with "miseries." Based on this statement, which focused assessment should the nurse
conduct?
A. Inquire about the source and type of pain.
B. Examine the nose for congestion and discharge.
C. Take vital signs for temperature elevation.
D. Explore the abdominal area for distension. ✅- Different cultural groups often have their
own terms for health conditions. African-American clients may refer to pain as "the
miseries. " Based on understanding this term, the nurse should conduct a focused
assessment on the source and type of pain (A). (B, C, and D) are important, but do not
focus on "miseries" (pain).
Correct Answer: A
The nurse notices that the Hispanic parents of a toddler who returns from surgery offer the
child only the broth that comes on the clear liquid tray. Other liquids, including gelatin,
popsicles, and juices, remain untouched. What explanation is most appropriate for this
behavior?
A. The belief is held that the "evil eye" enters the child if anything cold is ingested.
B. After surgery the child probably has refused all foods except broth.
C. Eating broth strengthens the child's innate energy called "chi."
D. Hot remedies restore balance after surgery, which is considered a "cold" condition. ✅Common parental practices and health beliefs among Hispanic, Chinese, Filipino, and
Arab cultures classify diseases, areas of the body, and illnesses as "hot" or "cold" and
must be balanced to maintain health and prevent illness. The perception that surgery is a
"cold" condition implies that only "hot" remedies, such as soup, should be used to restore
the healthy balance within the body, so (D) is the correct interpretation. (A, B, and C) are
not correct interpretations of the noted behavior. "Chi" is a Chinese belief that an innate
energy enters and leaves the body via certain locations and pathways and maintains
health. The "evil eye," or "mal ojo," is believed by many cultures to be related to the
balance of health and illness but is unrelated to dietary practice.
Correct Answer: D
A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the
infusion site. The nurse observes erythema, swelling, and a red streak along the vessel
above the IV access site. Which action should the nurse take at this time? A. Administer the
medication more rapidly using the same IV site.
B. Initiate an alternate site for the IV infusion of the medication.
C. Notify the healthcare provider before administering the next dose.
D. Give the client a PRN dose of aspirin while the medication infuses. ✅- A cephalosporin
antibiotic that is administered IV may cause vessel irritation. Rotating the infusion site
minimizes the risk of thrombophlebitis, so an alternate infusion site should be initiated
(B) before administering the next dose. Rapid administration (A) of intravenous
cephalosporins can potentiate vessel irritation and increase the risk of thrombophlebitis.
(C) is not necessary to initiate an alternative IV site. Although aspirin has
antiinflammatory actions, (D) is not indicated.
Correct Answer: B
The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for
fifteen seconds, large amounts of thick yellow secretions return. What action should the
nurse implement next?
A. Encourage the client to cough to help loosen secretions.
B. Advise the client to increase the intake of oral fluids.
C. Rotate the suction catheter to obtain any remaining secretions.
D. Re-oxygenate the client before attempting to suction again. ✅- Suctioning should not be
continued for longer than ten to fifteen seconds, since the client's oxygenation is
compromised during this time (D). (A, B, and C) may be performed after the client is
reoxygenated and additional suctioning is performed.
Correct Answer: D
A female client with a nasogastric tube attached to low suction states that she is nauseated.
The nurse assesses that there has been no drainage through the nasogastric tube in the last
two hours. What action should the nurse take first?
A. Irrigate the nasogastric tube with sterile normal saline.
B. Reposition the client on her side.
C. Advance the nasogastric tube an additional five centimeters.
D. Administer an intravenous antiemetic prescribed for PRN use. ✅- The immediate
priority is to determine if the tube is functioning correctly, which would then relieve the
client's nausea. The least invasive intervention, (B), should be attempted first, followed
by (A and C), unless either of these interventions is contraindicated. If these measures
are unsuccessful, the client may require an antiemetic (D).
Correct Answer: B
During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis
using a goniometer. Which finding should the nurse expect to measure? A. Adequate
venous blood flow to the lower extremities.
B. Estimated amount of body fat by an underarm skinfold.
C. Degree of flexion and extension of the client's knee joint.
D. Change in the circumference of the joint in centimeters. ✅- The goniometer is a
twopiece ruler that is jointed in the middle with a protractor-type measuring device that
is placed over a joint as the individual extends or flexes the joint to measure the degrees
of flexion and extension on the protractor (C). A doppler is used to measure blood flow
(A). Calipers are used to measure body fat (B). A tape measure is used to measure
circumference of body parts (D).
Correct Answer: C
During a physical assessment, a female client begins to cry. Which action is best for the
nurse to take?
A. Request another nurse to complete the physical assessment.
B. Ask the client to stop crying and tell the nurse what is wrong.
C. Acknowledge the client's distress and tell her it is all right to cry.
D. Leave the room so that the client can be alone to cry in private. ✅- Acknowledging the
client's distress and giving the client the opportunity to verbalize her distress (C) is a
supportive response. (A, B, and D) are not supportive and do not facilitate the client's
expression of feelings.
Correct Answer: C
A female client asks the nurse to find someone who can translate into her native language
her concerns about a treatment. Which action should the nurse take?
A. Explain that anyone who speaks her language can answer her questions.
B. Provide a translator only in an emergency situation.
C. Ask a family member or friend of the client to translate.
D. Request and document the name of the certified translator. ✅- A certified translator
should be requested to ensure the exchanged information is reliable and unaltered. To
adhere to legal requirements in some states, the name of the translator should be
documented (D). Client information that is translated is private and protected under
HIPAA rules, so (A) is not the best action. Although an emergency situation may require
extenuating circumstances (B), a translator should be provided in most situations.
Family members may skew information and not translate the exact information, so (C) is
not preferred.
Correct Answer: D
The nurse is teaching a client with numerous allergies how to avoid allergens. Which
instruction should be included in this teaching plan?
A. Avoid any types of sprays, powders, and perfumes.
B. Wearing a mask while cleaning will not help to avoid allergens.
C. Purchase any type of clothing, but be sure it is washed before wearing it.
D. Pollen count is related to hay fever, not to allergens. ✅- The client with allergies should
be instructed to reduce any exposure to pollen, dust, fumes, odors, sprays, powders, and
perfumes (A). The client should be encouraged to wear a mask when working around
dust or pollen (B). Clients with allergies should avoid any clothing that causes itching;
washing clothes will not prevent an allergic reaction to some fabrics (C). Pollen count is
related to allergens (D), and the client should be instructed to stay indoors when the
pollen count is high.
Correct Answer: A
Evolve HESI Fundamentals 2021/2022
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. ✅- Answer: C
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
(C). The client should have at least 240 mL of urine after 8 hours. (A) does not resolve the
problem. (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 (D).
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" ✅- Answer: C
A health promotion brochure about decreasing cholesterol (C) 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. (A) does not
address the underlying causes of arteriosclerosis. (B and D) are also important factors for
reversing arteriosclerosis but are not as important as lowering cholesterol (C).
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
implement 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. ✅- Answer: B
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 (B) to be sure that the client understands and can legally provide consent
for surgery. (A) does not provide sufficient follow-up. If the nurse determines that the client
is confused, the surgeon must be notified (C) and permission obtained from the next of kin
(D).
The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to
prevent complications of immobility. Which intervention 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. ✅- Answer: A
Performing range-of-motion exercises (A) is beneficial in reducing contractures around
joints. (B, C, and D) are all potentially harmful practices that place the immobile client at
risk of complications.
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. ✅- Answer: D
(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. (A) is important but should be done after the
client is in a safe position. Because the client is not supporting himself, (B) is impractical.
(C) is likely to cause chaos on the unit and might alarm the other clients.
A female nurse is assigned to care for a close friend, who says, "I am worried that friends
will find out about my diagnosis." The nurse tells her friend that legally she must protect a
client's confidentiality. Which resource describes the nurse's legal responsibilities?
A. Code of Ethics for Nurses
B. State Nurse Practice Act
C. Patient's Bill of Rights
D. ANA Standards of Practice ✅- Answer: B
The State Nurse Practice Act (B) contains legal requirements for the protection of client
confidentiality and the consequences for breaches in confidentiality. (A) outlines ethical
standards for nursing care but does not include legal guidelines. (C and D) describe
expectations for nursing practice but do not address legal implications.
The nurse is teaching a client how to perform progressive muscle relaxation techniques to
relieve insomnia. A week later the client reports that he is still unable to sleep, despite
following the same routine every night. Which action should the nurse take first? 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 that the client is currently following. ✅- Answer:
D
The nurse should first evaluate whether the client has been adhering to the original
instructions (D). A verbal report of the client's routine will provide more specific
information than the client's written diary (B). The nurse can then determine which
changes need to be made (A). The routine practiced by the client is clearly unsuccessful, so
encouragement alone is insufficient (C).
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 at least every hour.
C. Increase daily intake of water or other oral fluids.
D. Purchase a newer model wheelchair. ✅- Answer: B
The most important teaching is to change positions frequently (B) because pressure is the
most significant factor related to the development of pressure ulcers. Increased vitamin
and fluid intake (A and C) may also be beneficial promote healing and reduce further risk.
(D) is an intervention of last resort because this will be very expensive for the client.
When turning an immobile bedridden client without assistance, which action by the nurse
best ensures client safety?
A. 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. ✅- Answer: B
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 (B). (A) can cause client
injury to the skin or joint. (C and D) are useful techniques while turning a client but have
less priority in terms of safety than use of the bed rails.
A female client with frequent urinary tract infections (UTIs) asks the nurse to explain her
friend's advice about drinking a glass of juice daily to prevent future UTIs. Which response
is best for the nurse 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. ✅- Answer: C
Cranberry juice (C) maintains urinary tract health by reducing the adherence of Escherichia
coli bacteria to cells within the bladder. (A, B, and D) have not been shown to be as effective
as cranberry juice (C) in preventing UTIs.
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 ✅- Answer: A
Long-term protein deficiency is required to cause significantly lowered serum albumin
levels (A). 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. (B) is a serum protein with a half-life of only 8 to 10
days, so it will drop with an acute protein deficiency. Neither (C or D) are clinical measures
of protein malnutrition.
The nurse identifies a potential for infection in a patient with partial-thickness
(seconddegree) and full-thickness (third-degree) burns. What intervention 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. Application of a topical antibacterial cream
D. Limiting visitors to the client with burns ✅- Answer: B
Careful hand washing technique (B) is the single most effective intervention for the
prevention of contamination to all clients. (A) reverses the hypovolemia that initially
accompanies burn trauma but is not related to decreasing the proliferation of infective
organisms. (C and D) are recommended by various burn centers as possible ways to reduce
the chance of infection. (B) is a proven technique to prevent infection.
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 ✅- Answer: D
Monitoring serum sodium levels (D) for hyponatremia is indicated during prolonged NG
suctioning because of loss of fluids. Changes in levels of (A, B, or C) are not typically
associated with prolonged NG suctioning.
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 that the operative permit is not signed and the client has questions
about the surgery.
D. Reassure the client that the surgeon will answer any questions before the anesthesia is
administered. ✅- Answer: C
The surgeon should be informed immediately that the permit is not signed (C). It is the
surgeon's responsibility to explain the procedure to the cliesxnt and obtain the client's
signature on the permit. Although the nurse can witness an operative permit (A), the
procedure must first be explained by the health care provider or surgeon, including
answering the client's questions (B). The client's questions should be addressed before the
permit is signed (D).
The nurse is preparing an older client for discharge. Which method is best for the nurse to
use when evaluating the client's ability to perform a dressing change at home? A.
Determine how the client feels about changing the dressing.
B. Ask the client to describe the procedure in writing.
C. Seek a family member's evaluation of the client's ability to change the dressing.
D. Observe the client change the dressing unassisted. ✅- Answer: D
Observing the client directly (D) will allow the nurse to determine if mastery of the skill has
been obtained and provide an opportunity to affirm the skill. (A) may be therapeutic but
will not provide an opportunity to evaluate the client's ability to perform the procedure. (B)
may be threatening to an older client and will not determine his ability. (C) is not as
effective as direct observation by the nurse.
A client in a long-term care facility reports to the nurse that he has not had a bowel
movement in 2 days. Which intervention should the nurse implement first? 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. ✅Answer: C
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 (C). (A, B, or D) may
then be implemented, if warranted.
The nurse is instructing a client with cholecystitis regarding diet choices. Which meal best
meets the dietary needs of this client? A. Steak, baked beans, and a salad
B. Broiled fish, green beans, and an apple
C. Pork chops, macaroni and cheese, and grapes
D. Avocado salad, milk, and angel food cake ✅- Answer: B
Clients with cholecystitis (inflammation of the gallbladder) should follow a low-fat diet,
such as (B). (A) is a high-protein diet and (C and D) contain high-fat foods, which are
contraindicated for this client.
When bathing an uncircumcised boy older than 3 years, which action should the nurse
take?
A. Remind the child to clean his genital area.
B. Defer perineal care because of the child's age.
C. Retract the foreskin gently to cleanse the penis.
D. Ask the parents why the child is not circumcised. ✅- Answer: C
The foreskin (prepuce) of the penis should be gently retracted to cleanse all areas that
could harbor bacteria (C). The child's cognitive development may not be at the level at
which (A) would be effective. Perineal care needs to be provided daily regardless of the
client's age (B). (D) is not indicated and may be perceived as intrusive.
The nurse who is preparing to give an adolescent 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. ✅- Answer: C
The nurse should not give the medication and should document the reason (C) 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 (A) or a health care provider's
permission (B), unless conditions are met to justify coerced treatment. (D) is not necessary
unless the medication had previously been administered.
A nurse is working in an occupational health clinic when an employee walks in and states
that he was struck by lightning while working in a truck bed. 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 ✅- Answer: A
Lightning is a jolt of electrical current and can produce a "natural" defibrillation, so
assessment of the pulse rate and regularity (A) is a priority. Because the client is talking, he
has an open airway (B), so that assessment is not necessary. Assessing for (C and D) should
occur after assessing for adequate circulation.
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. ✅- Answer: D
The best nursing action is to discuss the client another time (D). Confidentiality must be
observed at all times, so the nurse should not discuss the client when the conversation can
be overheard by others. Details can identify the client when referring to the client by
gender (A) or age (B), and even when not using the client's name (C).
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 ✅- Answer: B
Anticoagulants (B) 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 (A) may be
more susceptible to the development of thrombi, such problems usually occur
postoperatively. A client with (C or D) is at less of a surgical risk than (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. ✅- Answer: B
(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 (A). Clients should never be lifted under the axillae (C); 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 (D); this places undue stress on
the nurse's neck and back and increases the risk for a fall.
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." ✅- Answer: B The
medication should be inhaled through the mouth simultaneously with compression of
the inhaler (B). This will facilitate the desired destination of the aerosol medication deep
in the lungs for an optimal bronchodilation effect. (A, C, and D) do not allow for deep
lung penetration.
The nurse finds a client crying behind a locked bathroom door. The client will not open the
door. Which action should the nurse implement 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. ✅- Answer: D The
nurse's first concern should be for the client's safety, so an immediate assessment of the
client's situation is needed (D). (A) is incorrect; the nurse should implement the
intervention. The nurse may offer to stay nearby after first assessing the situation more
fully (B). Although (C) may be correct, the nurse should determine if the client's safety is
compromised and offer assistance, even if it is refused.
Which step(s) 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. ✅- Answer: A, B
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 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. ✅- Answer: A
The client has demonstrated a purposeful response to pain, which should be documented
as such (A). Response to painful stimulus is assessed after response to verbal stimulus, not
before (B). There is no indication for placing the client on seizure precautions (C).
Reporting (D) is nonpurposeful movement.
A hospitalized client has had difficulty falling asleep for 2 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 every
8 hours.
D. Encourage the client to avoid pain medication during the day, which might increase
daytime napping. ✅- Answer: A
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 (A). (B, C, and D) decrease the
client's standard of care and compromise safety.
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." ✅- Answer: A
(A) offers an open-ended question most relevant to the client's statement. (B) does not
offer the client the opportunity to express concerns. (C and D) are even less relevant to the
client's statement.
The health care provider has changed a client's prescription from the PO to the IV route of
administration. The nurse should anticipate which change in the pharmacokinetic
properties of the medication?
A. The client will experience increased tolerance to the drug's effects and may need a
higher dose.
B. The onset of action of the drug will occur more rapidly, resulting in a more rapid effect.
C. The medication will be more highly protein-bound, increasing the duration of action.
D. The therapeutic index will be increased, placing the client at greater risk for toxicity. ✅Answer: B
Because the absorptive process is eliminated when medications are administered via the IV
route, the onset of action is more rapid, resulting in a more immediate effect (B). Drug
tolerance (A), protein binding (C), and the drug's therapeutic index (D) are not affected by
the change in route from PO to IV. In addition, an increased therapeutic index reduces the
risk of drug toxicity.
A male client is laughing at a television program with his wife when the evening nurse
enters the room. He says his foot is hurting and he would like a pain pill. How should the
nurse respond?
A. Ask him to rate his pain on a scale of 1 to 10.
B. Encourage him to wait until bedtime so the pill can help him sleep.
C. Attend to an acutely ill client's needs first because this client is laughing.
D. Instruct him in the use of deep breathing exercises for pain control. ✅- Answer: A
Obtaining a subjective estimate of the pain experience by asking the client to rate his pain
(A) 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 (B). (C) is judgmental.
(D) should be used as an adjunct to pain medication, not instead of medication.
The nurse determines that a postoperative client's respiratory rate has increased from 18
to 24 breaths/min. Based on this assessment finding, which intervention is most important
for the nurse to implement?
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. ✅- Answer: D
Pain, anxiety, and increasing fluid accumulation in the lungs (D) can cause tachypnea
(increased respiratory rate). Encouraging (A) when the respiratory rate is rising above
normal limits puts the client at risk for further oxygen desaturation. (B) can increase the
client's carbon metabolism, so an alternative source of energy, such as Pulmocare liquid
supplement, should be offered instead. (C) could increase respiratory congestion in a client
with a poorly functioning cardiopulmonary system, placing the client at risk of fluid
overload.
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. ✅Answer: D
Because a shower is most beneficial for the client in terms of hygiene, the client should
receive teaching first (D), respecting any personal beliefs such as cultural or spiritual
values. After client teaching, the client may still choose (A or B). Brochures reinforce the
teaching (C).
Based on the nursing diagnosis of Risk for infection, which intervention is best for the
nurse to implement when providing care for an older 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. ✅- Answer: A
The best action to decrease the risk of infection in vulnerable clients is hand washing (A).
(B) is not necessary unless the client has an infection. (C) increases the risk of infection. (D)
does not reduce the risk of infection.
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
should the nurse document?
A. 14
B. 16
C. 17
D. 28 ✅- Answer: B
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 (B). (A, C, and D) are inaccurate recordings.
The nurse prepares to insert a nasogastric tube in a client with hyperemesis who is awake
and alert. Which intervention(s) is(are) correct? (Select all that apply.) A. Place the client
in a high Fowler's position.
B. Help the patient assume a left side-lying position.
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. ✅Answer: A, D
(A and D) are the correct steps to follow during nasogastric intubation. Only the
unconscious or obtunded client should be placed in a left side-lying position (B). 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).
During a routine assessment, an obese 50-year-old female client expresses concern about
her sexual relationship with her husband. 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. ✅- Answer: D
(D) provides an opportunity for the client to verbalize her concerns and provides the nurse
with more assessment data. (A and B) may not be related to her current concern, assume
that obesity is the problem, and are communication blocks. (C) may be appropriate after
discussing the concerns she is having.
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. ✅- Answer: D 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 (D). (A, B, and C) describe incorrect procedures.
A.
B.
C.
D.
The nurse teaches the use of a gait belt to a male caregiver whose wife 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 perform this procedure correctly?
Standing on his wife's strong side, the caregiver is ready to hold the gait belt if any evidence
of weakness is observed.
Standing on his wife's weak side, the caregiver provides security by holding the gait belt
from the back.
Standing behind his wife, the caregiver provides balance by holding both sides of the gait
belt.
Standing slightly in front and to the right of his wife, the caregiver guides her forward by
gently pulling on the gait belt. ✅- Answer: B
His wife is most likely to lean toward the weak side and needs extra support on that side
and from the back (B) to prevent falling. (A, C, and D) provide less security for her.
A client has a nursing diagnosis of Altered sleep patterns related to nocturia. Which client
instruction is important for the nurse to provide?
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. ✅- Answer: A
Nocturia is urination during the night. (A) is helpful to decrease the production of urine,
thus decreasing the need to void at night. (B) helps prevent bladder infections. (C) may
promote sleep, but the fluid will contribute to nocturia. (D) may result in urinary
incontinence if the client is sedated and does not awaken to void.
Which nursing diagnosis has the highest priority when planning care for a client with an
indwelling urinary catheter?
A. Self-care deficit
B. Functional incontinence
C. Fluid volume deficit
D. High risk for infection ✅- Answer: D
Indwelling urinary catheters are a major source of infection (D). (A and B) are both
problems that may require an indwelling catheter. (C) is not affected by an indwelling
catheter.
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. ✅- Answer: C
Deflating the cuff for 30 to 60 seconds (C) allows blood flow to return to the extremity so
that an accurate reading can be obtained on that extremity a second time. (A) could result
in a falsely high reading. (B) reduces circulation, causes pain, and could alter the reading.
(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. ✅- Answer: D
Comparing this reading with previous readings (D) will provide information about what is
normal for this client; this action should be taken first. (A) might unnecessarily alarm the
client. (B) is premature. Further assessment is needed to determine if the reading is
abnormal for this client. (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 is the most likely
outcome of this lawsuit?
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 were 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. ✅- Answer: C
The Good Samaritan Act (C) 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 (A). The state Board of Nursing has no reason to revoke a registered nurse's
license (B) 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 (D).
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 intervention is best for the nurse to implement? 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.
D. Review the schedule of outdoor breaks with the client. ✅- Answer: D
The best nursing action is to review the schedule of outdoor breaks (D) and provide
concrete information about the schedule. (A) is contraindicated if the client wants to
continue smoking. (B) is insufficient to encourage a trusting relationship with the client. (C)
is preferential for this client only and is inconsistent with unit rules.
The nurse is obtaining a lie-sit-stand blood pressure reading on a client. Which action is
most important for the nurse to implement?
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 son has the right to waive informed consent
for her.
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. ✅- Answer: A
Although all these measures are important, (A) is most important because it helps ensure
client safety. (B) is necessary but does not have the priority of (A). (C and D) are important
measures to ensure accuracy of the recording but are of less importance than providing
client safety.
The nurse selects the best site for insertion of an IV catheter in the client's right arm. Which
documentation should the nurse use to identify placement of the IV access?
A. Left brachial vein
B. Right cephalic vein
C. Dorsal side of the right wrist
D. Right upper extremity ✅- Answer: B
The cephalic vein is large and superficial and identifies the anatomic name of the vein that
is accessed, which should be included in the documentation (B). The basilic vein of the arm
is used for IV access, not the brachial vein (A), which is too deep to be accessed for IV
infusion. Although veins on the dorsal side of the right wrist (C) are visible, they are fragile
and using them would be painful, so they are not recommended for IV access. (D) is not
specific enough for documenting the location of the IV access.
The nurse is administering the 0900 medications to a client who was admitted during the
night. Which client statement indicates that the nurse should further assess the medication
order?
A. "At home I take my pills at 8:00 am."
B. "It costs a lot of money to buy all of these pills."
C. "I get so tired of taking pills every day."
D. "This is a new pill I have never taken before." ✅- Answer: D
The client's recognition of a "new" pill requires further assessment (D) to verify that the
medication is correct, if it is a new prescription or a different manufacturer, or if the client
needs further instruction. The time difference may not be as significant in terms of its
effect, but this should be explained (A). Although comments about cost (B) should be
considered when developing a discharge plan, (D) is a higher priority. The client's feelings
(C) should be acknowledged, but observation of the five rights of medication administration
is most essential.
Which instruction is most important for the nurse to include when teaching a client with
limited mobility strategies to prevent venous thrombosis? A. Perform cough and deep
breathing exercises hourly.
B. Turn from side to side in bed at least every 2 hours.
C. Dorsiflex and plantarflex the feet 10 times each hour.
D. Drink approximately 4 ounces of water every hour. ✅- Answer: C
To reduce the risk of venous thrombosis, the nurse should instruct the client in measures
that promote venous return, such as dorsiflexion and plantar flexion (C). (A, B, and D) are
helpful to prevent other complications of immobility but are less effective in preventing
venous thrombus formation than (C).
Which action should the nurse implement when providing wound care instructions to a
client who does not speak English?
A. Ask an interpreter to provide wound care instructions.
B. Speak directly to the client, with an interpreter translating.
C. Request the accompanying family member to translate.
D. Instruct a bilingual employee to read the instructions. ✅- Answer: B
Wound care instructions should be given directly to the client by the nurse with an
interpreter (B) who is trained to provide accurate and objective translation in the client's
primary language, so that the client has the opportunity to ask questions during the
teaching process. The interpreter usually does not have any health care experience, so the
nurse must provide client teaching (A). Family members should not be used to translate
instructions (C) because the client or family member may alter the instructions during
conversation or be uncomfortable with the topics discussed. The employee should be a
trained interpreter (D) to ensure that the nurse's instructions are understood accurately by
the client.
An older client who had abdominal surgery 3 days earlier was given a barbiturate for sleep
and is now requesting to go to the bathroom. Which action should the nurse implement? A.
Assist the client to walk to the bathroom and do not leave the client alone.
B. Request that the UAP assist the client onto a bedpan.
C. Ask if the client needs to have a bowel movement or void.
D. Assess the client's bladder to determine if the client needs to urinate. ✅- Answer: A
Barbiturates cause central nervous system (CNS) depression and individuals taking
these medications are at greater risk for falls. The nurse should assist the client to the
bathroom (A). A bedpan (B) is not necessary as long as safety is ensured. Whether the
client needs to void or have a bowel movement, (C) is irrelevant in terms of meeting this
client's safety needs. There is no indication that this client cannot voice her or his needs,
so assessment of the bladder is not needed (D).
One week after being told that she has terminal cancer with a life expectancy of 3 weeks, a
female client tells the nurse, "I think I will plan a big party for all my friends." How should
the nurse respond?
A. "You may not have enough energy before long to hold a big party."
B. "Do you mean to say that you want to plan your funeral and wake?"
C. "Planning a party and thinking about all your friends sounds like fun."
D. "You should be thinking about spending your last days with your family." ✅- Answer: C
Setting goals that bring pleasure are appropriate and should be encouraged by the nurse
(C) as long as the nurse does not perpetuate a client's denial. (A) is a negative response,
implying that the client should not plan a party. (B) puts words in the client's mouth that
may not be accurate. The nurse should support the client's goals rather than telling the
client how to spend her time (D).
The nurse observes a UAP taking a client's blood pressure in the lower extremity. Which
observation of this procedure requires the nurse's intervention? A. The cuff wraps
around the girth of the leg.
B. The UAP auscultates the popliteal pulse with the cuff on the lower leg.
C. The client is placed in a prone position.
D. The systolic reading is 20 mm Hg higher than the blood pressure in the client's arm. ✅Answer: B
When obtaining the blood pressure in the lower extremities, the popliteal pulse is the site
for auscultation when the blood pressure cuff is applied around the thigh. The nurse should
intervene with the UAP who has applied the cuff on the lower leg (B). (A) ensures an
accurate assessment, and (C) provides the best access to the artery. Systolic pressure in the
popliteal artery is usually 10 to 40 mm Hg higher (D) than in the brachial artery.
By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain of
infection?
A. Mode of transmission
B. Portal of entry
C. Reservoir
D. Portal of exit ✅- Answer: A
The contaminated gloves serve as the mode of transmission (A) from the portal of exit (D)
of the reservoir (C) to a portal of entry (B).
The nurse assesses a 2-year-old who is admitted for dehydration and finds that the
peripheral IV rate by gravity has slowed, even though the venous access site is healthy.
What should the nurse do next?
A. Apply a warm compress proximal to the site.
B. Check for kinks in the tubing and raise the IV pole.
C. Adjust the tape that stabilizes the needle.
D. Flush with normal saline and recount the drop rate. ✅- Answer: B
The nurse should first check the tubing and height of the bag on the IV pole (B), which are
common factors that may slow the rate. Gravity infusion rates are influenced by the height
of the bag, tubing clamp closure or kinks, needle size or position, fluid viscosity, client blood
pressure (crying in the pediatric client), and infiltration. Venospasm can slow the rate and
often responds to warmth over the vessel (A), but the nurse should first adjust the IV pole
height. The nurse may need to adjust the stabilizing tape on a positional needle (C) or flush
the venous access with normal saline (D), but less invasive actions should be implemented
first.
Which client is most likely to be at risk for spiritual distress?
A. Roman Catholic woman considering an abortion
B. Jewish man considering hospice care for his wife
C. Seventh-Day Adventist who needs a blood transfusion
D. Muslim man who needs a total knee replacement ✅- Answer: A
In the Roman Catholic religion, any type of abortion is prohibited (A), so facing this decision
may place the client at risk for spiritual distress. There is no prohibition of hospice care for
members of the Jewish faith (B). Jehovah's Witnesses prohibit blood transfusions, not
Seventh-Day Adventists (C). There is no conflict in the Muslim faith with regard to joint
replacement (D).
Which intervention is most important to include in the plan of care for a client at high risk
for the development of postoperative thrombus formation? A. Instruct in the use of the
incentive spirometer.
B. Elevate the head of the bed during all meals.
C. Use aseptic technique to change the dressing.
D. Encourage frequent ambulation in the hallway. ✅- Answer: D
Thrombus (clot) formation can occur in the lower extremities of immobile clients, so the
nurse should plan to encourage activities to increase mobility, such as frequent ambulation
(D) in the hallway. (A) helps promote alveolar expansion, reducing the risk for atelectasis.
(B) reduces the risk for aspiration. (C) reduces the risk for postoperative infection.
In taking a client's history, the nurse asks about the stool characteristics. Which description
should the nurse report to the health care provider as soon as possible?
A. Daily black, sticky stool
B. Daily dark brown stool
C. Firm brown stool every other day
D. Soft light brown stool twice a day ✅- Answer: A
Black sticky stool (melena) is a sign of gastrointestinal bleeding and should be reported to
the health care provider promptly (A). (C) indicates constipation, which is a lesser priority.
(B and D) are variations of normal.
In assisting an older adult client prepare to take a tub bath, which nursing action is most
important?
A. Check the bath water temperature.
B. Shut the bathroom door.
C. Ensure that the client has voided.
D. Provide extra towels. ✅- Answer: A
To prevent burns or excessive chilling, the nurse must check the bath water temperature
(A). (B, C, and D) promote comfort and privacy and are important interventions but are of
less priority than promoting safety.
After the nurse tells an older client that an IV line needs to be inserted, the client becomes
very apprehensive, loudly verbalizing a dislike for all health care providers and nurses.
How should the nurse respond?
A. Ask the client to remain quiet so the procedure can be performed safely.
B. Concentrate on completing the insertion as efficiently as possible.
C. Calmly reassure the client that the discomfort will be temporary.
D. Tell the client a joke as a means of distraction from the procedure. ✅- Answer: C The
nurse should respond with a calm demeanor (C) to help reduce the client's
apprehension. After responding calmly to the client's apprehension, the nurse may
implement (A, B, or D) to ensure safe completion of the procedure.
Which nonverbal action should the nurse implement to demonstrate active listening? A.
Sit facing the client.
B. Cross arms and legs.
C. Avoid eye contact.
D. Lean back in the chair. ✅- Answer: A
Active listening is conveyed using attentive verbal and nonverbal communication
techniques. To facilitate therapeutic communication and attentiveness, the nurse should sit
facing the client (A), which lets the client know that the nurse is there to listen. Active
listening skills include postures that are open to the client, such as keeping the arms open
and relaxed, not (B), and leaning toward the client, not (D). To communicate involvement
and willingness to listen to the client, eye contact should be established and maintained (C).
A seriously ill female client tells the nurse, "I am so tired and in so much pain! Please help
me to die." Which is the best response for the nurse to provide?
A. Administer the prescribed maximum dose of pain medication.
B. Talk with the client about her feelings related to her own death.
C. Collaborate with the health care provider about initiating antidepressant therapy.
D. Refer the client to the ethics committee of her local health care facility. ✅- Answer: B
The nurse should first assess the client's feelings about her death and determine the
extent to which this statement expresses her true feelings (B). The client may need
additional pain management, but further assessment is needed before implementing (A).
(C and D) are both premature interventions and should not be implemented until further
assessment is obtained.
A community hospital is opening a mental health services department. Which document
should the nurse use to develop the unit's nursing guidelines?
A. Americans with Disability Act of 1990
B. ANA Code of Ethics with Interpretative Statements
C. ANA's Scope and Standards of Nursing Practice
D. Patient's Bill of Rights of 1990 ✅- Answer: C
The ANA Scope of Standards of Practice for Psychiatric-Mental Health Nursing (C) serves to
direct the philosophy and standards of psychiatric nursing practice. (A and D) define the
client's rights. (B) provides ethical guidelines for nursing.
While conducting an intake assessment of an adult male at a community mental health
clinic, the nurse notes that his affect is flat, he responds to questions with short answers,
and he reports problems with sleeping. He reports that his life partner recently died from
pneumonia. Which action is most important for the nurse to implement? A. Encourage the
client to see the clinic's grief counselor.
B. Determine if the client has a family history of suicide attempts.
C. Inquire about whether the life partner was suffering from AIDS.
D. Consult with the health care provider about the client's need for antidepressant
medications. ✅- Answer: A
The client is exhibiting normal grieving behaviors, so referral to a grief counselor (A) is the
most important intervention for the nurse to implement. (B) is indicated, but is not a
highpriority intervention. (C) is irrelevant at this time but might be important when
determining the client's risk for contracting the illness. An antidepressant may be indicated
(D), depending on further assessment, but grief counseling is a better action at this time
because grief is an expected reaction to the loss of a loved one.
After receiving written and verbal instructions from a clinic nurse about a newly prescribed
medication, a client asks the nurse what to do if questions arise about the medication after
getting home. How should the nurse respond?
A. Provide the client with a list of Internet sites that answer frequently asked questions
about medications.
B. Advise the client to obtain a current edition of a drug reference book from a local
bookstore or library.
C. Reassure the client that information about the medication is included in the written
instructions.
D. Encourage the client to call the clinic nurse or health care provider if any questions arise.
✅- Answer: D
To ensure safe medication use, the nurse should encourage the client to call the nurse or
health care provider (D) if any questions arise. (A, B, and C) may all include useful
information, but these sources of information cannot evaluate the nature of the client's
questions and the follow-up needed.
The nurse is preparing to administer 10 mL of liquid potassium chloride (Kay Ciel) through
a feeding tube, followed by 10 mL of liquid acetaminophen (Tylenol). Which action should
the nurse include in this procedure?
A. Dilute each of the medications with sterile water prior to administration.
B. Mix the medications in one syringe before opening the feeding tube.
C. Administer water between the doses of the two liquid medications.
D. Withdraw any fluid from the tube before instilling each medication. ✅- Answer: C
Water should be instilled into the feeding tube between administering the two medications
(C) to maintain the patency of the feeding tube and ensure that the total dose of medication
enters the stomach and does not remain in the tube. These liquid medications do not need
to be diluted (A) when administered via a feeding tube and should be administered
separately (B), with water instilled between each medication (D).
When emptying 350 mL of pale yellow urine from a client's urinal, the nurse notes that this
is the first time the client has voided in 4 hours. Which action should the nurse take next? A.
Record the amount on the client's fluid output record.
B. Encourage the client to increase oral fluid intake.
C. Notify the health care provider of the findings.
D. Palpate the client's bladder for distention. ✅- Answer: A
The amount and appearance of the client's urine output is within normal limits, so the
nurse should record the output (A), but no additional action is needed (B, C, and D).
The nurse transcribes the postoperative prescriptions for a client who returns to the unit
following surgery and notes that an antihypertensive medication that was prescribed
preoperatively is not listed. Which action should the nurse take?
A. Consult with the pharmacist about the need to continue the medication.
B. Administer the antihypertensive medication as prescribed preoperatively.
C. Withhold the medication until the client is fully alert and vital signs are stable.
D. Contact the health care provider to renew the prescription for the medication. ✅Answer: D
Medications prescribed preoperatively must be renewed postoperatively, so the nurse
should contact the health care provider if the antihypertensive medication is not included
in the postoperative prescriptions (D). The pharmacist (A) does not prescribe medications
or renew prescriptions. The nurse must have a current prescriptions before administering
any medications (B and C).
After a needlestick occurs while removing the cap from a sterile needle, which action
should the nurse implement?
A. Complete an incident report.
B. Select another sterile needle.
C. Disinfect the needle with an alcohol swab.
D. Notify the supervisor of the department immediately. ✅- Answer: B
After a needlestick, the needle is considered used, so the nurse should discard it and select
another needle (B). Because the needle was sterile when the nurse was stuck and the
needle was not in contact with any other person's body fluids, the nurse does not need to
complete an incident report (A) or notify the occupational health nurse (D). Disinfecting a
needle with an alcohol swab (C) is not in accordance with standards for safe practice and
infection control.
A client has a nasogastric tube connected to low intermittent suction. When administering
medications through the nasogastric tube, which action should the nurse do first?
A. Clamp the nasogastric tube.
B. Confirm placement of the tube.
C. Use a syringe to instill the medications.
D. Turn off the intermittent suction device. ✅- Answer: D
The nurse should first turn off the suction (D) and then confirm placement of the tube in
the stomach (B) before instilling the medications (C). To prevent immediate removal of the
instilled medications and allow absorption, the tube should be clamped for a period of time
(A) before reconnecting the suction.
During evacuation of a group of clients from a medical unit because of a fire, the nurse
observes an ambulatory client walking alone toward the stairway at the end of the hall.
Which action should the nurse take?
A. Assign an unlicensed assistive personnel to transport the client via a wheelchair.
B. Remind the client to walk carefully down the stairs until reaching a lower floor.
C. Ask the client to help by assisting a wheelchair-bound client to a nearby elevator.
D. Open the closest fire doors so that ambulatory clients can evacuate more rapidly. ✅Answer: B
During evacuation of a unit because of fire, ambulatory clients should be evacuated via the
stairway if at all possible and reminded to walk carefully (B). Ambulatory clients do not
require the assistance of a wheelchair to be evacuated (A). Elevators (C) should not be used
during a fire and fire doors should be kept closed (D) to help contain the fire.
When the health care provider diagnoses metastatic cancer and recommends a gastrostomy
for an older female client in stable condition, the son tells the nurse that his mother must
not be told the reason for the surgery because she "can't handle" the cancer diagnosis.
Which legal principle is the court most likely to uphold regarding this client's right to
informed consent?
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 son has the right to waive informed consent
for her.
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. ✅- Answer: D
Health care providers may be found guilty of negligence (D), specifically assault and battery,
if they carry out a treatment without the client's consent. The client's condition is stable, so
(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
(B). Although (C) may have been upheld in the past, when paternalistic medical practice
was common, today's courts are unlikely to accept it.
During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often
awake until midnight playing and is then very difficult to awaken in the morning for school.
Which assessment data should the nurse obtain in response to the mother's report?
A. The occurrence of any episodes of sleep apnea
B. The child's blood pressure, pulse, and respirations
C. Length of rapid eye movement (REM) sleep that the child is experiencing
D. Description of the family's home environment ✅- Answer: D
School-age children often resist bedtime. The nurse should begin by assessing the
environment of the home (D) to determine factors that may not be conducive to the
establishment of bedtime rituals that promote sleep. (A) often causes daytime fatigue
rather than resistance to going to sleep. (B) is unlikely to provide useful data. The nurse
cannot determine (C).
An older adult who recently began self-administration of insulin calls the nurse daily to
review the steps that should be taken when giving an injection. The nurse has assessed the
client's skills during two previous office visits and knows that the client is capable of giving
the daily injection. Which response by the nurse is likely to be most helpful in encouraging
the client to assume total responsibility for the daily injections? A. "I know you are capable
of giving yourself the insulin."
B. "Giving yourself the injection seems to make you nervous."
C. "When I watched you give yourself the injection, you did it correctly."
D. "Tell me what you want me to do to help you give yourself the injection at home." ✅Answer: C
The nurse needs to focus on the client's positive behaviors, so focusing on the client's
demonstrated ability to self-administer the injection (C) is likely to reinforce his level of
competence without sounding punitive. (A) does not focus on the specific behaviors related
to giving the injection and could be interpreted as punitive. (B) uses reflective dialogue to
assess the client's feelings, but telling the client that he is nervous may serve as a negative
reinforcement of this behavior. (D) reinforces the client's dependence on the nurse.
HESI Fundamentals Practice Test/Final 2 (NCLEX)
An adult is now alert and oriented following abdominal surgery. What position is most
appropriate for the client?
A. Semi-Fowler's
B. Prone
C. Supine
D. Sim's ✅- A
This position allows for greater thoracic expansion and puts less pressure on the suture
line
Following a craniotomy, the nurse positioned a client in low fowler's for which reason? A.
To promote comfort
B. To promote drainage from operation site
C. To promote thoracic expansion
D. To prevent circulatory overload ✅- B
The nurse is caring for a woman who had a CVA and has right-sided hemiplegia. Which
action is least appropriate?
a. Performing ROM exercise when bathing her
b. Changing her position every two hours
c. Suctioning the client supine and pulling the bed sheets tightly across her feet
d. Placing her in the prone position for one hour three times a day ✅- C
The sheets should not be drawn tightly across the feet as this may cause foot drop
The nurse is to help their client with right-sided hemiplegia get up into the wheelchair.
How should the nurse place the wheelchair?
a. On the left side of the bed facing the foot of the bed
b. On the right side of the bed facing the head of the bed
c. Perpendicular to the bed on the right side
d. Facing the bed in the left side of the bed ✅- A
The client can then stand on the unaffected foot and pivot to sit down
When caring for a client in hemorrhagic shock, how should the nurse position the client? a.
Flat in bed with legs elevated
b. Flat in bed
c. Trendelenburg position
d. Semi-Fowler's position ✅- A
Mr. Landon is to have a tracheostomy performed. What is the top nursing priority?
a. Shave the neck
b. Establish a means of communication
c. Insert a Foley catheter
d. Start an IV ✅- B
Mr. Landon is to have a tracheostomy performed. Which nursing action is essential during
tracheal suctioning?
a. Using a lubricant such as petroleum jelly
b. Administering 100% oxygen before and after suctioning
c. Making sure that the suction catheter is open or on during insertion
d. Assisting the client to assume a supine position during suctioning ✅- B--To prevent
hypoxia
Mr. Landon is to have a tracheostomy performed. Which of the following actions is most
appropriate for the nurse to take when suctioning the tracheostomy? a. Use sterile tube
each time and suction for 30 seconds
b. Use sterile technique and turn the suction off as the catheter is introduced
c. Use clean technique and suction for 10 seconds
d. Discard the catheter at the end of every shift ✅- B
Mr. Landon is to have a tracheostomy performed. While the nurse is suctioning a
tracheostomy tube, the client starts to cough. What is the best action for the nurse to take?
a. Suction deeper to pick up secretions
b. Gently withdraw suction tubing to allow suction or coughing out of mucous
c. Remove the suction as quickly as possible
d. Put the suction in and out several times to pick up secretions ✅- D
During the suctioning of a tracheostomy tube, the catheter appears to attach to the tracheal
walls and creates a pulling sensation. What is the best action for the nurse to take? a.
Release the suction by opening the vent
b. Continue suctioning to remove obstruction
c. Increase the pressure
d. Suction deeper ✅- A
Warm compresses are ordered for an open wound. Which action is appropriate for the
nurse?
a. Use sterile technique when applying the dressing
b. Leave the compresses on the area continuously, pouring warm solution on the area when
it cools down
c. Alternate warm compressed with cold ones
d. Apply wet dressing, cover with dry dressing ✅- A
The day after surgery in which a colostomy was performed, the client says "I know the
doctor did not really do a colostomy". The nurse understands that the client is in an early
stage of adjustment to the diagnosis or surgery, with nursing action is indicated at this
time?
a. Agree with the client until he is ready to accept the colostomy
b. Say "It must be difficult to have this kind of surgery"
c. Force the client to look at his colostomy
d. Ask the surgeon to explain the surgery to the client ✅- B
The nurse is preparing to insert an indwelling catheter. What type of technique should the
nurse observe to perform this procedure?
a. Clean technique
b. Medical Asepsis
c. Isolation Protocol
d. Sterile Technique ✅- D
. The nurse is performing a urethral catheterization on a female. After separating the labia,
where would the nurse observe the urethral meatus?
a. Between the vaginal orifice and the anus
b. Between the clitoris and the vaginal orifice
c. Just above the clitoris
d. Within the vaginal canal ✅- B
The nurse is attempting to pass an indwelling catheter in an adult male and is having
difficulty. What is the most appropriate action for the nurse?
a. Remove the catheter and reinsert it with the client positioned differently
b. Try a straight catheter instead
c. Try a smaller catheter
d. Discontinue the procedure and notify the physician ✅- D-- This may indicate an
obstruction
After insertion of the indwelling catheter, how should the nurse position the drainage
container?
a. With the drainage tubing taut to maintain maximum suction on the urinary bladder.
b. Lower than the bladder to maintain a constant downward flow of urine from the bladder.
c. At the head of the bed for easy and accurate measurement of urine.
d. Beside the patient in his bed to avoid embarrassment. ✅- B
An adult had an indwelling catheter removed, after she voids for the first time, the nurse
catheterizes her as ordered and obtained 200 cc of urine. What is the best interpretation of
this finding? The client:
a. Is voiding normally
b. Has urinary retention
c. Has developed renal failure
d. Needs an indwelling catheter ✅- B
The nurse plans to foster a therapeutic relationship with the patient utilizing therapeutic
techniques of communication. It is most important that the nurse:
a. Work on establishing a friendship with the patient
b. Use humour to diffuse emotionally charged topics of discussion
c. Sympathize with the patient when the patient shares sad feelings
d. Demonstrate respect when discussing emotionally charged topics ✅- D
The main purpose of the working phase of the nurse-patient relationship is to:
a. Establish a formal or informal contract that adheres to the patient's problems.
b. Implement nursing interventions that are designed to achieve expected patient outcome.
c. Develop rapport and trust so the patient feels protected and initial plan can be identified.
d. Clearly identify the role of the nurse and establish the parameters of the professional
relationship. ✅- B
A patient says, "I don't know if I'll make it through this surgery", which response by the
nurse may block further communication?
a. "You sound scared"
b. "You think you will die."
c. "Surgery can be frightening"
d. "Everything will be alright" ✅- C
A patient, who is to receive nothing by mouth (NPO) in preparation for bronchoscopy says
"I'm worried about the test and I can't even have a drink of water." What is the best
response by the nurse?
a. "Lets talk about your concerns regarding the test".
b. "I'll see if the doctor will let you have some ice chips".
c. "The doctor will review the results of the test as soon as possible".
d. "As soon as the test is over, I'll get you whatever you would like to drink". ✅- A
Which are components of a complete health history? Select all that apply.
a. Chief complain
b. History of the present illness
c. Past medical/surgical history
d. Family, personal, and social history
e. Review of systems
f. Physical exam ✅- A-E, physical exam is not part of the health history
Following amputation of a lower extremity, a patient with prosthesis, should be educated
by the nurse to
a. Wear the prosthesis daily, but remove immediately when discomfort is experienced
b. Adjust the fit of the prosthesis by wearing a heavier sock to insure a tight fit
c. To put the prosthesis on immediately upon rising in the morning and keep it on all day
d. To apply oil or lotion to the stump before applying prosthesis ✅- C
When preparing a client for a blood transfusion, the nurse should consider for which of the
following? (Select all that apply)
a. Blood typing and cross-matching must be completed prior to a blood transfusion
b. Clients with type A should only receive Type A blood but may receive type O in an
emergency
c. clients with type B blood should only receive type B blood, but may receive type A in an
emergency
d. Clients with type AB blood are "universal recipients" and should only receive type AB
blood but may, in an emergency receive all four types of blood ✅- A, B, D
During a skin assessment, a client asks a question about what the skin does. The nurse's
response would be based on the knowledge that the functions of the skin include (Select all
that apply.)
a. Temperature regulation
b. Sensory perception
c. Identification
d. Protection ✅- All answers are correct
The skin regulates temperature through changes in its blood flow and through sweating.
The skin provides sensory information through its nerve endings. Fingerprints allow for
identification of individuals. The skin and mucous membranes are the first line of defense
against injury and invasion of microorganisms.
Which of the following is an ABNORMAL finding when observing Water Sealed Chest
Drainage for proper functioning?
a. Bubbling initially with coughing and deep inspiration
b. Continuous bubbling where the water seal is maintained
c. Water level fluctuations with breathing
d. A collection chamber that is less than 1/2 full ✅- B
Hyperolality ✅- Symptom of dementia associated with the 3rd stage of Alzheimer's
disease
An elderly patient has been living in a nursing home for several years. The nursing staff has
begun to notice a change in her behavior. All of the following are symptoms of depression
except:
a. Changes in sleep patterns
b. Changes in eating patterns with weight loss
c. Excessive fatigue and increased concern with bodily functions
d. Hyperorality ✅- D
The census on the unit is 90 percent and there are no private rooms available. An elderly
client with influenza is admitted. Which of the following rooms would it be appropriate to
assign this client?
a. A double room with a client admitted for impetigo.
b. A double room with another client with the same diagnosis.
c. A four-bed room with three clients who have had orthopedic surgery.
d. A double room with an elderly client with a diagnosis of chickenpox. ✅- B
If a private room is not available, the client should be placed with another client with the
same diagnosis where droplet precautions would already be in place. The staff and visitors
should be told to stay at least 3 feet away without a mask because large-particle droplets
travel only about 3 feet before falling from the air.
You are assigned to teach a nursing student how to suction an adult patient with a
tracheostomy. Which of the following actions by the nursing student would be INCORRECT?
a. Pre-oxygenation of the patient with a Resusibag at 100% 02 several times before
suctioning
b. Maintains wall suction pressure at 110-150mmHG
c. Does not suction for greater than 10-15 seconds at a time
d. Applies gentle intermittent pressure and rotates catheter during insertion phase of
suctioning ✅- D
In suctioning a patient with a Tracheostomy, the nurse should employ all of the above
choices, except choice (4). However, when the catheter is inserted it should be done gently,
and to a depth of 10-12.5cms (4-5"s) or until the patient begins to cough. Suction should
never be applied when inserting the catheter, not should it be rotated during this period.
Suction should be applied by occluding the Y-port with the thumb of the unsterile gloved
hand, while the catheter is rotated gently during withdrawal. The patient should never be
suctioned for more than 10 seconds at one time to avoid the development of hypoxia.
When a client has suffered severe burns all over his body, the most effective method of
monitoring the cardiovascular system is a. Cuff blood pressure.
b. Arterial pressure.
c. Pulmonary artery pressure.
d. Central venous pressure. ✅- C
When is the first dose of Hep B given? ✅- In the hospital at birth
An adult has just died. How should the nurse prepare the body for transfer to the mortuary?
a. Leave the body as is, no prep needed
b. Bathe the body and put ID tags on it
c. Remove dentures before bathing body
d. Position the body with its head down and arms folded on its chest. ✅- B
A patient has decreased cardiac output following a surgery. What will the nurse likely see in
this patient?
a. Decreased urine output
b. Increased urine output
c. Flushing of the skin
d. Hyperventilation ✅- A
The nurse counts an adult's apical heart beat at 110 beats per min. The nurse describes this
as
a. asystole
b. bigeminy
c. tachycardia
d. bradycardia ✅- C
A client as an elevated AST 24 hours following chest pain and shortness of breath. This is
suggestive of which of the following? a. Gallbladder disease
b. Liver disease
c. Myocardial infarction
d. Skeletal muscle injury ✅- C
AST is an enzyme released in response to tissue damage. AST rises 24 hours after an MI. It
will also rise with liver and skeletal muscle injuries
An adult has a coagulation time of 20 minutes. The nurse should observe the client for
which of the following? a. blood clots
b. Ecchymotic areas
c. jaundice
d. infection ✅- B
A prothrombin time test should be performed regularly on persons who are taking which
medication? a. Heparin
b. Warfarin
c. Phenobarbital
d. Digoxin ✅- B
Which prothrombin time value would be considered normal for a client who is receiving
warfarin?
a. 12 seconds
b. 20 seconds
c. 60 seconds
d. 90 seconds ✅- B
The nurse is caring for a client who is receiving heparin. What drug should be readily
available?
a. Vitamin K
b. Caffeine
c. Calcium gluconate
d. Protamine sulfate ✅- D- The antidote for heparin
Vit K is antidote for Coumadin
During the admission interview, a client who is admitted for a cardiac catheterization says,
"Every time I eat shrimp I get a rash". What action is essential for the nurse to take at this
time?
a. Notify the physician
b. Ask the client if they get a rash from any other foods
c. Instruct the dietary department not to give the client shrimp
d. Teach the client the dangers of eating shrimp and other shellfish ✅- A
When a client returns from undergoing a cardiac cath, it is most essential for the nurse to a.
Check peripheral pulses
b. Maintain NPO
c. Apply heat to the insertion site
d. Start range of motion exercises immediately ✅- A
An adult who is receiving heparin asks the nurse why it cannot be given by mouth. The
nurse responds that heparin is given parenterally because a. it is destroyed by gastric
secretions
b. It irritates the gastric mucosa
c. It irritates the intestinal lining
d. Therapeutic levels can be attained more therapeutically ✅- A--Because of this it is given
either subq or IV
A client with asbestosis must see his doctor regularly for a check up. What is the primary
reason for him to have frequent checkups?
A. Patients with asbestosis are at high risk for developing bronchogenic cancer.
B. His doctor is monitoring him closely to look for signs of improvement.
C. Patients who use low flow oxygen for long periods are at high risk for developing
neurological symptoms.
D. Periodic sputum samples are needed to follow the progress of the disease. ✅- A
An order is written for oxygen by nasal cannula at 2 liters per minute. In assessing the
adequacy of the oxygen therapy, which of the following is most effective? A. Checking
the respiratory rate.
B. Checking the color of mucous membranes.
C. Measurement of pulmonary functions.
D. Measurement of arterial blood gasses ✅- D
A patient is admitted with histoplasmosis. Which item in the patient's history is most likely
related to the onset of the disease? A. He works in a factory.
B. He likes to explore caves.
C. He has three cats.
D. He smokes four packs of cigarettes a week. ✅- B-- Histoplasmosis is caused by a fungus
that grows in chicken and bat manure. Bats live in caves...
The nurse in a medical unit is caring for a client with heart failure. The client suddenly
develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects
pulmonary edema. The nurse immediately notifies the registered nurse and expects which
interventions to be prescribed? Select all that apply.
Administering oxygen
Administering Digoxin
Inserting a Foley catheter
Administering furomeside (Lasix)
Administering morphine sulfate intravenously ✅- Administering oxygen
Inserting a Foley catheter
Administering furomeside (Lasix)
Administering morphine sulfate intravenously
The nurse is caring for a client with left-sided heart failure. Which clinical signs are most
important for the nurse to communicate to the health care provider? Select all that apply.
Pink-tinged frothy sputum
Decrease in respiratory rate
Increase in respiratory rate
Yellow tinged sputum
Auscultation of crackles throughout the lungs ✅- Pink-tinged frothy sputum
Increase in respiratory rate
Auscultation of crackles throughout the lungs
The nurse is caring for a client who is developing pulmonary edema. The client exhibits
respiratory distress, but the blood pressure is unchanged from the client's baseline. As an
immediate action before help arrives, the nurse should perform which action?
A. Place the client in high-Fowler's position
B. Lie the client flat
C. Place client in prone position
D. Place client in Semi-Fowler's ✅- A
A client has just returned from the cardiac catheterization laboratory. The left femoral
vessel was used as the access site. After returning the client to bed, the nurse places a sign
above the bed stating that the client should remain on bed rest and in which position?
A. With the head of the bed elevated no more than 15 degrees
B. At a 30-45 Degree angle
C. Lying flat
D. High-Fowler's ✅- A
A client with myocardial infarction suddenly becomes tachycardic, shows signs of air
hunger, and begins coughing frothy, pink-tinged sputum. The nurse listens to breath
sounds, expecting to hear which breath sounds bilaterally? A. Wheezes
B. Scratching
C. Crackles
D. Air ✅- C
Blood flows to the
atrium from the superior and inferior vena cavae ✅- right
Blood flows from the right atrium to the right ventricle via the
Blood flows from the right ventricle to the lungs for
valve ✅- tricuspid
✅- oxygenation
to the left atrium ✅- lungs
Blood flows from the
Blood flows from the left atrium via the
Blood flows from the
valve to the left ventricle ✅- mitral
ventricle to the aorta and then to the systemic circulation ✅- left
The nurse is caring for a client who has had a recent myocardial infarction involving the left
ventricle. Which assessment finding is expected? a.
Faint S1 and S2 sounds
b.
Decreased cardiac output
c.
Increased blood pressure
d.
Absent peripheral pulses ✅- B
The myocardium is the layer responsible for the contractile force of the heart. Damage to
this layer can result in decreased cardiac output. This most likely would result in decreased
blood pressure and strength of peripheral pulses. Absent peripheral pulses would be
caused by an arterial occlusion. S1 and S2 most likely would not be affected.
The nurse is assessing a client following a myocardial infarction. The client is hypotensive.
What additional assessment finding does the nurse expect? a.
Heart rate of 120 beats/min
b.
Cool, clammy skin
c.
Oxygen saturation of 90%
d.
Respiratory rate of 8 breaths/min ✅- A
When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure
decrease in the vessels. The parasympathetic system responds by lessening the inhibitory
effect on the sinoatrial (SA) node. This results in an increase in heart rate. This tachycardia
is an early response and is seen even when blood pressure is not critically low.
The nurse is caring for a client with coronary artery disease. What assessment finding does
the nurse expect if the client's mean arterial blood pressure decreases below 60 mm Hg? a.
Increased cardiac output
b.
Hypertension
c.
Chest pain
d.
Decreased heart rate ✅- C
Coronary artery blood flow occurs primarily during diastole. Mean arterial pressure (MAP)
of 60 mg Hg is necessary for adequate blood flow to coronary arteries, and MAP of 60 to 70
mm Hg is necessary for adequate perfusion to major body organs. If MAP decreases to
below 60 mm Hg, the client with cardiac disease may have chest pain. Cardiac output most
likely would decrease, and blood pressure also would decrease. Heart rate may increase as
the body initiates compensatory mechanisms.
The nurse administers a beta blocker to a client after a myocardial infarction. What
assessment finding does the nurse expect? a.
Blood pressure increase of 10%
b.
Increasing respiratory rate
c.
Increased cardiac output
d.
Pulse decrease from 100 to 80 beats/min ✅- D
Beta blockers block the stimulation of beta1-adrenergic receptors. They block the
sympathetic (fight-or-flight) response and decrease the heart rate (HR). The beta blocker
will decrease HR and blood pressure, increasing ventricular filling time. It usually does not
have effects on beta2-adrenergic receptor sites. Cardiac output will drop because of
decreased heart rate.
The nurse is assessing clients at a community health center. Which client does the nurse
determine is at high risk for cardiovascular disease? a.
Older adult man with a history of asthma
b.
Asian-American man with colorectal cancer c.
American Indian woman with diabetes mellitus d.
Postmenopausal woman on hormone therapy ✅- C
The incidence of coronary artery disease and hypertension is higher in American Indians
than in whites or Asian Americans. Diabetes mellitus increases the risk for hypertension
and coronary artery disease in people of any race or ethnicity.
A nurse is performing an admission assessment on an older adult client with multiple
chronic diseases. The nurse assesses the heart rate to be 48 beats/min. What does the
nurse do first?
a.
Document the finding in the chart.
b.
Evaluate for a pulse deficit.
c.
Assess the client's medications. d.
Administer 1 mg of atropine. ✅- C
Pacemaker cells in the conduction system decrease in number as a person ages, resulting in
bradycardia. The nurse should check the medication reconciliation for medications that
might cause such a drop in heart rate, then should inform the health care provider.
Documentation is important, but it is not the priority action. The heart rate is not low
enough for atropine to be needed
HESI Fundamentals Exam Answered.
An adult is now alert and oriented following abdominal surgery. What position is most
appropriate for the client?
A. Semi-Fowler's
B. Prone
C. Supine
D. Sim's ✅- A
This position allows for greater thoracic expansion and puts less pressure on the suture
line
Following a craniotomy, the nurse positioned a client in low fowler's for which reason? A.
To promote comfort
B. To promote drainage from operation site
C. To promote thoracic expansion
D. To prevent circulatory overload ✅- B
The nurse is caring for a woman who had a CVA and has right-sided hemiplegia. Which
action is least appropriate?
a. Performing ROM exercise when bathing her
b. Changing her position every two hours
c. Suctioning the client supine and pulling the bed sheets tightly across her feet
d. Placing her in the prone position for one hour three times a day ✅- C
The sheets should not be drawn tightly across the feet as this may cause foot drop
The nurse is to help their client with right-sided hemiplegia get up into the wheelchair.
How should the nurse place the wheelchair?
a. On the left side of the bed facing the foot of the bed
b. On the right side of the bed facing the head of the bed
c. Perpendicular to the bed on the right side
d. Facing the bed in the left side of the bed ✅- A
The client can then stand on the unaffected foot and pivot to sit down
When caring for a client in hemorrhagic shock, how should the nurse position the client? a.
Flat in bed with legs elevated
b. Flat in bed
c. Trendelenburg position
d. Semi-Fowler's position ✅- A
Mr. Landon is to have a tracheostomy performed. What is the top nursing priority? a.
Shave the neck
b. Establish a means of communication
c. Insert a Foley catheter
d. Start an IV ✅- B
Mr. Landon is to have a tracheostomy performed. Which nursing action is essential during
tracheal suctioning?
a. Using a lubricant such as petroleum jelly
b. Administering 100% oxygen before and after suctioning
c. Making sure that the suction catheter is open or on during insertion
d. Assisting the client to assume a supine position during suctioning ✅- B--To prevent
hypoxia
Mr. Landon is to have a tracheostomy performed. Which of the following actions is most
appropriate for the nurse to take when suctioning the tracheostomy? a. Use sterile tube
each time and suction for 30 seconds
b. Use sterile technique and turn the suction off as the catheter is introduced
c. Use clean technique and suction for 10 seconds
d. Discard the catheter at the end of every shift ✅- B
Mr. Landon is to have a tracheostomy performed. While the nurse is suctioning a
tracheostomy tube, the client starts to cough. What is the best action for the nurse to take?
a. Suction deeper to pick up secretions
b. Gently withdraw suction tubing to allow suction or coughing out of mucous
c. Remove the suction as quickly as possible
d. Put the suction in and out several times to pick up secretions ✅- D
During the suctioning of a tracheostomy tube, the catheter appears to attach to the tracheal
walls and creates a pulling sensation. What is the best action for the nurse to take? a.
Release the suction by opening the vent
b. Continue suctioning to remove obstruction
c. Increase the pressure
d. Suction deeper ✅- A
Warm compresses are ordered for an open wound. Which action is appropriate for the
nurse?
a. Use sterile technique when applying the dressing
b. Leave the compresses on the area continuously, pouring warm solution on the area when
it cools down
c. Alternate warm compressed with cold ones
d. Apply wet dressing, cover with dry dressing ✅- A
The day after surgery in which a colostomy was performed, the client says "I know the
doctor did not really do a colostomy". The nurse understands that the client is in an early
stage of adjustment to the diagnosis or surgery, with nursing action is indicated at this
time?
a. Agree with the client until he is ready to accept the colostomy
b. Say "It must be difficult to have this kind of surgery"
c. Force the client to look at his colostomy
d. Ask the surgeon to explain the surgery to the client ✅- B
The nurse is preparing to insert an indwelling catheter. What type of technique should the
nurse observe to perform this procedure?
a. Clean technique
b. Medical Asepsis
c. Isolation Protocol
d. Sterile Technique ✅- D
. The nurse is performing a urethral catheterization on a female. After separating the labia,
where would the nurse observe the urethral meatus?
a. Between the vaginal orifice and the anus
b. Between the clitoris and the vaginal orifice
c. Just above the clitoris
d. Within the vaginal canal ✅- B
The nurse is attempting to pass an indwelling catheter in an adult male and is having
difficulty. What is the most appropriate action for the nurse?
a. Remove the catheter and reinsert it with the client positioned differently
b. Try a straight catheter instead
c. Try a smaller catheter
d. Discontinue the procedure and notify the physician ✅- D-- This may indicate an
obstruction
After insertion of the indwelling catheter, how should the nurse position the drainage
container?
a. With the drainage tubing taut to maintain maximum suction on the urinary bladder.
b. Lower than the bladder to maintain a constant downward flow of urine from the bladder.
c. At the head of the bed for easy and accurate measurement of urine.
d. Beside the patient in his bed to avoid embarrassment. ✅- B
An adult had an indwelling catheter removed, after she voids for the first time, the nurse
catheterizes her as ordered and obtained 200 cc of urine. What is the best interpretation of
this finding? The client:
a. Is voiding normally
b. Has urinary retention
c. Has developed renal failure
d. Needs an indwelling catheter ✅- B
The nurse plans to foster a therapeutic relationship with the patient utilizing therapeutic
techniques of communication. It is most important that the nurse:
a. Work on establishing a friendship with the patient
b. Use humour to diffuse emotionally charged topics of discussion
c. Sympathize with the patient when the patient shares sad feelings
d. Demonstrate respect when discussing emotionally charged topics ✅- D
The main purpose of the working phase of the nurse-patient relationship is to:
a. Establish a formal or informal contract that adheres to the patient's problems.
b. Implement nursing interventions that are designed to achieve expected patient outcome.
c. Develop rapport and trust so the patient feels protected and initial plan can be identified.
d. Clearly identify the role of the nurse and establish the parameters of the professional
relationship. ✅- B
A patient says, "I don't know if I'll make it through this surgery", which response by the
nurse may block further communication?
a. "You sound scared"
b. "You think you will die."
c. "Surgery can be frightening"
d. "Everything will be alright" ✅- C
A patient, who is to receive nothing by mouth (NPO) in preparation for bronchoscopy says
"I'm worried about the test and I can't even have a drink of water." What is the best
response by the nurse?
a. "Lets talk about your concerns regarding the test".
b. "I'll see if the doctor will let you have some ice chips".
c. "The doctor will review the results of the test as soon as possible".
d. "As soon as the test is over, I'll get you whatever you would like to drink". ✅- A
Which are components of a complete health history? Select all that apply.
a. Chief complain
b. History of the present illness
c. Past medical/surgical history
d. Family, personal, and social history
e. Review of systems
f. Physical exam ✅- A-E, physical exam is not part of the health history
Following amputation of a lower extremity, a patient with prosthesis, should be educated
by the nurse to
a. Wear the prosthesis daily, but remove immediately when discomfort is experienced
b. Adjust the fit of the prosthesis by wearing a heavier sock to insure a tight fit
c. To put the prosthesis on immediately upon rising in the morning and keep it on all day
d. To apply oil or lotion to the stump before applying prosthesis ✅- C
When preparing a client for a blood transfusion, the nurse should consider for which of the
following? (Select all that apply)
a. Blood typing and cross-matching must be completed prior to a blood transfusion
b. Clients with type A should only receive Type A blood but may receive type O in an
emergency
c. clients with type B blood should only receive type B blood, but may receive type A in an
emergency
d. Clients with type AB blood are "universal recipients" and should only receive type AB
blood but may, in an emergency receive all four types of blood ✅- A, B, D
During a skin assessment, a client asks a question about what the skin does. The nurse's
response would be based on the knowledge that the functions of the skin include (Select all
that apply.)
a. Temperature regulation
b. Sensory perception
c. Identification
d. Protection ✅- All answers are correct
The skin regulates temperature through changes in its blood flow and through sweating.
The skin provides sensory information through its nerve endings. Fingerprints allow for
identification of individuals. The skin and mucous membranes are the first line of defense
against injury and invasion of microorganisms.
Which of the following is an ABNORMAL finding when observing Water Sealed Chest
Drainage for proper functioning?
a. Bubbling initially with coughing and deep inspiration
b. Continuous bubbling where the water seal is maintained
c. Water level fluctuations with breathing
d. A collection chamber that is less than 1/2 full ✅- B
Hyperolality ✅- Symptom of dementia associated with the 3rd stage of Alzheimer's
disease
An elderly patient has been living in a nursing home for several years. The nursing staff has
begun to notice a change in her behavior. All of the following are symptoms of depression
except:
a. Changes in sleep patterns
b. Changes in eating patterns with weight loss
c. Excessive fatigue and increased concern with bodily functions
d. Hyperorality ✅- D
The census on the unit is 90 percent and there are no private rooms available. An elderly
client with influenza is admitted. Which of the following rooms would it be appropriate to
assign this client?
a. A double room with a client admitted for impetigo.
b. A double room with another client with the same diagnosis.
c. A four-bed room with three clients who have had orthopedic surgery.
d. A double room with an elderly client with a diagnosis of chickenpox. ✅- B
If a private room is not available, the client should be placed with another client with the
same diagnosis where droplet precautions would already be in place. The staff and visitors
should be told to stay at least 3 feet away without a mask because large-particle droplets
travel only about 3 feet before falling from the air.
You are assigned to teach a nursing student how to suction an adult patient with a
tracheostomy. Which of the following actions by the nursing student would be INCORRECT?
a. Pre-oxygenation of the patient with a Resusibag at 100% 02 several times before
suctioning
b. Maintains wall suction pressure at 110-150mmHG
c. Does not suction for greater than 10-15 seconds at a time
d. Applies gentle intermittent pressure and rotates catheter during insertion phase of
suctioning ✅- D
In suctioning a patient with a Tracheostomy, the nurse should employ all of the above
choices, except choice (4). However, when the catheter is inserted it should be done gently,
and to a depth of 10-12.5cms (4-5"s) or until the patient begins to cough. Suction should
never be applied when inserting the catheter, not should it be rotated during this period.
Suction should be applied by occluding the Y-port with the thumb of the unsterile gloved
hand, while the catheter is rotated gently during withdrawal. The patient should never be
suctioned for more than 10 seconds at one time to avoid the development of hypoxia.
When a client has suffered severe burns all over his body, the most effective method of
monitoring the cardiovascular system is a. Cuff blood pressure.
b. Arterial pressure.
c. Pulmonary artery pressure.
d. Central venous pressure. ✅- C
When is the first dose of Hep B given? ✅- In the hospital at birth
An adult has just died. How should the nurse prepare the body for transfer to the mortuary?
a. Leave the body as is, no prep needed
b. Bathe the body and put ID tags on it
c. Remove dentures before bathing body
d. Position the body with its head down and arms folded on its chest. ✅- B
A patient has decreased cardiac output following a surgery. What will the nurse likely see in
this patient?
a. Decreased urine output
b. Increased urine output
c. Flushing of the skin
d. Hyperventilation ✅- A
The nurse counts an adult's apical heart beat at 110 beats per min. The nurse describes this
as
a. asystole
b. bigeminy
c. tachycardia
d. bradycardia ✅- C
A client as an elevated AST 24 hours following chest pain and shortness of breath. This is
suggestive of which of the following? a. Gallbladder disease
b. Liver disease
c. Myocardial infarction
d. Skeletal muscle injury ✅- C
AST is an enzyme released in response to tissue damage. AST rises 24 hours after an MI. It
will also rise with liver and skeletal muscle injuries
An adult has a coagulation time of 20 minutes. The nurse should observe the client for
which of the following? a. blood clots
b. Ecchymotic areas
c. jaundice
d. infection ✅- B
A prothrombin time test should be performed regularly on persons who are taking which
medication? a. Heparin
b. Warfarin
c. Phenobarbital
d. Digoxin ✅- B
Which prothrombin time value would be considered normal for a client who is receiving
warfarin?
a. 12 seconds
b. 20 seconds
c. 60 seconds
d. 90 seconds ✅- B
The nurse is caring for a client who is receiving heparin. What drug should be readily
available?
a. Vitamin K
b. Caffeine
c. Calcium gluconate
d. Protamine sulfate ✅- D- The antidote for heparin
Vit K is antidote for Coumadin
During the admission interview, a client who is admitted for a cardiac catheterization says,
"Every time I eat shrimp I get a rash". What action is essential for the nurse to take at this
time?
a. Notify the physician
b. Ask the client if they get a rash from any other foods
c. Instruct the dietary department not to give the client shrimp
d. Teach the client the dangers of eating shrimp and other shellfish ✅- A
When a client returns from undergoing a cardiac cath, it is most essential for the nurse to
a. Check peripheral pulses
b. Maintain NPO
c. Apply heat to the insertion site
d. Start range of motion exercises immediately ✅- A
An adult who is receiving heparin asks the nurse why it cannot be given by mouth. The
nurse responds that heparin is given parenterally because a. it is destroyed by gastric
secretions
b. It irritates the gastric mucosa
c. It irritates the intestinal lining
d. Therapeutic levels can be attained more therapeutically ✅- A--Because of this it is given
either subq or IV
A client with asbestosis must see his doctor regularly for a check up. What is the primary
reason for him to have frequent checkups?
A. Patients with asbestosis are at high risk for developing bronchogenic cancer.
B. His doctor is monitoring him closely to look for signs of improvement.
C. Patients who use low flow oxygen for long periods are at high risk for developing
neurological symptoms.
D. Periodic sputum samples are needed to follow the progress of the disease. ✅- A
An order is written for oxygen by nasal cannula at 2 liters per minute. In assessing the
adequacy of the oxygen therapy, which of the following is most effective? A. Checking
the respiratory rate.
B. Checking the color of mucous membranes.
C. Measurement of pulmonary functions.
D. Measurement of arterial blood gasses ✅- D
A patient is admitted with histoplasmosis. Which item in the patient's history is most likely
related to the onset of the disease? A. He works in a factory.
B. He likes to explore caves.
C. He has three cats.
D. He smokes four packs of cigarettes a week. ✅- B-- Histoplasmosis is caused by a fungus
that grows in chicken and bat manure. Bats live in caves...
The nurse in a medical unit is caring for a client with heart failure. The client suddenly
develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects
pulmonary edema. The nurse immediately notifies the registered nurse and expects which
interventions to be prescribed? Select all that apply.
Administering oxygen
Administering Digoxin
Inserting a Foley catheter
Administering furomeside (Lasix)
Administering morphine sulfate intravenously ✅- Administering oxygen
Inserting a Foley catheter
Administering furomeside (Lasix)
Administering morphine sulfate intravenously
The nurse is caring for a client with left-sided heart failure. Which clinical signs are most
important for the nurse to communicate to the health care provider? Select all that apply.
Pink-tinged frothy sputum
Decrease in respiratory rate
Increase in respiratory rate
Yellow tinged sputum
Auscultation of crackles throughout the lungs ✅- Pink-tinged frothy sputum
Increase in respiratory rate
Auscultation of crackles throughout the lungs
The nurse is caring for a client who is developing pulmonary edema. The client exhibits
respiratory distress, but the blood pressure is unchanged from the client's baseline. As an
immediate action before help arrives, the nurse should perform which action?
A. Place the client in high-Fowler's position
B. Lie the client flat
C. Place client in prone position
D. Place client in Semi-Fowler's ✅- A
A client has just returned from the cardiac catheterization laboratory. The left femoral
vessel was used as the access site. After returning the client to bed, the nurse places a sign
above the bed stating that the client should remain on bed rest and in which position?
A. With the head of the bed elevated no more than 15 degrees
B. At a 30-45 Degree angle
C. Lying flat
D. High-Fowler's ✅- A
A client with myocardial infarction suddenly becomes tachycardic, shows signs of air
hunger, and begins coughing frothy, pink-tinged sputum. The nurse listens to breath
sounds, expecting to hear which breath sounds bilaterally?
A. Wheezes
B. Scratching
C. Crackles
D. Air ✅- C
Blood flows to the
atrium from the superior and inferior vena cavae ✅- right
Blood flows from the right atrium to the right ventricle via the
Blood flows from the right ventricle to the lungs for
Blood flows from the
to the left atrium ✅- lungs
valve ✅- tricuspid
✅- oxygenation
Blood flows from the left atrium via the
Blood flows from the
valve to the left ventricle ✅- mitral
ventricle to the aorta and then to the systemic circulation ✅- left
The nurse is caring for a client who has had a recent myocardial infarction involving the left
ventricle. Which assessment finding is expected? a.
Faint S1 and S2 sounds
b.
Decreased cardiac output
c.
Increased blood pressure
d.
Absent peripheral pulses ✅- B
The myocardium is the layer responsible for the contractile force of the heart. Damage to
this layer can result in decreased cardiac output. This most likely would result in decreased
blood pressure and strength of peripheral pulses. Absent peripheral pulses would be
caused by an arterial occlusion. S1 and S2 most likely would not be affected.
The nurse is assessing a client following a myocardial infarction. The client is hypotensive.
What additional assessment finding does the nurse expect? a.
Heart rate of 120 beats/min
b.
Cool, clammy skin
c.
Oxygen saturation of 90%
d.
Respiratory rate of 8 breaths/min ✅- A
When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure
decrease in the vessels. The parasympathetic system responds by lessening the inhibitory
effect on the sinoatrial (SA) node. This results in an increase in heart rate. This tachycardia
is an early response and is seen even when blood pressure is not critically low.
The nurse is caring for a client with coronary artery disease. What assessment finding does
the nurse expect if the client's mean arterial blood pressure decreases below 60 mm Hg? a.
Increased cardiac output
b.
Hypertension
c.
Chest pain
d.
Decreased heart rate ✅- C
Coronary artery blood flow occurs primarily during diastole. Mean arterial pressure (MAP)
of 60 mg Hg is necessary for adequate blood flow to coronary arteries, and MAP of 60 to 70
mm Hg is necessary for adequate perfusion to major body organs. If MAP decreases to
below 60 mm Hg, the client with cardiac disease may have chest pain. Cardiac output most
likely would decrease, and blood pressure also would decrease. Heart rate may increase as
the body initiates compensatory mechanisms.
The nurse administers a beta blocker to a client after a myocardial infarction. What
assessment finding does the nurse expect? a.
Blood pressure increase of 10%
b.
Increasing respiratory rate
c.
Increased cardiac output
d.
Pulse decrease from 100 to 80 beats/min ✅- D
Beta blockers block the stimulation of beta1-adrenergic receptors. They block the
sympathetic (fight-or-flight) response and decrease the heart rate (HR). The beta blocker
will decrease HR and blood pressure, increasing ventricular filling time. It usually does not
have effects on beta2-adrenergic receptor sites. Cardiac output will drop because of
decreased heart rate.
The nurse is assessing clients at a community health center. Which client does the nurse
determine is at high risk for cardiovascular disease? a.
Older adult man with a history of asthma
b.
Asian-American man with colorectal cancer c.
American Indian woman with diabetes mellitus d.
Postmenopausal woman on hormone therapy ✅- C
The incidence of coronary artery disease and hypertension is higher in American Indians
than in whites or Asian Americans. Diabetes mellitus increases the risk for hypertension
and coronary artery disease in people of any race or ethnicity.
A nurse is performing an admission assessment on an older adult client with multiple
chronic diseases. The nurse assesses the heart rate to be 48 beats/min. What does the
nurse do first?
a.
Document the finding in the chart.
b.
Evaluate for a pulse deficit.
c.
Assess the client's medications. d.
Administer 1 mg of atropine. ✅- C
Pacemaker cells in the conduction system decrease in number as a person ages, resulting in
bradycardia. The nurse should check the medication reconciliation for medications that
might cause such a drop in heart rate, then should inform the health care provider.
Documentation is important, but it is not the priority action. The heart rate is not low
enough for atropine to be needed
Fundamentals HESI Test 55 Questions Answered.
1. Older female client can't sleep at night. Nurse recommends SATA A.
Take afternoon nap
B. Ask HCP for prescription of mild sedative at bedtime
C. Establish regular time for getting up and going to bed
D. Drink whiskey, water and honey before bed
E. Avoid drinking caffeine before bedtime ✅- Ans: C, E
2. The nurse has been alerted by the EMR when scanning the dispensed medication that the
dosage is two times higher than the prescribed dose. The nurse should:
A. Report mismatch of prescription and available dosages
B. Withhold medication until exact dose is available
C. Ask pharmacy if another dose can be dispensed
D. Calculate dose on hand to match the prescribed dose ✅- Ans: D
3. A patient diagnosed with small bowel obstruction refuses surgery. The nurse should:
A. Assess client needs for antiemetics and pain medications
B. Prepare nasogastric tube compress
C. Sent patient to CT abdominal scan
D. Notify HCP that patient refuses surgery ✅- Ans: D
4. What is the most important factor for obesity referral? A.
BMI >35
B. Client expressed desire to lose 50 pounds
C. Body weight is 10% over ideal weight
D. Daily calorie intake is 3,500 ✅- Ans: A
5. An elderly patient returns to the clinic for chronic pain management. He is prescribed MS
Contin PO Q12H. He states that he only takes it when the pain is so severe that he can't
sleep.
A. Long time use of opioids may cause drug addiction
B. Take medication Q12H as prescribed
C. Teach alternative methods for pain management
D. Continue taking MS Contin for severe pain. ✅- Ans: B
6. IM ventrogluteal landmark
A. Upper outer quadrant of buttock
B. Deltoid
C. Knee and greater trochanter
D. Greater trochanter and anterior superior iliac spine ✅- Ans: D
7. A client with a nasogastric tube is receiving low intermittent suction and is complaining
of dry mouth. What should the nurse implement?
A. Tell the client that the mucosa must stay dry to prevent aspiration
B. Turn off suction so that the client can rinse his mouth with cold water
C. Provide oral sponge toothettes so the client can clean and moisten his mouth
D. Instill 50 mL of normal saline and clamp ✅- Ans: C
8. A client who is 12 days post op complains of thoracic incisional pain 2 hours after he
received his pain medication. The HCP has been called. What should the nurse do next? A.
Guided imagery and deep breathing
B. Turn on a T.V. show and music for distraction
C. Put a hot device on the area
D. Provide a 20 minute back massage ✅- Ans: A
9. A post-op patient is grimacing when moving from bed to chair but denies pain. What
should the nurse do next?
A. Administer pain medication PRN
B. Review his pain medications that are prescribed
C. Monitor patient's nonverbal actions
D. Ask what is making him grimace ✅- Ans: D
10. A client is on a mechanical soft diet and is constipated. He requests for prune juice. The
nurse should:
A. Restrict fluid
B. Initiate bowel training protocol
C. Advance to regular diet
D. Offer to warm up the prune juice ✅- Ans: D
11. The nurse is assessing a client's ability to perform activities of daily living (ADL) safely.
The client has steady gait and is able to ambulate from the door to the bed with full ROM.
The nurse should:
A. Teach the client to take shorter strides for better balance
B. Record client's ability to perform ADL safely
C. Initiate fall risk protocol
D. Determine client's activity tolerance ✅- Ans: D
12. A patient is demonstrating diaphragmatic breathing by holding her abdomen while
inhaling and removing her hands during exhalation.
A. The demonstration was successful
B. The hands do not need be on the abdomen, but the demonstration was still correct
C. Keep light pressure on abdomen and cough after inspiration
D. Expand abdomen during inspiration and let the abdomen sink during exhalation ✅Ans: D
13. Highest priority?
A. Impaired bed mobility
B. Fluid volume deficit
C. Bowel incontinence
D. Caregiver role strain ✅- Ans: B
14. The computer system shuts down while the nurse was inputting client data. What
should the nurse do next?
A. Print EMR from backup server
B. Wait for notification that the EMR is rebooted
C. Identify information as late entry
D. Notify IT ✅- Ans: D
15. The student nurse assesses an adult client's TM by pulling the ear up and back. The
preceptor:
A. Provides positive reinforcement to the student nurse for using correct technique B.
Tells the student nurse that the ear should be pulled down ✅- Ans: A
16. How should the nurse instruct the mother of an adolescent with Diabetes Type 1 to
inject insulin? [Picture of injection at deltoid]
A. Correct her to the proper injection site
B. Instruct mother how to insert needle with dart-like motion ✅- Ans: B
17. A client in pre-op reports "I feel funny all over...my belly feels weird" right before
surgery. What is the nurse's best response?
A. "Describe what your HCP told you regarding your surgery."
B. "You say you feel funny everywhere. Is it located mostly in your stomach?"
C. "Are you becoming frightened?"
D. "Tell me more about the feelings in your belly." ✅18. Which related data should be obtained if a client is wheezing?
A. Radiates to other parts of the body
B. Heart sounds
C. Body temperature
D. Precipitating factors ✅- Ans: D
19. Picture of a nurse about to open an ampule. What should the nurse do next? A.
Clean neck of ampule with alcohol
B. Position gauze around neck of ampule
C. Apply clean gloves before breaking the ampule open
D. Snap neck away from hands ✅- Ans: B
20. UAP is not fitted for a respirator mask and requests to be re-assigned from a client with
droplet precautions. The charge nurse should:
A. Before changing assignments, check to see which nurses are fitted for the respirators B.
Send UAD to get fitted for the respirator immediately so that she can return to take care of
the patient
C. Tell the UAP that she can wear a standard mask during vitals and use a respirator mask
for other tasks
D. Tell the UAP that a standard face mask is sufficient ✅- Ans: D
21. Patient complains that he hates how his boss orders him around and how he doesn't
listen to his ideas. What is the nurse's best response?
A. "I'm sure that it will get better with time."
B. "It must be difficult for you to work in a place that makes you feel so bad."
C. "How do you feel when your boss doesn't listen to you?"
D. "You should change how you interact with your boss." ✅- Ans: C
22. A Native American client complains of abdominal cramping and nausea. What is the
most important factor to assess?
A. Family decision-making regarding health
B. Recent use of home remedies and herbs
C. Employment status ✅- Ans: B
23. A patient with a latex allergy needs a dressing change. The nurse notices redness on the
skin around the draining wound. The nurse should: A. Obtain sample from draining wound
B. Replace dressing with cotton gauze and silk tape
C. Measure ankle to brachial index
D. Administer antibiotics ✅- Ans: B
24. A nurse is educating a client on 24-hour urine test. The client states that the first void is
in the urinal.
A. Add the urine from the urinal to the collection container
B. Start collecting with next void
C. Start collecting the next day
D. Check urine for sediments ✅- Ans: B
25. A Muslim female comes to the clinic for an initial assessment
A. Obtain most of her history from her family members
B. Determine what the client consider to be her ethnicity ✅- Ans: B
26. Which outcome is appropriate for the planning stage?
A. The client will adhere to medication after discharge
B. The client will successfully demonstrate dressing change within 2 days of hospitalization
C. The nurse will assess the patient every 2 hours ✅- Ans: B
27. Which is the most appropriate method to teach young adults? A.
Simulation activities
B. Positive reinforcement
C. Physical demonstrations
D. Verbal analogies ✅- Ans: A
28. What to assess first for a client with cyanosis
A. Temperature
B. Heart rate
C. Blood pressure
D. Respiratory rate ✅- Ans: D
29. What should the nurse implement when inserting an indwelling catheter to an
uncircumcised male.
A. Clean meatus before retracting the foreskin
B. Advance catheter before inflating balloon
C. Sterile field should be even between nurse's hips
D. Wipe the meatus back and forth ✅- Ans: B
30. A nurse notices a fire in the bathroom of an empty room and reports the location of the
fire immediately. What should the nurse do next? A. Close the door to all the client's rooms
in the hallway
B. Evacuate clients in the rooms close to the fire
C. Shut the door to the bathroom and the empty room
D. Obtain fire extinguisher on the unit ✅- Ans: C
31. HCP tells the nurse that he will be prescribing a placebo to a client. The nurse should:
A. Inform the nurse supervisor and refuse to administer placebo
B. Administer the placebo to the client
C. Inform the patient that he will be receiving a placebo
D. Discuss ethical concerns with HCP ✅- Ans: D
32. Proper method of wound care
A. Cleaning outwards to inward
B. Cleaning inward to outward
C. Cleaning back and forth
D. Wiping sterile cotton swab twice ✅- Ans: B
33. A nurse walks into a client's room to see him coughing non-productively into his upper
sleeve. The nurse should:
A. Obtain face masks for all staff entering client's room
B. Teach client how to cough into his hands
C. Provide tissues for the client to cough into ✅- Ans: C
34. A client has concerns and fears about his new temporary pacemaker. The nurse should:
A. Encourage discussion about concerns and fears
B. Use simple terms how pacemaker functions
C. Offer reassurance that pacemaker his temporary
D. Reminds him that the pacemaker will be monitored at all times ✅- Ans: A
35. A client with a new exercise regimen states that it still takes him an hour to fall asleep.
The nurse should:
A. Tell the client that it usually takes a few weeks for the body to regulate a new exercise
regimen
B. Ask client to describe his exercise regimen ✅- Ans: B
36. Order: 1.2 Million units. Available: 600,000 units in 2 mL. Give how many mL?
1,200,000 U x 2 mL = 4 mL
600,000 U ✅37. Order: 1200 mg divided in 3 doses. Available: 400 mg in a capsule. How many capsules
in one dose?
1200 mg x capsule = 1 capsule
3 doses 400 mg dose ✅38. A confused elderly patient is having trouble sleeping and is often found wandering the
halls. The nurse should:
A. Administer PRN sedative
B. Have client's room door open slightly
C. Provide back rub before bed
D. Apply soft wrist restraints to prevent wandering ✅- Ans: C
39. Intervention for skin turgor in aging client:
A. Bathe daily with mild soap and water
B. Apply lubricating lotion to skin ✅- Ans: B
40. A mother requests to see her 18 year-old lab results. What is the nurse's best response?
A. I will give you the results when it is back.
B. I can only give the results to your son. He is an adult.
C. The healthcare provider will give you the results. ✅- Ans: B
41. What should the nurse do when interviewing a client about sexual and
reproductive matters? ✅- Ans: Begin with less sensitive topic
42. What should be monitored when assessing for water intoxication? A.
Serum sodium levels
B. Serum potassium levels
C. Creatine ✅- Ans: A
43. A client is on a full liquid diet for "Volume deficit related to less than required oral
intake." What should the nurse give to the client?
A. Beef or chicken broth
B. Ensure
C. Low-fat milk
D. Apple or grapefruit juice ✅- Ans: B
44. What is the purpose of logrolling?
A. Maintain straight spinal alignment
B. Rolling has less friction than pulling
C. Safer for multiple nurses to move client ✅- Ans: A
45. A client with heart failure states that she does not want heroic measures performed if
cardiac arrests.
A. Discuss what heroic measures mean to her
B. Obtain DNR order ✅- Ans: A
46. A client on nasal cannula 3L/min has O2 saturation of 91%.
A. Apply lubricant to the tubing
B. Discontinue nasal cannula use
C. Put padding around NC tubing
D. Decrease oxygen to 1L/min ✅- Ans: C
47. Which factor is most important when selecting blood pressure cuff?
A. Limited ROM
B. 89 year-old
C. BMI of 15
D. Female ✅- Ans: C
48. Which client has the highest risk of nosocomial infection? ✅- Ans: Cancer patient
receiving immunosuppressed medication
49. A post-op client has concerns with using his bedpan. He is prescribed activity from bed
to chair at least 3 times a day. ✅- Ans: Encourage client to use bedside commode
50. A nurse is providing passive ROM pronation and supination on an adolescent. What
should the nurse do next? [Picture of adolescent hand on nurse's hand in pronation).
✅- Ans: Turn hand so palm faces up
51. Active ROM of hinge joints
A. Extend arm at side and rotate in circles
B. Flexing ulnar to humerus
C. Rotating hips ✅- Ans: B
52. Priority assessment for client with 2.9 serum potassium level. A.
Deep tendon reflexes
B. Heart rate and rhythm ✅- Ans: B
53. What is the most important thing to assess prior to applying a heating pad? ✅- Ans:
Degree of neurosensory impairment
54. The family of a confused client remove her restraints and left. What should nurse do?
A. Call HCP for renewal order of restraints
B. Continue to monitor client
C. Reassess need to continue restraints
D. Reapply the restraints ✅- Ans: C
55. Hospice SATA
A. Provides comfort and dignity
B. Can be at home
C. Living will not active in hospice
D. Services can be initiated before discharge
E. Family members can be involved in care ✅- Ans: A, B, D, E
PN Hesi Fundamentals Questions and Answers
Which assessment should the practical nurse (PN) make to best evaluate a client's fluid
status? ✅- Daily body weight
The practical nurse (PN) is changing a postoperative dressing for a client with a horizontal
lower abdominal incision. What method should the PN use to remove the tape from the
dressing? ✅- Remove all four sides by moving to the center of the incision.
A male client ho is 2 days postoperative for exploratory abdominal surgery is ambulating in
the hall with the practical nurse (PN). The client tells the PN, "I think something in my
incision just let go." Which action should the PN implement first? ✅- Assist the client to a
supine position.
An older client who is unable to swallow is receiving continuous NGT feeding. Before
administering medications through the NGT, what action should the practical nurse
implement? ✅- Flush the feeding tube with water.
Which action should the practical nurse implement to help a male client cope with his fear
as he approaches death? ✅- Hold the client's hand and tell him he is no alone.
The practical nurse is giving oral care to an older female client with tender gums that bleed
easily because of a medication she is taking. What intervention should the PN implement?
✅- Obtain a soft-bristle brush for the client.
The practical nurse is caring for a client who is admitted with influenza and vomiting for 3
days. The clients skin turbot is poor and oral mucous membranes are dry. Which finding is
most important for the PN to report to the charge nurse? ✅- Hypotension and tachycardia
Which food should the practical nurse recommend for a client to increase the dietary intake
of potassium? ✅- Baked potatoes
When irrigating the external ear canals of an older adult client, which action should the PN
use to soften dry cerumen for removal? ✅- Instill mineral oil in the external auditory canal
overnight before irrigation.
An older female state the medication tablet brought in a cup looks different from the tablet
that she takes at home. Which action should the practical nurse take? ✅- Check the written
prescription to verify the medication
Which action should the PN implement when administering a subcutaneous injection to a
client who weighs 325 pounds? ✅- Select a needle with a longer shaft
Which intervention provides confirmation of NGT placement before NGT feedings are
started? ✅- X-ray of the abdomen
An older male client who is incontinent receives a prescription for a condom catheter.
Which steps should the PN implement when applying the external catheter. ✅- Wrap the
adhesive strip in a spiral around the penis
Apply skin prep to the penile shaft and allow to dry
Leave 1-2 inches between the tip of the penis and condom catheter
Acetaminophen is prescribed for an unconscious client with a temp of 104' F. Which route
should the PN plan to administer this medication? ✅- Rectal
An older male client who is sedentary complains of not having a formed bowel movement
in four days and tells the PN that he feels rectal pressure and has a constant headache. The
PN determines the client is having frequent small, liquid stools. Which nursing action
should the PN take first? ✅- Digitally assess for impacted stool.
The PN is adding tap water to several medication for administration via feeding tube.
Which preparation should the PN administer without delay? ✅- Time release capsule
Which action should the PN follow when applying an elasticize bandage to a client's leg?
✅- Overlap turns of the bandage equally
The PN obtains an elevated blood pressure reading for an older male client is is alert. When
the PN offer the client his morning blood pressure medication, he refuses to take it. What
action should the PN take? ✅- Explain the importance of routine use of antihypertensives.
What position should the PN place client in who is receiving an enteral tube feeding? ✅Supine with the head of bed elevated to 30-45 degrees.
The PN is preparing an intramuscular injection for a client who is 5 feet tall and weighs 90
pounds. Which needle size should the PN select for a 3 mL syringe when using the IM
ventrogluteal injection site? ✅- 1 inch
An older male client tells the PN that his religion does not permit him to bathe daily. How
should the PN respond? ✅- Request that the client clarify his religious beliefs about
bathing.
The PN identifies several findings in an older female who is on prolonged bed rest. Which
finding requires prompt action by the PN? ✅- Bowel movements decreases to one every
third day.
A client is prescribed a medication that is labeled as a sustained released (SR). What action
should the PN implement when administering this drug form? ✅- Do not crush or dissolve
the table or capsule contents
The practical nurse is checking the surgical dressing for a client who arrived on the
postoperative unit an hour ago. The dressing has an increase in the accumulation of
serosanguinous drainage. What nursing action should the PN take? ✅- Mark the outlined
area of drainage with date, time and initials
A client with gastroenteritis, nausea and vomiting is currently on NPO status. The
healthcare provider prescribed oral intake to be advanced as towered. Which fluid should
the PN offer first? ✅- Water
Which time frame should the PN res position a client? ✅- Every 2 hours
While taking an adult's vital signs, the PN notes an irregular radial pulse. What action
should the PN implement to obtain the most accurate assessment? ✅- Perform an
apicalradial pulse assessment with another nurse
The practical nurse is providing wound care for a client with a stage III pressure ulcer on
the left heel. To achieve the goal, "An increase granulation tissue will develop within 2
weeks," which intervention should the PN implement.? ✅- Irrigation of the wound with
sterile normal saline
A client receiving supplemental oxygen needs to be suctioned to remove excess secretions
from the airway. Which intervention should the PN implement to maximize the client's
oxygenation? ✅- Provide oxygen during rest periods between suctioning.
An older client who complains of dry mouth is having trouble swallowing pills. What action
should the PN take when administering an enter-coated tablet? ✅- Place the whole tablet
in a spoonful of pudding.
The PN is assisting a client plan a balanced vegetarian diet that provides the highest in
protein quality. Which selection should the PN recommend to the client? ✅- Soybeans
The PN observes a client who begins to choke during a meal. After determining that the
client cannot speak, what action should the PN implement? ✅- Place a fist halfway
between the xiphoid process and umbilicus.
The practical nurse is irrigation a clients indwelling catheter. After injecting sterile solution
as prescribed what action should the PN implement? ✅- Unclamped the tubing and lower
the collection bag.
The PN hears breath sounds that are short, popping, and discontinuous on inspiration
when auscultations a clients lungs. Which description should the PN document in the
clients record? ✅- Crackles auscultated
A male client is upset with the healthcare providers recommendation that he should
consent to an above-knee amputation. He tells the PN, "If they want to cut off my left, they
should just shoot me instead." How should the PN respond? ✅- As the client how the
surgery might effect his lifestyle
Which findings indicates to the PN that an older client who is receiving intravenous therapy
is experiencing fluid overload? ✅- Crackles in the lungs
Which action should the PN implement when supporting an older client who is afraid of
dying? ✅- Use open-ended questions to encourage the client to share feelings
A client is receiving a continuous tube feeding. While checking the gastric residual volume,
the PN aspirated 150 mL of gastric contents. What action should the PN take? ✅- Return
all aspirated fluid to the stomach followed with water and consult agency policy.
The PN is assessing a client with dark skin who is in respiratory distress. Which client
response should the PN evaluate to determine cyanosis in the client? ✅- The lips and
mucous membranes of a client with dark skin are dusky in color
Which intervention should the PN implement to help a client cope effectively with chronic
pain? ✅- Encourage using relaxation techniques.
Which growth and developmental characteristics should the PN consider when discussing
spiritually with an adolescent client? ✅- Questions religious practices and values.
During the insertion of a NGT into the right nares, the client starts to cough. Which action
should the PN implement? ✅- Withdrawal the NGT to the oral pharynx, reposition the
clients head and reinsert.
Which intervention should the PN use to prevent obstruction of a gastric feeding tube? ✅Obtain a prescription for a liquid drug form instead of crushing tablets.
A male Native American client with TB is visiting a health care clinic for a follow up
treatment. During the interview, the PN notices that the client keeps his eyes on the flow
and does make eye contact. How should the PN interprets this client's behavior? ✅- His
culture finds sustained eye contact rude or disrespectful
An 80 year old male client who has arthritis and who is having difficulty walking tells the
PN, "It's awful to be old. It's seems as though everyday is a struggle. No one cares about an
old person." What is the best response for the PN to provide? ✅- It's sounds as though you
are having a difficult time. Tell me about it.
An older female recently diagnosed with coronary artery diesel cooks at home using
saturated fats. Which intervention should the PN implement to help the client reduce
modifiable risk factors? ✅- Encourage food preparation with various vegetable oils
What position should the PN place a client in who is receiving an enteral tube feeding? ✅Supine with the HOB elevated to 30-45 degrees.
The PN is applying a dry, sterile dressing to a clients abdominal wound. Which allergy
should the PN verify with the client? ✅- Tape
Which food should the PN recommend to a client as a source of complete protein? ✅- Eggs
In planning care for an older client on bed rest, which intervention should the PN include in
the prevention of pressure ulcers? ✅- Elevate the HOB less than 30 degrees
Which action by the PN demonstrates the value of dignity in client care? ✅- Closes the
doors and covers the client during a bath.
The PN is obtaining information for a male clients psychosocial assessment. Which action
should the PN implement first? ✅- Establish a therapeutic relationship
What is the most important for the PN to include when performing pain assessment after
giving an analgesic? ✅- Use a pain scale to describe the intensity.
The PN is obtaining the vital signs for a client who has a urinary tract infection with MRSA.
How should the PN proceed? ✅- Don a gown and gloves before entering the room.
An older client who is admitted to the hospital with dehydration and electrolyte imbalance
is confused and incontinent of urine. Which action provides the best strategy to the PN to
implement for the clients incontinence? ✅- Establish a 2 hour voiding schedule
When irrigating the eyes of a client, which action should the PN implement? ✅- Direct the
irrigation flow from the inner canthus to the canthus of the affected eye.
A client whose diet is low in fiber is at risk for which condition? ✅- Colon cancer
Which position is best for the PN to place the client in during administration of a rectal
suppository for constipation? ✅- Left sims position with upper leg flexed.
Which information should the PN provide a client who is selecting a site for self injection of
insulin? ✅- Rotate sites with the same location for a week before choosing a new location
The PN is caring for an older client who is NPO after surgery. The client complains that his
mouth and mucous membranes are dry. Which intervention should the PN implement to
increase the clients comfort? ✅- Perform oral hygiene frequently.
The PN is preparing to reconstitute a drug from powder form for IM administration. Which
step should the PN implement first? ✅- Verify the drug with MAR
Following a cholecystectomy, a client ask the PN about dietary restrictions that may need to
be followed. Which diet should the PN recommend? ✅- A well balanced diet with no other
restrictions
A client is receiving a daily script for Lasik 40 mg PO but is unable to swallow. The PN
should consult with the healthcare provider about which component of the prescription?
✅- The route of adminstration
A family member of a dying client asks the PN if the client knows the family is at the
bedside. The PN explains that which of the five senses persist the longest during the dying
process? ✅- Hearing
Which technique should the PN nurse use to give a Z-track IM injection? ✅- Inject the med
into the dorsal gluteal site
A client who has pressure relieving mattress overly is mobilized to a chair and imprints of
the client buttocks, heels, and scapula are evident on the mattress overlay. What action
should the PN implement? ✅- Apply a different pressure relieving device and assess its
effectiveness for this client
Which technique should the PN use to most accurately assess a clients baseline blood
pressure during a routine health examination? ✅- Measure the pressure in each arm while
the clients sits with the arm supported at heart level.
What nutritional information should the PN provide a client with heart failure? ✅- Restrict
dietary sodium intake
Which interventions should the PN implement to reduce the incidence of UTI in a client
with an indwelling catheter? ✅- Cleanse the peri area with soap and water BID and PRN
The PN identifies a clients need for spiritual support. What is the first action the PN should
take? ✅- Determine the clients perceptions and belief systems.
A client is receiving a Mantoux test for TB screening. Which angle should the PN insert the
needle for injection? ✅- 15 degrees
A client with cancer who has been taking opioid analgesics for two years now requires
increased doses to obtain pain relief. The client expresses fear about becoming addicted to
these drugs. What information should the PN provide? ✅- Prescribe opiates for cancer
pain relief improve qualify of life.
What action should the PN take when drawing meds from an ampule? ✅- Aspirate with a
filter needle and syringe.
The PN contacts the healthcare provider about an older client who is agitated and
aggressive with the staff. Which reason should the PN use to request a prescription for
wrist restraints? ✅- To ensure the clients safety when the benefits outweighs the risks.
An older client is receiving NGT feedings for several days. Which finding should the PN
report to the healthcare provider? ✅- Abdominal distention and nausea
A client reports feeling dizzy and lightheaded when moving from a supine position to a
sitting position. What is the PN priority intervention? ✅- Obtain orthostatic blood
pressures.
HESI Fundamentals Exam Test Bank; Complete Review A+ guide.
What can a blood pressure cuff that's too narrow cause? ✅- falsely elevated BP reading
this insulin should be drawn up into the syringe first so it doesn't contaminate the other
type of insulin ✅- regular
rumbling sounds heard on lung auscultation ✅- rhonchi
this type of adventitious lung sounds can be more pronounced during expiration than
during inspiration ✅- rhonchi
forced feeding, usually through a gastric tube ✅- gavage
a tube passed into the stomach through the mouth ✅- gastric tube
What portion of Maslow's hierarchy of needs has the highest priority? ✅- physiologic
needs (air, water, food, shelter, activity, comfort)
this is the safest and surest way to verify a patient's identity ✅- check the ID band on wrist
What is the primary concern in the therapeutic environment? ✅- patient safety
What does fluid oscillation in the tubing of a chest drainage system indicate? ✅- system is
working properly
What position should a nurse place a patient who has a Sengstaken-Blakemore tube? ✅semi-Fowlers
How can a nurse elicit Trousseau's sign? ✅- occluding the brachial or radial artery
What indicates Trousseau's sign? ✅- hand and finger spasms during occlusion
What does Trousseau's sign suggest? ✅- hypocalcemia
What is the appropriate needle size for adult blood transfusions? ✅- 16 to 20G
this type of pain is incapacitating and can't be relieved by drugs ✅- intractable pain
How can a consent for treatment be obtained in an emergency? ✅- fax, telephone (or other
telegraphic means)
the unit of measurement of sound ✅- decibel
this is required for any invasive procedure ✅- informed consent
What must a patient do who can't write their name to give consent for treatment? ✅- make
an X in the presence of two witnesses (such as a nurse, priest, or physician)
this IM injection method seals the drug deep into the muscle ✅- Z-track method
this IM injection method minimizes skin irritation and staining ✅- Z-track method
What length needle is required for the Z-track IM injection method? ✅- 1" or longer
What acronym is often used in the event of a fire? ✅- RACE (REMOVE the patient,
ACTIVATE the alarm, Attempt to CONTAIN the fire by closing the door, EXTINGUISH the fire
if it can be done safely)
Who should be assigned to a registered nurse to perform bedside care, such as suctioning
or drug administration? ✅- LPN (or licensed vocational nurse)
What must be done if the patient cannot void? ✅- bladder palpation to assess for bladder
distention
What side should the patient who uses a cane carry it on? ✅- unaffected side
How should a patient use a cane? ✅- advance it at the same time as the affected extremity
How is a supine patient fitted for crutches? ✅- measure from the axilla to the sole and add
2" to the measurement
What is the timeline for assessment? ✅- begins with the nurse's first encounter with the
patient and continues through the patient's stay
How does the nurse obtain assessment data? ✅- health history, physical examination,
review of diagnostic studies
What is the appropriate size needle for insulin injection? ✅- 25G and 5/8" long
What is urine called that remains in the bladder after voiding? ✅- residual urine
normal amount of residual urine ✅- 50 to 100 mL
5 stages of the nursing process ✅- assessment, nursing diagnosis, planning,
implementation, evaluation (ADPIE)
this stage of the nursing process is when the nurse continuously collects data to identify a
patient's actual and potential health needs ✅- assessment
this stage of the nursing process is then the nurse makes a clinical judgement about
individual, family, or community responses to actual or potential health problems or life
processes ✅- nursing diagnosis
this stage of the nursing process is the stage in which the nurse assigns priorities to nursing
diagnoses, defines short-term and long-term goals and expected outcomes, and establishes
the nursing care plan ✅- planning
this stage of the nursing process is the stage in which the nurse puts the nursing care plan
into action, delegates specific nursing interventions to members of the nursing team, and
charts patient responses to nursing interventions ✅- implementation
this stage of the nursing process is the stage in which the nurse compares objective and
subjective data with the outcome criteria and, if needed, modifies the nursing care plan ✅evaluation
What should the nurse do before administering any "as needed" pain medication? ✅indicate the location of the pain
this religious belief believes that they shouldn't receive blood components donated by other
people ✅- Jehovah's Witness
to test this, the nurse should ask the patient to cover each eye separately and to read the
eye chart with glasses and without, as appropriate ✅- visual acuity
What must be done when providing oral care for an unconscious patient to minimize the
risk of aspiration? ✅- position the patient on the side
How far away must a patient stand from the chart when assessing distance vision? ✅- 20
feet
What is the ideal room temperature for a geriatric patient or one who is extremely ill? ✅66 to 76 F
What is normal room humidity? ✅- 30% to 60%
this is the single best method of limiting the spread of microorganisms ✅- hand washing
How long must hands be washed once gloves are removed after routine contact with a
patient? ✅- 10 to 15 seconds
What position should a nurse place a woman to perform catheterization? ✅- dorsal
recumbent (lithotomy)
How are electrolytes measured in a solution? ✅- milliequivalents per liter
What is a milliequivalent? ✅- number of milligrams per 100 mL of a solution
What might a positive Homan's sign indicate? ✅- thrombophlebitis
2 phases of metabolism ✅- anabolism, catabolism
the constructive phase of metabolism ✅- anabolism
the destructive phase of metabolism ✅- catabolism
the amount of energy needed to maintain essential body functions ✅- basal metabolic rate
When is basal metabolic rate measured? ✅- patient awake and resting, not eaten in 14-18
hours, in a comfortable and warm environment
how basal metabolic rate is expressed ✅- calories consumed per hour per kilogram of
body weight
this supplies bulk, maintains intestinal motility, helps to establish bowel habits ✅- dietary
fiber (roughage)
Where is alcohol metabolized primary? Where is it metabolized in smaller amounts? ✅primarily in the liver, smaller amounts by the kidney and lungs
tiny, round, purplish red spots that appear on the skin and mucous membranes as a result
of intradermal or submucosal hemorrhage ✅- petechiae
a purple discoloration of the skin that's caused by blood extravasation ✅- purpura
this should never be done with needles after using them and is the cause of most needle
sticks ✅- recap needles
what a nurse uses to administer a drug by IV push to deliver the dose directly into a vein, IV
tubing, or catheter ✅- needle and syringe
What should be done when changing the ties on a tracheostomy tube? ✅- leave the old ties
in place until the new ones are applied
What is always used for blood transfusions? ✅- filter
this ambulatory device is indicated when a patient needs more stability than a regular cane
can provide ✅- quad (four-point) cane
a good way to begin a patient interview ✅- "What made you seek medical help?"
the most abundant cation in intracellular fluid ✅- potassium (K+)
in this gait, the patient first moves the right crutch followed by the left foot and then the left
crutch followed by the right foot ✅- four-point or alternating gait
in this gait, the patient moves two crutches and the affected leg simultaneously and then
moves the unaffected leg ✅- three-point gait
in this gait, the patient moves the right leg and the left crutch simultaneously and then
moves the left leg and the right crutch simultaneously ✅- two-point gait
the Vitamin B complex, water soluble vitamins that are essential for metabolism ✅thiamine (B1), riboflavin (B2), niacin (B3), pyridoxine (B6), cyanocobalamin (B12)
how the patient should be dressed when being weighed ✅- lightly dressed and shoeless
what should be done before taking an adult's oral temp ✅- nurse should ensure that the
patient hasn't smoked or consumed any hot/cold substances in the previous 15 minutes
when the nurse should not take an adult's rectal temp ✅- patient has cardiac disorder, anal
lesions, bleeding hemorrhoids, or recently undergone rectal surgery
taking adult's rectal temp in a patient that has a cardiac disorder ✅- may stimulate a vagal
response and lead to vasodilation and decreased cardiac output
how the nurse should record pulse amplitude and rhythm ✅- 0 absent pulse; 1+ thready
or weak pulse; 2+ normal pulse; 3+ bounding pulse
this period begins when a patient is transferred to the operating room bed and ends when
the patient is admitted to the postanesthesia care unit ✅- intraoperative period
what should be done the morning of a patient's surgery ✅- consent form signed, patient
hasn't taken anything by mouth since midnight,
taken a shower in microbial soap, mouth
care w/o swallowing water, removed
common jewelry,
received preoperative meds as prescribed, vital
signs taken and recorded,
(artificial limbs and other prostheses are usually removed)
comfort measures that may decrease the patient's need for analgesics or may enhance their
effectiveness ✅- positioning, rubbing the patient's back, providing a restful environment
a drug's three names ✅- generic, trade/brand, chemcial
how a patient should take a liquid iron preparation ✅- through a straw to avoid teeth
staining
what injection method should be used when administering iron dextran (Imferon) IM ✅Z-track method (IM)
where an organism can enter the body ✅- nose, mouth, rectum, urinary or reproductive
tract, skin
levels of consciousness in order ✅- alertness, lethargy, stupor, light coma, deep coma
portion of the stethoscope used to hear high-pitched sounds, such as breath sounds ✅diaphragm
differences in the BP between the right and left arms ✅- slight difference is normal (5-10
Hg)
where to place BP cuff ✅- 1" above the antecubital fossa
what to do when instilling ophthalmic ointments ✅- waste the first bead of ointment, then
apply the ointment from the inner canthus to the outer canthus
measuring BP in an obese patient ✅- use leg cuff
if a BP cuff is applied too loosely ✅- false lower reading
drooping of the eyelid ✅- ptosis
this type of table is useful for a patient with a spinal cord injury, orthostatic hypotension, or
brain damage because it can move the patient gradually from a horizontal to a vertical
(upright) position ✅- tilt table
how to perform a venipuncture with the least injury to the vessel ✅- turn the bevel
upward when the vessel's lumen is larger than the needle, turn it downward when the
lumen is only slightly larger than the needle
patient should wear
when being measured for crutches ✅- shoes
never attach a restraint to this portion of the bed ✅- mattress, side rails (always the bed
frame)
position for a sigmoidoscopy ✅- knee-chest or Sims
order of Maslow's hierarchy of needs ✅- physiologic, safety and security, love and
belonging, self-esteem and recognition, self-actualization
this should be applied to the nostril to prevent soreness when caring for a patient with a
nasogastric tube ✅- water-soluble lubricant
gastric lavage procedure (stomach pump) ✅- nasogastric tube inserted, stomach is
flushed, ingested substances removed through tube
documenting drainage of a surgical dressing ✅- size, color, consistency of drainage
to elicit this reflex, the nurse strokes the sole of the patient's foot with a moderately sharp
object ✅- Babinski's reflex
positive Babinski's reflex ✅- fanning toes
assessing for bladder distension ✅- check the contour of the lower abdomen for a rounded
mass above the symphysis pubis
best way to prevent pressure ulcers ✅- turn and reposition patient at least every 2 hours
this decompresses the superficial blood vessels, reducing the risk of thrombus formation
✅- antiembolism stockings (TED hose)
most convenient veins for venipuncture for adults ✅- basilic, median cubital
what must be done 2-3 hours before beginning a tube feeding ✅- aspirate the patient's
stomach to verify that gastric emptying is adequate
universal blood donors ✅- type O
universal blood recipients ✅- type AB
unit of measurement of sound frequency ✅- Hz (Hertz)
sound intensity level when hearing protection is required ✅- exceeds 84 db
sound intensity level when double hearing protection is required ✅- exceeds 104 db
where prothombin, a clotting factor, is produced ✅- liver
what should be done if a patient is menstruating when a urine sample is collected ✅- note
on lab request
what must be noted during a lumbar puncture ✅- initial intracranial pressure, color of
cerebrospinal fluid
this type of treatment can be used to help obtain a sample if a patient can't cough to provide
a sputum sample for culture ✅- heated aerosal treatment
What must be instilled first in eye ointment and eyedrops must be instilled in the same eye?
✅- eyedrops
first to be removed for PPE ✅- gloves before mask (because fewer pathogens are on mask)
the most effective means of traction, applying to a bone with wire pins or tongs ✅- skeletal
traction
preparation of TPN ✅- stored in a refrigerator, removed 30-60 minutes before use
symptoms of delivering a chilled solution ✅- pain, hypothermia, venous spasm, venous
constriction
where drugs aren't routinely injected intramuscularly because they may not be absorbed
✅- edematous tissue
explaining actions when caring for a comatose patient ✅- explain in a normal voice
cleaning dentures ✅- in a sink that's lined with a washcloth
patient should void within
an
hours after surgery ✅- 8 hours
identifies normal and abnormal brain waves ✅- EEG
these types of lab tests should be delivered to the lab without delay and without
refrigeration ✅- feces (for ova) samples, parasite tests
this nervous system regulates the cardiovascular and respiratory systems ✅- autonomic
nervous system
intermittent suction should be applied no more than
seconds using a slight twisting
motion when providing tracheostomy care ✅- 15 seconds
low-residue diet foods ✅- roasted chicken, rice, pasta
why a rectal tube shouldn't be inserted no longer than 20 minutes ✅- irritation of the
rectal mucosa, can cause loss of sphincter control
order of bed bath ✅- face, neck, arms, hands, chest, abdomen, back, legs, perineum
muscles the nurse uses to prevent injury when lifting and moving a patient ✅- upper leg
muscles
patient prep for cholecystography ✅- ingestion of a contrast medium and a low-fat evening
meal
what to do while an occupied bed is being changed ✅- cover patient with a bath blanket to
promote warmth and prevent exposure
mourning that occurs for an extended time when the patient realizes death is inevitable
✅- anticipatory grief
foods that can alter the color of feces ✅- beets (red), cocoa (dark red/brown), licorice
(black), spinach (green), meat protein (dark brown)
patient should remove all jewelry and dentures when preparing for a
x-ray
x-ray ✅- skull
the flight-or-flight response comes a response from this nervous system ✅- sympathetic
nervous system
if bronchovesicular sounds are heard in peripheral lung fields ✅- abnormal
what bronchovesicular lung sounds suggest if heard in peripheral lung fields ✅pneumonia
an abnormal, high-pitched breath sound that's acccentuated on expiration ✅- wheezing
this in the ear should be flushed out gently by irrigation with warn saline solution ✅- wax
or a foreign body
what should be done if a patient complains that their hearing aid is "not working" ✅check the switch to see if it's turned on, check batteries
grading hyperactive biceps and triceps reflexes ✅- 4+
if two eye medications are prescribed for twice-daily instillation ✅- should be
administered 5 minutes apart
forcing fluids in a post-op patient ✅- helps prevent constipation
Who establishes the standards of care? ✅- American Nurses association, state regulations,
facility policy
a unit of energy measurement that represents the amount of heat needed to raise the
temperature 1 kilogram of water 1 degree C ✅- kilocalorie (kcal)
What do nutrients undergo as they move through the body? ✅- ingestion, digestion,
absorption, transport, cell metabolism, excretion
how the body metabolizes alcohol ✅- fixed rate, regardless of serum concentration
this reflects the percentage of alcohol multiplied 2 in an alcohol beverage (a 100-proof
beverage contains 50% alcohol) ✅- proof
a witnessed document that states a patient's desire for certain types of care and treatment
✅- living will
what decisions in a living will are based on ✅- patient's wishes and views on quality of life
how often nurse should flush a peripheral heparin lock ✅- every 8 hours (if it wasn't used
during the previous 8 hours) and as needed with normal saline solution to maintain
patency
a method of determining whether nursing actions and practices meet established standards
✅- quality assurance
Six rights of medication administration ✅- right drug,
right dose, right documentation, right route,
right time,
right patient
this phase of the nursing process is to determine whether nursing interventions have
enabled the patient to meet the desired goals ✅- evaluation
only these forms of nitroglycerine should be used to relieve acute anginal attacks outside
the hospital setting ✅- sublingual, translingual
this phase of the nursing process involves recording the patient's response to the nursing
plan, putting the nursing plan into action, delegating specific nursing interventions, and
coordinating patient's activities ✅- implementation
this offers patients guidance and protection by stating the responsibilities of the hospital
and its staff toward and their families during hospitalization ✅- Patient's Bill of Rights
the nurse should record this as soon as it's gathered to minimize omission and distortion of
fats ✅- information
the nurse should record current illness this way when assessing a patient's health history
✅- chronologically, beginning with the onset of the problem and continuing to the present
never give
to a patient ✅- false assurance
after receiving preoperative medication, a patient isn't competent to do this ✅- sign an
informed consent form
a nurse uses this instead of the strength in her arms when lifting a patient ✅- weight of her
body
What must be done if a patient has questions about informed consent? ✅- refer to the
physician
a nurse can do this about an operation or a procedure to a patient ✅- clarify a physician's
explanation
the nurse should limit questions to those that provide necessary information when
obtaining a health history from these patients ✅- acutely ill or agitated patient
what to do if a chest drainage system line is broken or interrupted ✅- clamp tube
immediately
why should you never use the thumb to take a patient's pulse rate ✅- thumb has a pulse
that can be confused with the patient's pulse; index and middle finger should be used
instead
these 2 things count as one respiration ✅- inspiration, expiration
term for normal respiration ✅- eupnea
positioning of a patient's arm during blood pressure measurement ✅- rest arm against a
surface
if a patient uses muscle strength to hold up the arm when taking blood pressure ✅- may
raise BP
major, unalterable risk factors for coronary artery disease ✅- heredity, sex, race, age
the most frequently used assessment technique ✅- inspection
What should family members of an elderly person in a long-term care facility do to provide
a comfortable atmosphere? ✅- transfer some personal items to the person's room (such as
photographs, a favorite chair, knickknacks, etc.)
a regular pulse rhythm with alternating weak and strong beats that occurs in ventricular
enlargement because the stroke volume varies with each heartbeat ✅- pulsus alternans
What does the upper respiratory tract do to inspired air? ✅- warms and humidifies
What does the upper respiratory tract play a part in? ✅- taste, smell, mastication
What are shoulder elevation, intercostal muscle retraction, and scalene and
sternocleidomastoid muscle use signs of during respiration? ✅- accessory muscle use
What should bear the brunt of the weight with patients using axillary crutches? ✅- palms
What are eating, bathing, dressing, grooming, toileting, and interacting socially examples
of? ✅- activities of daily living (ADLs)
2 phases of a normal gait ✅- stance phase (patient's foot rests on the ground), swing phase
(patient's foot moves forward)
4 phases of mitosis ✅- prophase, metaphase, anaphase, telophase
What should the nurse follow when providing routine care for all patients? ✅- standard
precautions
part of the stethoscope used to listen for venous hums and cardiac murmurs ✅- bell
example of a question to assess a patient's general knowledge ✅- "Who is the president of
the United States?"
What is applied for the first 20-48 hours after an injury? ✅- cold packs
What is applied after a cold pack after an injury? ✅- heat
how a cold application is applied after an injury ✅- 20 minutes, removed 10-15 minutes
(to prevent reflex dilation, a rebound phenomenon, and frostbite injury)
this is located above the medulla and consists of white and gray amtter ✅- pons
this nervous system controls the smooth muscles ✅- autonomic nervous system
Who collaborates with the nurse to develop a patient goal? ✅- patient
5 basic notes of percussion ✅- tympany (loud intensity, as heard over a gastric air bubble
or puffed out cheek),
hyperresonance (very loud, as heard over an emphysematous lung), resonance
(loud, as heard over a normal lung),
dullness (medium intensity, as heard over the liver or other solid organ), flatness
(soft, as heard over the thigh)
description of the optic disk ✅- yellowish pink and circular, with a distinct border
What is a primary disability caused by? ✅- pathologic process
What is a secondary disability caused by? ✅- inactivity
this person is commonly held liable for failing to keep an accurate count of sponges and
other devices during surgery ✅- nurse
best dietary sources of vitamin B6 ✅- liver, kidney, pork soybeans, corn, whole-grain
cereals
iron-rich foods that commonly have a low water content ✅- organ meats, nuts, legumes,
dried fruit, green leafy vegetables, eggs, whole grains
this is a joint communication and decision making between nurses and physicians ✅collaboration
this is designed to meet patients' need by integrating the care regimens of both professions
into one comprehensive approach ✅- collaboration
a heart rate of fewer than 60 beats/minute ✅- bradycardia
a statement of a patient's actual or potential health problem that can be resolved,
diminished, or otherwise changed by nursing interventions ✅- nursing diganosis
analysis of 3 types of data collected during the assessment phase ✅- health history,
physical exam, lab and diagnostic test data
this consists primarily of subjective data, information that's supplied by the patient ✅health history
this includes objective data obtained by inspection, palpation, percussion, and
ausculatation ✅- physical exam
factors that can affect body temperature ✅- time of day, age, physical activity, phase of
menstrual cycle, pregnancy
the most commonly used artery for measuring a patient's pulse rate ✅- radial artery
the normal pulse rate is slightly faster in this gender ✅- women
the normal pulse rate is slightly faster in this age ✅- children
laboratory test results are an
form of assessment data ✅- objective
3 most commonly used measurement systems in clinical practice ✅- metric system,
apothecaries' system, household system
what the patient must know before signing an informed consent form ✅- other treatment
options are available, understand what will occur, the risks involved, the possible
complications, time required for surgery to recovery
a patient must sign one of these for each procedure ✅- informed consent form
this procedure is done to determine the size, shape, position, and density of underlying
organs and tissues, elicit tenderness, or assess reflexes ✅- percussion
a form of light palpation involving gentle, repetitive bouncing of tissues against the hand
and feeling their rebound ✅- ballottement
this keeps bed linen off the patient's feet to prevent skin irritation and breakdown,
especially in a patient who has peripheral vascular disease or neuropathy ✅- foot cradle
a flushing of the stomach and removal of ingested substances through a nasogastric tube,
used to treat poisoning or drug overdose ✅- gastric lavage
the nurse asses the patient's response to therapy during this step of the nursing process
✅- evaluation
this is commonly indicates a life- or limb- threatening vascular disease ✅- bruits
O.U. means... ✅- each eye
O.D. means... ✅- right eye
O.S. means... ✅- left eye
to remove a patient's artificial eye ✅- depress the lower lid
cleaning an artificial eye ✅- use a warm saline solution
this type of pulse is fine and scarcely palpable ✅- thready
this temp site is usually 1 degree F lower than oral temperature ✅- axillary temperature
what the nurse must document after suctioning a tracheostomy tube ✅- color, amount,
consistency, odor of secretions
what does "pc" mean on a prescription? ✅- after meals
what should be documented after a bladder irrigation ✅- amount, color, and clarity of
urine, presence of clots or sediment
the inside diameter of a needle (the smaller this is, the larger the diameter) ✅- gauge
normal number of permanent adult teeth ✅- 32
the purpose of therapeutic interaction ✅- to allow the client to autonomy to make choices
when appropriate. keep statements value-free, advice free, and reassurance-free
what action should the nurse take in a psychiatric situation when the client describes a
physical problem? ✅- assess. example: if a client has schizophrenia complains of chest
pain take their blood pressure
basic communication principles ✅- establish trust, nonjudgemental attitude,active
listening, offer self, accept client's feelings, validate client's statements, matter of fact
approach
nausea is a common complaint after ECT ✅- vomiting by an unconscious can lead to
aspiration. maintain a paten airway
common physiological responses to anxiety ✅- increased heart rate, and blood pressure,
rapid shallow respirations, dry mouth, tight feeling in throat, tremors, muscle twitching,
anorexia, urinary frequency, palmar sweating
nurse-client anxiety ✅- anxiety is contagious, nurse needs to asses on anxiety level and
remain calm. it helps gain control, decrease anxiety, and increase feelings of security
desensitization ✅- is the nursing intervention for phobia disorders. --assess client to
recognize the factors associated with feared stimuli. -teach and practice with client
alternative coping strategies
-expose client to feared stimuli
-provide positive reinforcement
the nurse should place an anxious client where there are reduced environmental stimuli
✅- quiet area of the unit away from the nurse's station
the best time for interaction with a client is at the completion of the performed ritual ✅the client's anxiety is lowest at this time and its an optimal time for learning
compulsive acts are used in response to anxiety, which may or may not be related to the
obsession. its the nurse's responsibility help alleviate anxiety ✅- its the nurse's
responsibility help alleviate anxiety, interfering will increase the anxiety
as long as the client's acts are free of violence: nurse should ....✅- -actively listen to the
clients obsessive themes
-acknowledge the effects that ritualistic acts have on the client
-demonstrate empathy
-avoid being judgmental
ford clients with PTSD, the nurse should.... ✅- -actively listen to client's stories of
experiences surrounding the traumatic event
-assess suicide risk
-assist client to develop objectivity about the event and problem solve regarding possible
means of controlling anxiety related to the event
-encourage group therapy with other clients who have experienced the same traumatic
event
be aware of your own feelings when dealing with this somatoform clients. ✅- the pain is
real to the person experiencing it
theses disorders cannot be explained medically, it results from internal conflict. the nurse
should... ✅- -acknowledge the symptom or complaint
-reaffirm that diagnostic test results reveal no organic pathology
-determine the secondary gains acquired by the client
avoid giving clients with dissociative disorders too much information about past events at
one time ✅- the various types of amnestic that accompany dissociative disorders provide
protection from pain and too much to soon can cause decompensation
personality disorders are long standing behavioral traits that are maladaptive responses to
anxiety and that cause difficulty in relating to and working with other individuals ✅persons with personality disorders are usually comfortable with their disorders and
believe that they are right and the world is wrong and have little motivation
people with anorexia gain pleasure from providing others with food and watching them eat
✅- these behaviors reinforce their perception of self-control. don not allow these clients to
plan or prepare food for unit-based activities
individuals with Bulimia often use syrup of ipecac to induce vomiting. if ipecac is not
vomited and is absorbed, cardiotoxicity may occur and cause conduction disturbances,
cardiac dysrhythmias, fatal myocarditis, and circulatory failure ✅- because heart failure is
not usually seen in this age group, it is often overlooked. assess for edema and listen to
breath sounds
physical assessment and nutritional support are a priority, the physiological implication are
great. nursing interventions should increase self-esteem and develop a positive body image.
✅- family therapy is most effective because issues of control are common in these (eating
disorders.) therapy is usually long term
the most important s/s of depression are a depressed mood with a loss of interest in the
pleasures in life ✅- the client has a sustained loss
s/s of depression ✅- -significant change in appetite
-insomnia
-fatigue or lack of energy
-feelings of hopelessness
-loss of ability to concentrate
-preoccupation with death or suicide
depressed clients have difficulty hearing and accepting compliments because of their
lowered self-concept ✅- comment on signs of improvement by noting behavior
the nurse knows depressed clients are improving when they ✅- begin to take an interest in
their appearance or begin to perform self-care activities
the nurse should suspect an imminent suicide attempt if a depressed client becomes
"better" ✅- be aware a happy affect may signify the the client feels relieved that a plan has
been made and is prepared for the suicide attempt
when dealing with a depressed client the nurse should assist with personal hygiene tasks
and encourage the client to initiate grooming activities even when they dont feel like doing
so ✅- this helps to promote self-esteem and a sense of control
nursing intervention for depressed client ✅- sit quietly with the client, offering your
support with your presence
side effects of antianxiety drugs ✅- sedation, drowsiness
s/e of antidepressants drugs ✅- anticholinergic effects, postural hypotension
s/e MAO inhibitors ✅- hypertensive crisis
lithium requires renal function assessment and monitoring ✅- phenothiazines cause EPS
(tardic dyskinesia can be permanent)
phenothiazines cause photosensitivity so client must wear protective clothing and
sunglasses ✅- MAO inhibitors require dietary restrictions to prevent hypertensive crisis
atypical antipsychotics drugs are also indication for mania ✅- monitor serum lithium
levels carefully. 0.-1.5 is therapeutic level, blood should be drawn every 12 hours after last
dose
manic clients can be very caustic toward authority figures ✅- avoid arguing or becoming
defensive
what activities are appropriate for a manic client? ✅- noncompetitive physical activities
that require the use of large muscle groups
where should a manic client be place on the unit? ✅- make every attempt to reduce stimuli
in the environment, place client in quiet part of the unit
what intervention should the nurse use if the client becomes abusive ✅- -redirect negative
behavior -suggest a walk
-set limits on intrusive behavior
-seclude or administer medication
Bleuler's 4 A's for schizophrenia ✅- autism (preoccupied with self)
affect (flat) associations (loose)
ambivalence (difficulty making decisions)
observe for increased motor activity and erratic response to staff and other clients ✅client may experiencing an increase in command in hallucinations, when this occurs there
is an increased potential for aggressive behavior
don't argue with a client about the delusions. ✅- logic only increases a client's anxiety, so
be matter of fact and divert delusional thought to reality
what medication can the nurse expect to administer to chemically dependent clients? ✅librium or ativan, antabuse for alcohol abuse
what type of therapy is used with chemically dependent clients? ✅- group therapy
harm reduction is a community health strategy designed to reduce the harm of substance
abuse to families, individuals, community, and society ✅- denial and rationalization are
the two most common coping styles used for substance abuse
what basic needs take priority when working with chemically dependent clients? ✅nutrition is a priority, alcohol and drug intake has superseded the intake of food for these
clients
what behaviors are expected during withdrawal? ✅- in the alcoholic DT's occur 12-36
hours after the last intake of alcohol
select only one nurse to care for an abused child ✅- abused children have difficulty
establishing trust, and the child will be less anxious with one consistent caregiver
women who are abused may rationalize the spouse's behavior and unnecessarily accept
blame for his actions. ✅- the woman may or may not choose to press charges. be sure to
give her the number of a shelter or help line
it is difficult for an elderly person to admit abuse for fear of being placed in a nursing home
or being abandoned ✅- it is imperative to establish a trusting relationship with elderly
client
rape victims are at high risk for PTSD. immediate intervention to diminish distress is vital.
✅- the nurse should also assess for and intervene for sequelae such as unwanted
pregnancy, STD's, and HIV
in child abuse, the nurse is responsible for reporting all suspected cases of abuse ✅- in
intimate abuse, its the adult's decision and the nurse should be supportive
the basic difference between delirium and dementia is ... ✅- delirium is acute and
reversible but dementia is gradual and permanent
confusion in the elderly is often accepted as being part of growing old. ✅- however, the
confusion may be caused from dehydration and is usually due to a specific stressor
confabulation is not lying ✅- it is used by the client to decrease anxiety and protect the ego
Alzheimer medication ✅- you can use atypical antipsychotics. Clozaril is not a front line
agent because of side effects. one may also give mood stabilizers, and antianxiety
medications
nursing interventions for confused elderly ✅- -maintain client's health and safety
-encourage self care
-reinforce reality orientation
-provide safe, consistent environment
provide a consistent caregiver is priority in planning nursing care for the confused older
client ✅- change increases anxiety and confusion
children experience depression, which presents as headaches, stomachaches, and other
somatic complaints ✅- assess suicide risks, especially in the adolescent
the child/adolescent's lack of remorse about antisocial behavior represents a malfunction
of the superego ✅- the id functions on the basic instinct level and strives to meet
immediate needs. the ego is in touch with external reality and is the part of personality that
makes decisions
provide consistent interventions for children ✅- this helps to prevent manipulation
because inconsistency does not help the client develop self control
What type of procedures should be assigned to professional nurses? ✅- Inform the health
care provider or physician; record that the health care provider or physician was informed
and the health care provider's or physician's response to such information; inform the
nursing supervisor; refuse to carry out the prescription
Describe the nurse's legal responsibility when asked to perform a task for which he or she
is unprepared. ✅- Inform the health care provider or physician or person asking the nurse
to perform the task that he or she is unprepared to carry out the task; refuse to perform the
task
Describe nursing care for a restrained client. ✅- Apply restraints properly; check
restraints frequently to see that they are not causing injury and record such monitoring;
remove restraints as soon as possible; use restraints only as a last resort.
Describe six patient rights guaranteed under HIPAA regulations that nurses must be aware
of in practice. ✅- a. A patient must give written consent before health care providers can
use or disclose personal health information
b. Health care providers and physicians must give patients notice about providers'
responsibilities regarding patient confidentiality
c. Patient's must have access to their medication records; Providers who restrict access must
explain why and must offer patients a description of the complaint process
d. Patients have the right to request that changes be made in their medical records to correct
inaccuracies
e. Health care providers must follow specific tracking procedures for any disclosures made
that ensure accountability for maintenance of patient confidentiality
f. Patients have the right to request that health care providers and physicians restrict the use
and disclosure of their personal health information, though the provider may decline to do
so.
A UAP may perform care that falls within which component of the nursing process? ✅Implementation
What are the five rights of delegation? ✅- A. Right task
B. Right circumstance
C. Right person
D. Right direction or communication
E. Right supervision
Common causes of fluid volume deficit: ✅- a. Gastrointestinal causes b.
Vomiting
c. Diarrhea
d. GI suctioning
e. Decrease in fluid intake
f. Increase in fluid output such as sweating
g. Massive edema
h. Ascites
Common causes of fluid volume overload: ✅- a. Heart failure b.
Renal failure
c. Cirrhosis
d. Excess ingestion of table salt
e. Overhydration with sodium containing fluids
Identify two examples of isotonic IV fluids. ✅- a. Ringers lactate b.
Normal saline
List three systems that maintain acid base balance. ✅- a. Lungs b.
Kidneys
c. Chemical buffers
normal ABGs ✅- a. pH: 7.35-7.45 b.
PaCO2: 35-45
c. HCO3: 22-26
Variables that increase surgical risk. ✅- a. Age: very young and very old b.
Obesity
c. Malnutrition
d. Preoperative dehydration/hypovolemia
e. Preoperative infection
f. Use of anticoagulants (aspirin) preoperatively
Why is a client with liver disease at increased risk of operative complications? ✅- a.
Impairs ability to detoxify medications used during surgery
b. Impairs ability to produce prothrombin to reduce hemorrhage
Preoperative teaching should include demonstration and explanation of expected
postoperative client activities. What activities should be included? ✅- a. Respiratory
activities: coughing, breathing, use of spirometer
b. Exercises: range of motion, leg exercises, turning
c. Pain Management: medications and splinting
d. Dietary restrictions: NPO evolving to progressive diet
e. Dressings and drains: orientation to recovery room environment
What items should the nurse assist the client in removing before surgery? ✅- Contact
lenses; Glasses; Dentures; Partial plates; Wigs; Jewelry; Prosthesis; Makeup; Nail polish.
Nursing actions that prevent postoperative wound dehiscence and evisceration: ✅- a.
Teaching client to splint incision when coughing
b. Encouraging coughing and deep breathing in early postoperative period when sutures
are strong.
c. Monitoring for signs of infection
d. Malnutrition
e. Dehydration
f. Encouraging high-protein diet
Identify three nursing interventions that prevent postoperative urinary tract infections.
✅- a. Avoiding postoperative catheterization b.
Increasing oral fluid intake
c. Emptying bladder every 4 to 6 hours
d. Early ambulation
Identify nursing/medical interventions that prevent postoperative paralytic ileus. ✅- a.
Early ambulation
b. Limiting use of narcotic analgesics
c. NG tube decompression
List four interventions that prevent postoperative thrombophlebitis. ✅- a. Teaching
performance of in bed leg exercises b. Encouraging early ambulation
c. Applying antiembolus stockings
d. Teaching avoidance of positions and pressures that obstruct venous flow
What six factors should the nurse include when assessing the pain experience? ✅- a.
Location
b. Intensity
c. Comfort measures
d. Quality
e. Chronology
f. Subjective view of pain
List the six modalities that are considered noninvasive, nonpharmacological pain relief
measures. ✅- a. Heat and cold application b. TENS
c. Massage
d. Distraction
e. Relaxation techniques
f. Biofeedback techniques
Identify the five stages of death and dying. ✅- a. Denial b.
Anger
c. Bargaining
d. Depression
e. Acceptance
List five nursing interventions to promote adequate bowel functioning for older persons.
✅- a. Determine what is "normal" GI functioning for each individual b.
Increase fiber and bulk in the diet
c. Provide adequate hydration
d. Encourage eating small meals frequently
What areas of care are important for end-of-life care? ✅- a. Pain b.
Dyspnea
c. Anxiety
d. GI symptoms
e. Psychiatric symptoms
f. Spirituality
g. Support for family caregivers
h. Family support during bereavement period
Vegetables High in Sodium: ✅- Canned vegetables
Carrots, particularly canned
Tomatoes, particularly canned
Tomato, catsup
Tomato juice
Condiments High in Sodium: ✅- Bouillon cubes
Mustard
Olives, pickled, canned or bottled
Pickles, cucumber, dill
Salad dressings, commercially prepared
Soy Sauce
Other Foods High in Sodium ✅- Bacon
Cheeses
Ready-to-eat breakfast cereals
Peanut butter
Soups, commercially prepared, canned
Corned beef
Calcium ✅- Milk, cheese, dark green vegetables, dried figs, soy, and legumes
Phosphorus ✅- Milk, liver, legumes, fish, and soy
Magnesium ✅- Whole grains, green leafy vegetables, tea, nuts, and fruit
Iron ✅- Meats, eggs, legumes, whole grains, green leafy vegetables , and dried fruits Iodine
✅- Marine fish, shellfish, dairy products, iodized salt, and some breads
Potassium ✅- Citrus fruits, and dried fruit , bananas, watermelon, potatoes, legumes, tea,
and peanut butter
Zinc ✅- Meats, seafood and whole grains
apical pulse ✅- pulse normally heard at the heart's apex, usuallly gives the most accurate
assessment of pulse rate
apical-radial pulse ✅- reading done by measuring both the apical and radial pulse
simultaneously, used when it is suspected that the heart is not effectively pumping blood.
apnea ✅- cessatation of breathing
ausculation ✅- externally listening to sounds from within the body to determine abnormal
conditions, as in blood pressure
axillary ✅- under the armpit
bradycardia ✅- abnormally slow breathing/respiration
carotid pulse ✅- pulse felt on either side of the neck over the carotid artery
bradypenia ✅- condition where the breathes are abnormally slow and fall below 10
breathes/ minute.
celsius ✅- temperature scale which water boils @ 100 degrees and freezes @ zero
degrees.
Cheyne-stokes respirations ✅- breathing characterized by deep breathing alternating with
very slow breathing or apnea, indicative of brain damage, often precedes death.
crisis ✅- the turning point of a disease with intensification of symptoms
cyanosis ✅- blueness or duskiness of the skin due to lack of oxygen and excess carbon
dioxide
diastolic ✅- atrial and ventricular relaxation of which allows the chambers of the heart to
fill with blood
dyspnea ✅- difficulty breathing
euphea ✅- normal breathing
farenheit ✅- temperature scale at which water boils at 212 degrees and freezes at 32
degrees.
femoral pulse ✅- pulse felt in the groin over the femoral artery
fever ✅- abnormally high body temperature
hand sanitization ✅- cleansing the hands using a chemical agent or thorough hand
washing.
hypertension ✅- elevated blood pressure
hypotension ✅- abnormally low blood pressure
Korotkoff's sounds ✅- sound heard when measuring the heartbeat with a stethoscope
kussmaul's respirations ✅- severe paroxysmal dyspnea as in diabetic acidosis and coma
lysis ✅- destruction due to a specific agent; gradual recovery from disease or an elevated
temperature that gradually returns to normal
oral ✅- of or perrtaining to the mouth
orthopnea ✅- sitting or leaning forward to facilitate breathing
palpatation ✅- the act of feeling with the hand, placing two fingers on the body to
determing the condition of the underlying part
pedal pulse ✅- pulse in the foot.
popliteal pulse ✅- pulse located in the posterior of the knee
pulse ✅- the heartbeat as felt through the walls of the srteries and the skin or as heard at
the apex of the heart with a stethoscope
pulse pressure ✅- difference of systolic minus diastolic pressure
radial pulse ✅- pulsed measured on the wrist over the radial artery
rectal ✅- distal portion of the large intestines between the sigmoid colon and the anal
canal
sphygmomanometer ✅- device used is conjuction with a stethoscope to measure blood
pressure, consisting of a cuff and bulb
stertorous breathing ✅- breathing that occurs when air travels through secretions in the
air passage; snoring
stethoscope ✅- instrument used to hear internal sounds
systole ✅- contraction of the heartbeat systolic blood pressure; pressure of the blood
against the walls of the artery
tachycardia ✅- abnormally high heart beat
tachypnea ✅- abnormally fast breathing
temporal ✅- pertaining to the temple
tempanic ✅- ear/eardrum
AP ✅- apical pulse
A-R ✅- apical-radial pulse
Ax ✅- under the arm ; axillary
BPM ✅- Beats per minute
C ✅- celsius
DBP ✅- diastolic blood pressure
F ✅- farenheit
HR ✅- heart rate
I & O ✅- Intake and output
MAP ✅- mean arterial pressure
O ✅- oral/mouth
PMI ✅- point of maximal impulse
PO ✅- per os
R ✅- rectal
SBP ✅- systolic blood pressure
TA ✅- forehead
TM ✅- ear canal
TPR ✅- temperature, pulse, respiration
Evidence-based practice ✅- Use of current best evidence from nursing research, clinical
expertise, practice trends and patient preferences to guide nursing decisions about care
provided to patients
Certification ✅- Beyond NCLEX-RN; exam in nursing specialty; minimum practice
requirements are set depending in the certification; include years required working in
specialty area
Standards of practice ✅- A list of standards to assist the professional in making good
decisions while conducting day to day responsibilities within his or her scope of practice.
Licensure ✅- A mandatory credentialing process established by law, usually at the state
level, that grants the right to practice certain skills and endeavors
Accountability ✅- Taking responsibility for ones actions
Advanced roles of the RN ✅- caregiver, communicator, teacher, client advocate, counselor,
change agent, leader, manager and case manager
Career options for the RN ✅- Clinical specialist, nurse practitioner, midwife, anesthetist,
educator, entrepreneur, administrator
ANA ✅- American Nurses Association; concerned with legal aspects of nursing
NLN ✅- National League for Nursing; sets standards for excellence and innovation in
nursing education
State boards of nursing ✅- Reason for existance is public protection; regulation of nursing
care
Nurse practice act ✅- Nurses are required to be familiar with the laws that regulate their
practice; used to measure appropriateness of nurses actions and behavior
Autonomy ✅- Persons right to choose and the ability to act on that choice
Beneficence ✅- Duty to do or promote good; taking positive actions to help others
Fidelity ✅- Faithfulness; obligation to keep promises
Justice ✅- Obligation to be fair; equal treatment to all clients
Nonmaleficience ✅- Obligation to "do no harm"; prevent harm
Verocity ✅- Duty to tell the truth
Confidentiality ✅- Protection of personal health information
HIPAA ✅- Protection of personal health information
Responsibility ✅- Willingness to respect obligations; foloow through on promises
Values ✅- Strongly held personal beliefs about the worth and importance of an idea,
attitude, custom or object that sets standards that influence behavior
Value clarification ✅- Process of becoming conscious of and identifying ones values
Deontology ✅- Defines actions as right or wrong; looks to the presence of principle
regardless of outcome
Utilitarianism ✅- Act must result in the greatest good for the greatest number of people
Feminine ethics ✅- Looks at social issues; looks to the nature of relationships for guidance
of processing ethical demands
Ethic of care ✅- Caring, promoting dignity
Code of ethics ✅- Philosophical ideals of right and wrong that define the principles you
will use to provide care to your patients
Patient advocate ✅- Protect patients human and legal rights and provide assistance in
asserting these rights if the need arises
Caregiver ✅- Help patient maintain and regain health, manage disease and symptoms, and
attain a maximal level function and independence through the healing process
Educator ✅- Explain concepts and facts about health, describe the reason for routine care
activities, demonstrate self-care activities and reinforce learning
Advanced Practice Registered Nurse (APRN) ✅- Most independently functioning nurse;
has masters degree in nursing
Clinical Nurse Specialist (CNS) ✅- An APRN who is an expert clinician in a specialized area
of practice
Nurse Practitioner (NP) ✅- An APRN who provides health care to a group of patients,
usually in an outpatient, ambulatory care or community-based setting
Certified Nurse-Midwife (CNM) ✅- An APRN who is also educated in midwifery and is
certified by the American College of Nurse-Midwifes
Certified Registered Nurse Anesthetist (CRNA) ✅- An APRN with advanced education in a
nurse anesthetia accredited program
do not ✅- Incident reports do/do not belong in patient's chart
facility ✅- Incident reports help identify ?? issues needing attention/correction
slander ✅- ?? is when one makes false VERBAL statements
libel ✅- Written slander
malice ✅- Hurting someone on purpose, or with reckless disregard for the truth
assault ✅- ?? may be actual or threatened, such as giving an injection or threatening to
restrain a client who has refused a procedure
battery ✅- ?? is intentional touching without consent
false imprisonment ✅- ?? ?? is restraining a client without justification (w/o physicians
written order)
negligence ✅- ?? is conduct that falls below the standard of care
malpractice ✅- ?? is professional negligence
airborne ✅- ?? precautions are for droplet nuclei smaller than 5 mcg - measles, chickenpox
droplet ✅- ?? precautions are for droplets larger than 5 mcg being within 3 feet of client pneumonias, plague, pertussis, mumps
contact ✅- ?? precaution is direct client or contact - MRDO such as VRE or MRSA, RSV,
scabies
protective equipment ✅- ?? ?? alllogenic hymatopoietic stem cell transplants; private room
2 hours ✅- You must remove restraints every ?? ??
15 minutes ✅- You must check patient in a restraint every ?? ??
least restrictive ✅- You must use the ?? ?? method for a restraint
physicians written order ✅- You must have a ?? ?? ?? to use a restraint
ALL ✅- ?? other appropriate methods must have been exhausted before using a restraint
informed consent ✅- To put a restraint on a patient, you have their ?? ??
nausea dizziness headache fatigue ✅- Low O2 can cause ??, ??, ?? and ??
1 3 ✅- High O2 can cause death within ? to ? minutes
CO2 ✅- ??? is a colorless, ordorless gas that is emitted from improperly set furnaces,
heaters, and stoves
food water shelter clothing ✅- The lowest level of the Maslow's pyramid is ??, ??, ??, and ??
storage refrigeration preparation ✅- The proper ??, ??, and ?? of food is essential to be of
value to the human body
64 75 ✅- Normal room temperature is between ??F and ??F
hyperthermia ✅- ?? is when the body's core temp is too high
hypothermia ✅- ?? is when the body's core temp is below 95F
lifestyle ✅- Risks such as drug and alcohol abuse are considered ?? risk factors
heart disease cancer cerebrovascular disease ✅- The top three causes of death are ?? ??, ??,
and ?? ??
deficit ✅- Sensory ?? is reduced perception of sensory reception and perception
primary intention ✅- Healing process: ?? ?? is a wound that is closed
secondary intention ✅- Healing process: ?? ?? is where the wound edges are not
approximated
tertiary intention ✅- Healing process: ?? ?? is where the wound is open for several days
tertiary intention ✅- Wound that is left open to monitor for infection is considered ?? ??
(healing process)
secondary intention ✅- Wound resulting from surgery causing tissue loss is
considered ?? ?? (healing process)
stage 1 ✅- Pressure ulcer showing intact skin with nonblanchable redness of a localized
area
stage 2 ✅- Pressure ulcer showing partial-thickness skin loss involving epidermis, dermis,
or both
stage 3 ✅- Pressure ulcer where full-thickness skin loss; subcutaneous fat may be visible,
but bone, tendon, or muscles are not
stage 4 ✅- Pressure ulcer where full-thickness tissue loss with exposed bone, tendon, or
muscle
unstageable ✅- Pressure ulcer where wound cannot be visualized; ulcer is full-thickness
tissue loss in which base of the ulcer is covered by slough, typically has eschar
subjective findings ✅- S of SOAP ?? ??
objective findings ✅- O of SOAP ?? ??
assessment ✅- A of SOAP
interventions ✅- I of SOAPIE
evaluations ✅- E of SOAPIE
planning ✅- P of SOAP
sit facing the client ✅- S of SOLER (listening skills) ?? ?? ?? ??
observe an open posture ✅- O of SOLER (listening skills) ?? ?? ?? ??
lean toward the client ✅- L of SOLER (listening skills) ?? ?? ?? ??
establish and maintain intermittent eye contact ✅- E of SOLER (listening
skills) ?? ?? ?? ?? ?? ??
relax ✅- R of SOLER (listening skills) ??
assessment diagnose plan implement evaluate ✅- The 5 phases of the nursing process - ??,
??, ??, ??, and ??
NANDA ✅- Nursing diagnoses must come from the ?? approved list
diagnostic label ✅- ?? ?? is another term for the nursing diagnosis (from NANDA)
related factor ✅- The condition identified in the client's assessment data is called the ?? ??
(R/T)
etiology ✅- ?? is what which is within the nursing domain of practice
definition ✅- ?? helps describe the characteristics of the condition
risk factors ✅- ?? ?? are cues or clues which indicate diagnosis is applicable to the clients
condition
support ✅- ?? the diagnostic statement with specific assessment data which has defining
characteristics proving the accurate nursing diagnosis
as evidenced by ✅- AEB means
as manifested by ✅- AMB means
Acute pain ✅- -temporary
-occurs after an injury to the body
-includes postoperative pain, labor pain, renal calculus pain
Chronic pain ✅- -nonmalignant (low back pain, rheumatoid arthritis etc.)
-intermittent (migraine headaches etc.)
-malignant, associated w/ neoplastic diseases
Gate control theory ✅- pain impulses travel from the periphery to the gray matter in the
dorsal horn of the spinal cord along small nerve fibers
acupuncture ✅- the insertion of needles at various points on the body to relieve pain
-invasive
-associated with the gate control theory
-thought to increase the production of endogenous opiates
preparation for death ✅- -Denial: coping style used to protect self/ego; non compliance,
refusal to seek treatment, ignoring symptoms; changing the subject when speaking about
illness; stating, "not me, it must be a mistake."
-Anger:
often directing it a t family or health care team members; stating, "why me? it's not fair."
-Bargaining: making a deal with God to prolong life; usually not sharing this with anyone,
keeping it a very private experience
-Depression: results from the losses experienced because of health status & hospitalization;
anticipating the loss of life
-Acceptance:
accepting the inevitable; beginning to separate emotionally
dealing with delayed grief ✅- -unresolved grief (determine level of dysfunction)
-physical symptoms similar to those of the deceased
-clinical depression
-social isolation
-failure to acknowledge loss
Temperature range for adults ✅- 36-38 C (96.8-100.4 F)
Average oral temp ✅- 37 (98.6)
Average rectal temp ✅- 37.5 (99.5)
Average axillary temp ✅- 36.5 (97.7)
Pulse range ✅- 60-100 bpm
Respiration range ✅- 12-20 bpm
Prehypertension range ✅- 120-139/80-89
Stage 1 Hypertension ✅- 140-159/90-99
Stage 2 Hypertension ✅- Over 160/ over 100
Where should a blood pressure cuff NOT be placed? ✅- Not on site of IV, fistula,
mastectomy
What should a patient do before having their blood pressure taken? ✅- Avoid
caffeine/smoking, rest 5 minutes before taking BP
What sounds represent blood pressure noises? ✅- Korotkoff's sounds (1st-systolic,
4thdiastolic)
What is the most BP can vary between arms and still be considered normal? ✅- 10
Normal respirations in newborns ✅- 35-40
Normal respirations for infants ✅- 30-50
Normal respirations for toddlers ✅- 25-32
Normal respirations for children ✅- 20-30
Normal respirations for adolescents ✅- 16-20
Normal respirations for adults ✅- 12-20
Intervention for insomnia ✅- Sleep and exercise; encourage client to begin walking
routinely during the day, but not 2-3 hours before bedtime
Who can perform catheter insertions? ✅- RNs. UAP can only position patient, report
discomfort, report characterization of urine
How far should a catheter be inserted? ✅- 2-3 inches for female; 7-9 inches for male Chain
of infection ✅- Infectious agent/pathogen --> reservoir/source for growth --> portal of exit
from reservoir --> mode of transmission --> portal of entry to host --> susceptible host
Showering with an IV ✅- Adjust IV flow rate to KVO and remove IV tubing from pump.
Reset after shower is over.
Logrolling ✅- Obtain assistance; place pillow between client's knees (prevents tension on
the spinal column). Cross client's arms (prevents injury).
Measuring intake and output ✅- I-O= Total; when you flush a GI tube, have an IV running,
or wash the perineum, yo have subtract this from your output. Check I&O every 8 hours.
Weight can tell if fluid retention
Two types of contact transmission ✅- Direct and indirect
Direct contact transmission ✅- Applied to care and handling of contaminated body fluids
Indirect contact transmission ✅- Involves transfer of an infectious agent through a
contaminated intermediate object
Droplet precautions ✅- Used for diseases that are transmitted by large droplets that are
expelled into the air 3-6 feet. Mask, hand hygiene, dedicated care equipment. Ex. influenza
Airborne precautions ✅- Used for diseases that are transmitted by smaller droplets that
remain in the hair for long periods of time. Requires negative air flow; air filtered through
HEPA filter
Protective environment ✅- Focuses on clients w/ transplants or gene therapy; positive
airflow (>12 exchanges/hour).
Basic contact precautions for protective environments ✅- Hand hygiene before and after
entering room; dispose of contaminated supplies in a way that prevents the spread of
germs; use protective barriers; protect all persons who might be exposed during transport
Heat application guidelines ✅- Must have health care provider's orders
Do's for applying heat/cold therapy ✅- Explain sensations to be felt; report changes
immediately; provide timer and call light; look up safe temps
Don'ts for applying heat/cold therapy ✅- Don't let client adjust temp; don't allow client to
move application or place hands on wound; make sure client can move away from temp
source; don't leave client who can't feel temp changes
How long can a restraint order be good for? ✅- 4 hours for adults, 2 hours for children (917) and 1 hour for under 9
IM site/ ventrogluteal ✅- Deep site situated away from major nerves and blood vessels;
less chance of contamination; easily ID by bony landmarks; total IM volume is 3mL
6 Rights of Medication Administration ✅- Right dose, right time, right patient, right route,
right documentation, right medication
Syringe sizes used for IM and subQ injections ✅- 1-3ml
When are syringes larger than 5 mL used? ✅- Administer IV meds, add meds to IV
solutions, irrigate wounds
Insulin syringes ✅- .3-1 mL (calibrated in units). Most are 100 U
Tuberculin syringe ✅- 16ths of minim and 100ths of a mL. (capacity of 1mL). intradermal
or subQ
Incident pain ✅- Pain that is predictable and elicited by a specific behaviors such as
physical therapy or wound dressing changes
End-of-dose failure pain ✅- Pain that occurs toward the end of the usual dosing interval of
a regularly scheduled analgesic
Spontaneous pain ✅- Pain that is unpredictable and not associated with any activity or
event
Pulse Ox site ✅- Finger (remove nailpolish) or earlobe
Oxygen flow meter ✅- Meter that controls the amount of oxygen when using a nasal
cannula or mask
What level should O2 stats remain above? ✅- 90%
What is prune juice used for? ✅- Bowel stimulation
Diarrhea nursing diagnosis ✅- Diarrhea related to...
NG tubes ✅- Cannot be delegated; have patient sip water; can go into lungs; clients w;
impaired LOC are at risk for aspiration
Intermittent tube feedings ✅- Done periodically
Bolus tube feeding ✅- Large feeding done over 20-30 minutes
Continuous tube feeding ✅- Done continuously
Elimination in bedside chair ✅- Can be delegated; remind assistant to report any abnormal
findings
C. diff ✅- Can't use hand sanitizer; must wash with soap and water
SBAR ✅- Situation, background, assessment, recommendation
Noctural emissions ✅- Normal
Cultural/spiritual nursing process ✅- You must know yourself/your values before you can
help the patient. Always.
Penrose drain ✅- Lies under dressing; pin placed in drain to prevent it from slipping into
the wound
Skin break down ✅- Related to shear, friction, altered LOC, impaired mobility/sensory
perception and moisture; lead to ulcers
How should darker skinned individuals be assessed for skin breakdown? ✅- Use
natural/halogen light; will appear darker than surrounding tissue with purplish/bluish
hue; have initial warmth with coolness as tissue devitalizes; may appear taut, shiny, scaly
Wound dressings ✅- Protect, aid in homeostasis, promotes healing, supports, promotes
thermal insulation, protects client from seeing it; provides moist environment
Hypokalemia ✅- Low K; normally 3.6 to 5.2 mmol/L; lower than 2.5 mmol/L can be
lifethreateningin
the purpose of therapeutic interaction ✅- to allow the client to autonomy to make choices
when appropriate. keep statements value-free, advice free, and reassurance-free
what action should the nurse take in a psychiatric situation when the client describes a
physical problem? ✅- assess. example: if a client has schizophrenia complains of chest
pain take their blood pressure
basic communication principles ✅- establish trust, nonjudgemental attitude,active
listening, offer self, accept client's feelings, validate client's statements, matter of fact
approach
nausea is a common complaint after ECT ✅- vomiting by an unconscious can lead to
aspiration. maintain a paten airway
common physiological responses to anxiety ✅- increased heart rate, and blood pressure,
rapid shallow respirations, dry mouth, tight feeling in throat, tremors, muscle twitching,
anorexia, urinary frequency, palmar sweating
nurse-client anxiety ✅- anxiety is contagious, nurse needs to asses on anxiety level and
remain calm. it helps gain control, decrease anxiety, and increase feelings of security
desensitization ✅- is the nursing intervention for phobia disorders. --assess client to
recognize the factors associated with feared stimuli. -teach and practice with client
alternative coping strategies
-expose client to feared stimuli
-provide positive reinforcement
the nurse should place an anxious client where there are reduced environmental stimuli
✅- quiet area of the unit away from the nurse's station
the best time for interaction with a client is at the completion of the performed ritual ✅the client's anxiety is lowest at this time and its an optimal time for learning
compulsive acts are used in response to anxiety, which may or may not be related to the
obsession. its the nurse's responsibility help alleviate anxiety ✅- its the nurse's
responsibility help alleviate anxiety, interfering will increase the anxiety
as long as the client's acts are free of violence: nurse should ....✅- -actively listen to the
clients obsessive themes
-acknowledge the effects that ritualistic acts have on the client
-demonstrate empathy
-avoid being judgmental
ford clients with PTSD, the nurse should.... ✅- -actively listen to client's stories of
experiences surrounding the traumatic event
-assess suicide risk
-assist client to develop objectivity about the event and problem solve regarding possible
means of controlling anxiety related to the event
-encourage group therapy with other clients who have experienced the same traumatic
event
be aware of your own feelings when dealing with this somatoform clients. ✅- the pain is
real to the person experiencing it
theses disorders cannot be explained medically, it results from internal conflict. the nurse
should... ✅- -acknowledge the symptom or complaint
-reaffirm that diagnostic test results reveal no organic pathology
-determine the secondary gains acquired by the client
avoid giving clients with dissociative disorders too much information about past events at
one time ✅- the various types of amnestic that accompany dissociative disorders provide
protection from pain and too much to soon can cause decompensation
personality disorders are long standing behavioral traits that are maladaptive responses to
anxiety and that cause difficulty in relating to and working with other individuals ✅persons with personality disorders are usually comfortable with their disorders and
believe that they are right and the world is wrong and have little motivation
people with anorexia gain pleasure from providing others with food and watching them eat
✅- these behaviors reinforce their perception of self-control. don not allow these clients to
plan or prepare food for unit-based activities
individuals with Bulimia often use syrup of ipecac to induce vomiting. if ipecac is not
vomited and is absorbed, cardiotoxicity may occur and cause conduction disturbances,
cardiac dysrhythmias, fatal myocarditis, and circulatory failure ✅- because heart failure is
not usually seen in this age group, it is often overlooked. assess for edema and listen to
breath sounds
physical assessment and nutritional support are a priority, the physiological implication are
great. nursing interventions should increase self-esteem and develop a positive body image.
✅- family therapy is most effective because issues of control are common in these (eating
disorders.) therapy is usually long term
the most important s/s of depression are a depressed mood with a loss of interest in the
pleasures in life ✅- the client has a sustained loss
s/s of depression ✅- -significant change in appetite
-insomnia
-fatigue or lack of energy
-feelings of hopelessness
-loss of ability to concentrate
-preoccupation with death or suicide
depressed clients have difficulty hearing and accepting compliments because of their
lowered self-concept ✅- comment on signs of improvement by noting behavior
the nurse knows depressed clients are improving when they ✅- begin to take an interest in
their appearance or begin to perform self-care activities
the nurse should suspect an imminent suicide attempt if a depressed client becomes
"better" ✅- be aware a happy affect may signify the the client feels relieved that a plan has
been made and is prepared for the suicide attempt
when dealing with a depressed client the nurse should assist with personal hygiene tasks
and encourage the client to initiate grooming activities even when they dont feel like doing
so ✅- this helps to promote self-esteem and a sense of control
nursing intervention for depressed client ✅- sit quietly with the client, offering your
support with your presence
side effects of antianxiety drugs ✅- sedation, drowsiness
s/e of antidepressants drugs ✅- anticholinergic effects, postural hypotension
s/e MAO inhibitors ✅- hypertensive crisis
lithium requires renal function assessment and monitoring ✅- phenothiazines cause EPS
(tardic dyskinesia can be permanent)
phenothiazines cause photosensitivity so client must wear protective clothing and
sunglasses ✅- MAO inhibitors require dietary restrictions to prevent hypertensive crisis
atypical antipsychotics drugs are also indication for mania ✅- monitor serum lithium
levels carefully. 0.-1.5 is therapeutic level, blood should be drawn every 12 hours after last
dose
manic clients can be very caustic toward authority figures ✅- avoid arguing or becoming
defensive
what activities are appropriate for a manic client? ✅- noncompetitive physical activities
that require the use of large muscle groups
where should a manic client be place on the unit? ✅- make every attempt to reduce stimuli
in the environment, place client in quiet part of the unit
what intervention should the nurse use if the client becomes abusive ✅- -redirect negative
behavior -suggest a walk
-set limits on intrusive behavior
-seclude or administer medication
Bleuler's 4 A's for schizophrenia ✅- autism (preoccupied with self)
affect (flat) associations
(loose)
ambivalence (difficulty making decisions)
observe for increased motor activity and erratic response to staff and other clients ✅client may experiencing an increase in command in hallucinations, when this occurs there
is an increased potential for aggressive behavior
don't argue with a client about the delusions. ✅- logic only increases a client's anxiety, so
be matter of fact and divert delusional thought to reality
what medication can the nurse expect to administer to chemically dependent clients? ✅librium or ativan, antabuse for alcohol abuse
what type of therapy is used with chemically dependent clients? ✅- group therapy
harm reduction is a community health strategy designed to reduce the harm of substance
abuse to families, individuals, community, and society ✅- denial and rationalization are
the two most common coping styles used for substance abuse
what basic needs take priority when working with chemically dependent clients? ✅nutrition is a priority, alcohol and drug intake has superseded the intake of food for these
clients
what behaviors are expected during withdrawal? ✅- in the alcoholic DT's occur 12-36
hours after the last intake of alcohol
select only one nurse to care for an abused child ✅- abused children have difficulty
establishing trust, and the child will be less anxious with one consistent caregiver
women who are abused may rationalize the spouse's behavior and unnecessarily accept
blame for his actions. ✅- the woman may or may not choose to press charges. be sure to
give her the number of a shelter or help line
it is difficult for an elderly person to admit abuse for fear of being placed in a nursing home
or being abandoned ✅- it is imperative to establish a trusting relationship with elderly
client
rape victims are at high risk for PTSD. immediate intervention to diminish distress is vital.
✅- the nurse should also assess for and intervene for sequelae such as unwanted
pregnancy, STD's, and HIV
in child abuse, the nurse is responsible for reporting all suspected cases of abuse ✅- in
intimate abuse, its the adult's decision and the nurse should be supportive
the basic difference between delirium and dementia is ... ✅- delirium is acute and
reversible but dementia is gradual and permanent
confusion in the elderly is often accepted as being part of growing old. ✅- however, the
confusion may be caused from dehydration and is usually due to a specific stressor
confabulation is not lying ✅- it is used by the client to decrease anxiety and protect the ego
Alzheimer medication ✅- you can use atypical antipsychotics. Clozaril is not a front line
agent because of side effects. one may also give mood stabilizers, and antianxiety
medications
nursing interventions for confused elderly ✅- -maintain client's health and safety
-encourage self care
-reinforce reality orientation
-provide safe, consistent environment
provide a consistent caregiver is priority in planning nursing care for the confused older
client ✅- change increases anxiety and confusion
children experience depression, which presents as headaches, stomachaches, and other
somatic complaints ✅- assess suicide risks, especially in the adolescent
the child/adolescent's lack of remorse about antisocial behavior represents a malfunction
of the superego ✅- the id functions on the basic instinct level and strives to meet
immediate needs. the ego is in touch with external reality and is the part of personality that
makes decisions
provide consistent interventions for children ✅- this helps to prevent manipulation
because inconsistency does not help the client develop self control
What type of procedures should be assigned to professional nurses? ✅- Inform the health
care provider or physician; record that the health care provider or physician was informed
and the health care provider's or physician's response to such information; inform the
nursing supervisor; refuse to carry out the prescription
Describe the nurse's legal responsibility when asked to perform a task for which he or she
is unprepared. ✅- Inform the health care provider or physician or person asking the nurse
to perform the task that he or she is unprepared to carry out the task; refuse to perform the
task
Describe nursing care for a restrained client. ✅- Apply restraints properly; check
restraints frequently to see that they are not causing injury and record such monitoring;
remove restraints as soon as possible; use restraints only as a last resort.
b.
c.
d.
e.
f.
Describe six patient rights guaranteed under HIPAA regulations that nurses must be aware
of in practice. ✅- a. A patient must give written consent before health care providers can
use or disclose personal health information
Health care providers and physicians must give patients notice about providers'
responsibilities regarding patient confidentiality
Patient's must have access to their medication records; Providers who restrict access must
explain why and must offer patients a description of the complaint process
Patients have the right to request that changes be made in their medical records to correct
inaccuracies
Health care providers must follow specific tracking procedures for any disclosures made
that ensure accountability for maintenance of patient confidentiality
Patients have the right to request that health care providers and physicians restrict the use
and disclosure of their personal health information, though the provider may decline to do
so.
A UAP may perform care that falls within which component of the nursing process? ✅Implementation
What are the five rights of delegation? ✅- A. Right task
B. Right circumstance
C. Right person
D. Right direction or communication
E. Right supervision
Common causes of fluid volume deficit: ✅- a. Gastrointestinal causes b.
Vomiting
c. Diarrhea
d. GI suctioning
e. Decrease in fluid intake
f. Increase in fluid output such as sweating
g. Massive edema
h. Ascites
Common causes of fluid volume overload: ✅- a. Heart failure b.
Renal failure
c. Cirrhosis
d. Excess ingestion of table salt
e. Overhydration with sodium containing fluids
Identify two examples of isotonic IV fluids. ✅- a. Ringers lactate b.
Normal saline
List three systems that maintain acid base balance. ✅- a. Lungs b.
Kidneys
c. Chemical buffers
normal ABGs ✅- a. pH: 7.35-7.45 b.
PaCO2: 35-45
c. HCO3: 22-26
Variables that increase surgical risk. ✅- a. Age: very young and very old b.
Obesity
c. Malnutrition
d. Preoperative dehydration/hypovolemia
e. Preoperative infection
f. Use of anticoagulants (aspirin) preoperatively
Why is a client with liver disease at increased risk of operative complications? ✅- a.
Impairs ability to detoxify medications used during surgery
b. Impairs ability to produce prothrombin to reduce hemorrhage
Preoperative teaching should include demonstration and explanation of expected
postoperative client activities. What activities should be included? ✅- a. Respiratory
activities: coughing, breathing, use of spirometer
b. Exercises: range of motion, leg exercises, turning
c. Pain Management: medications and splinting
d. Dietary restrictions: NPO evolving to progressive diet
e. Dressings and drains: orientation to recovery room environment
What items should the nurse assist the client in removing before surgery? ✅- Contact
lenses; Glasses; Dentures; Partial plates; Wigs; Jewelry; Prosthesis; Makeup; Nail polish.
Nursing actions that prevent postoperative wound dehiscence and evisceration: ✅- a.
Teaching client to splint incision when coughing
b. Encouraging coughing and deep breathing in early postoperative period when sutures
are strong.
c. Monitoring for signs of infection
d. Malnutrition
e. Dehydration
f. Encouraging high-protein diet
Identify three nursing interventions that prevent postoperative urinary tract infections.
✅- a. Avoiding postoperative catheterization b.
Increasing oral fluid intake
c. Emptying bladder every 4 to 6 hours
d. Early ambulation
Identify nursing/medical interventions that prevent postoperative paralytic ileus. ✅- a.
Early ambulation
b. Limiting use of narcotic analgesics
c. NG tube decompression
List four interventions that prevent postoperative thrombophlebitis. ✅- a. Teaching
performance of in bed leg exercises b. Encouraging early ambulation
c. Applying antiembolus stockings
d. Teaching avoidance of positions and pressures that obstruct venous flow
What six factors should the nurse include when assessing the pain experience? ✅- a.
Location
b. Intensity
c. Comfort measures
d. Quality
e. Chronology
f. Subjective view of pain
List the six modalities that are considered noninvasive, nonpharmacological pain relief
measures. ✅- a. Heat and cold application b. TENS
c. Massage
d. Distraction
e. Relaxation techniques
f. Biofeedback techniques
Identify the five stages of death and dying. ✅- a. Denial b.
Anger
c. Bargaining
d. Depression
e. Acceptance
List five nursing interventions to promote adequate bowel functioning for older persons.
✅- a. Determine what is "normal" GI functioning for each individual b.
Increase fiber and bulk in the diet
c. Provide adequate hydration
d. Encourage eating small meals frequently
What areas of care are important for end-of-life care? ✅- a. Pain b.
Dyspnea
c. Anxiety
d. GI symptoms
e. Psychiatric symptoms
f. Spirituality
g. Support for family caregivers
h. Family support during bereavement period
Vegetables High in Sodium: ✅- Canned vegetables
Carrots, particularly canned
Tomatoes, particularly canned
Tomato, catsup
Tomato juice
Condiments High in Sodium: ✅- Bouillon cubes
Mustard
Olives, pickled, canned or bottled
Pickles, cucumber, dill
Salad dressings, commercially prepared
Soy Sauce
Other Foods High in Sodium ✅- Bacon
Cheeses
Ready-to-eat breakfast cereals
Peanut butter
Soups, commercially prepared, canned
Corned beef
Calcium ✅- Milk, cheese, dark green vegetables, dried figs, soy, and legumes
Phosphorus ✅- Milk, liver, legumes, fish, and soy
Magnesium ✅- Whole grains, green leafy vegetables, tea, nuts, and fruit
Iron ✅- Meats, eggs, legumes, whole grains, green leafy vegetables , and dried fruits
Iodine ✅- Marine fish, shellfish, dairy products, iodized salt, and some breads
Potassium ✅- Citrus fruits, and dried fruit , bananas, watermelon, potatoes, legumes, tea,
and peanut butter
Zinc ✅- Meats, seafood and whole grains
apical pulse ✅- pulse normally heard at the heart's apex, usuallly gives the most accurate
assessment of pulse rate
apical-radial pulse ✅- reading done by measuring both the apical and radial pulse
simultaneously, used when it is suspected that the heart is not effectively pumping blood.
apnea ✅- cessatation of breathing
ausculation ✅- externally listening to sounds from within the body to determine abnormal
conditions, as in blood pressure
axillary ✅- under the armpit
bradycardia ✅- abnormally slow breathing/respiration
carotid pulse ✅- pulse felt on either side of the neck over the carotid artery
bradypenia ✅- condition where the breathes are abnormally slow and fall below 10
breathes/ minute.
celsius ✅- temperature scale which water boils @ 100 degrees and freezes @ zero
degrees.
Cheyne-stokes respirations ✅- breathing characterized by deep breathing alternating with
very slow breathing or apnea, indicative of brain damage, often precedes death.
crisis ✅- the turning point of a disease with intensification of symptoms
cyanosis ✅- blueness or duskiness of the skin due to lack of oxygen and excess carbon
dioxide
diastolic ✅- atrial and ventricular relaxation of which allows the chambers of the heart to
fill with blood
dyspnea ✅- difficulty breathing
euphea ✅- normal breathing
farenheit ✅- temperature scale at which water boils at 212 degrees and freezes at 32
degrees.
femoral pulse ✅- pulse felt in the groin over the femoral artery
fever ✅- abnormally high body temperature
hand sanitization ✅- cleansing the hands using a chemical agent or thorough hand
washing.
hypertension ✅- elevated blood pressure
hypotension ✅- abnormally low blood pressure
Korotkoff's sounds ✅- sound heard when measuring the heartbeat with a stethoscope
kussmaul's respirations ✅- severe paroxysmal dyspnea as in diabetic acidosis and coma
lysis ✅- destruction due to a specific agent; gradual recovery from disease or an elevated
temperature that gradually returns to normal
oral ✅- of or perrtaining to the mouth
orthopnea ✅- sitting or leaning forward to facilitate breathing
palpatation ✅- the act of feeling with the hand, placing two fingers on the body to
determing the condition of the underlying part
pedal pulse ✅- pulse in the foot.
popliteal pulse ✅- pulse located in the posterior of the knee
pulse ✅- the heartbeat as felt through the walls of the srteries and the skin or as heard at
the apex of the heart with a stethoscope
pulse pressure ✅- difference of systolic minus diastolic pressure
radial pulse ✅- pulsed measured on the wrist over the radial artery
rectal ✅- distal portion of the large intestines between the sigmoid colon and the anal
canal
sphygmomanometer ✅- device used is conjuction with a stethoscope to measure blood
pressure, consisting of a cuff and bulb
stertorous breathing ✅- breathing that occurs when air travels through secretions in the
air passage; snoring
stethoscope ✅- instrument used to hear internal sounds
systole ✅- contraction of the heartbeat systolic blood pressure; pressure of the blood
against the walls of the artery
tachycardia ✅- abnormally high heart beat
tachypnea ✅- abnormally fast breathing
temporal ✅- pertaining to the temple
tempanic ✅- ear/eardrum
AP ✅- apical pulse
A-R ✅- apical-radial pulse
Ax ✅- under the arm ; axillary
BPM ✅- Beats per minute
C ✅- celsius
DBP ✅- diastolic blood pressure
F ✅- farenheit
HR ✅- heart rate
I & O ✅- Intake and output
MAP ✅- mean arterial pressure
O ✅- oral/mouth
PMI ✅- point of maximal impulse
PO ✅- per os
R ✅- rectal
SBP ✅- systolic blood pressure
TA ✅- forehead
TM ✅- ear canal
TPR ✅- temperature, pulse, respiration
Evidence-based practice ✅- Use of current best evidence from nursing research, clinical
expertise, practice trends and patient preferences to guide nursing decisions about care
provided to patients
Certification ✅- Beyond NCLEX-RN; exam in nursing specialty; minimum practice
requirements are set depending in the certification; include years required working in
specialty area
Standards of practice ✅- A list of standards to assist the professional in making good
decisions while conducting day to day responsibilities within his or her scope of practice.
Licensure ✅- A mandatory credentialing process established by law, usually at the state
level, that grants the right to practice certain skills and endeavors
Accountability ✅- Taking responsibility for ones actions
Advanced roles of the RN ✅- caregiver, communicator, teacher, client advocate, counselor,
change agent, leader, manager and case manager
Career options for the RN ✅- Clinical specialist, nurse practitioner, midwife, anesthetist,
educator, entrepreneur, administrator
ANA ✅- American Nurses Association; concerned with legal aspects of nursing
NLN ✅- National League for Nursing; sets standards for excellence and innovation in
nursing education
State boards of nursing ✅- Reason for existance is public protection; regulation of nursing
care
Nurse practice act ✅- Nurses are required to be familiar with the laws that regulate their
practice; used to measure appropriateness of nurses actions and behavior
Autonomy ✅- Persons right to choose and the ability to act on that choice
Beneficence ✅- Duty to do or promote good; taking positive actions to help others
Fidelity ✅- Faithfulness; obligation to keep promises
Justice ✅- Obligation to be fair; equal treatment to all clients
Nonmaleficience ✅- Obligation to "do no harm"; prevent harm
Verocity ✅- Duty to tell the truth
Confidentiality ✅- Protection of personal health information
HIPAA ✅- Protection of personal health information
Responsibility ✅- Willingness to respect obligations; foloow through on promises
Values ✅- Strongly held personal beliefs about the worth and importance of an idea,
attitude, custom or object that sets standards that influence behavior
Value clarification ✅- Process of becoming conscious of and identifying ones values
Deontology ✅- Defines actions as right or wrong; looks to the presence of principle
regardless of outcome
Utilitarianism ✅- Act must result in the greatest good for the greatest number of people
Feminine ethics ✅- Looks at social issues; looks to the nature of relationships for guidance
of processing ethical demands
Ethic of care ✅- Caring, promoting dignity
Code of ethics ✅- Philosophical ideals of right and wrong that define the principles you
will use to provide care to your patients
Patient advocate ✅- Protect patients human and legal rights and provide assistance in
asserting these rights if the need arises
Caregiver ✅- Help patient maintain and regain health, manage disease and symptoms, and
attain a maximal level function and independence through the healing process
Educator ✅- Explain concepts and facts about health, describe the reason for routine care
activities, demonstrate self-care activities and reinforce learning
Advanced Practice Registered Nurse (APRN) ✅- Most independently functioning nurse;
has masters degree in nursing
Clinical Nurse Specialist (CNS) ✅- An APRN who is an expert clinician in a specialized area
of practice
Nurse Practitioner (NP) ✅- An APRN who provides health care to a group of patients,
usually in an outpatient, ambulatory care or community-based setting
Certified Nurse-Midwife (CNM) ✅- An APRN who is also educated in midwifery and is
certified by the American College of Nurse-Midwifes
Certified Registered Nurse Anesthetist (CRNA) ✅- An APRN with advanced education in a
nurse anesthetia accredited program
do not ✅- Incident reports do/do not belong in patient's chart
facility ✅- Incident reports help identify ?? issues needing attention/correction
slander ✅- ?? is when one makes false VERBAL statements
libel ✅- Written slander
malice ✅- Hurting someone on purpose, or with reckless disregard for the truth
assault ✅- ?? may be actual or threatened, such as giving an injection or threatening to
restrain a client who has refused a procedure
battery ✅- ?? is intentional touching without consent
false imprisonment ✅- ?? ?? is restraining a client without justification (w/o physicians
written order)
negligence ✅- ?? is conduct that falls below the standard of care
malpractice ✅- ?? is professional negligence
airborne ✅- ?? precautions are for droplet nuclei smaller than 5 mcg - measles, chickenpox
droplet ✅- ?? precautions are for droplets larger than 5 mcg being within 3 feet of client pneumonias, plague, pertussis, mumps
contact ✅- ?? precaution is direct client or contact - MRDO such as VRE or MRSA, RSV,
scabies
protective equipment ✅- ?? ?? alllogenic hymatopoietic stem cell transplants; private room
2 hours ✅- You must remove restraints every ?? ??
15 minutes ✅- You must check patient in a restraint every ?? ??
least restrictive ✅- You must use the ?? ?? method for a restraint
physicians written order ✅- You must have a ?? ?? ?? to use a restraint
ALL ✅- ?? other appropriate methods must have been exhausted before using a restraint
informed consent ✅- To put a restraint on a patient, you have their ?? ??
nausea dizziness headache fatigue ✅- Low O2 can cause ??, ??, ?? and ??
1 3 ✅- High O2 can cause death within ? to ? minutes
CO2 ✅- ??? is a colorless, ordorless gas that is emitted from improperly set furnaces,
heaters, and stoves
food water shelter clothing ✅- The lowest level of the Maslow's pyramid is ??, ??, ??, and ??
storage refrigeration preparation ✅- The proper ??, ??, and ?? of food is essential to be of
value to the human body
64 75 ✅- Normal room temperature is between ??F and ??F
hyperthermia ✅- ?? is when the body's core temp is too high
hypothermia ✅- ?? is when the body's core temp is below 95F
lifestyle ✅- Risks such as drug and alcohol abuse are considered ?? risk factors
heart disease cancer cerebrovascular disease ✅- The top three causes of death are ?? ??, ??,
and ?? ??
deficit ✅- Sensory ?? is reduced perception of sensory reception and perception
primary intention ✅- Healing process: ?? ?? is a wound that is closed
secondary intention ✅- Healing process: ?? ?? is where the wound edges are not
approximated
tertiary intention ✅- Healing process: ?? ?? is where the wound is open for several days
tertiary intention ✅- Wound that is left open to monitor for infection is considered ?? ??
(healing process)
secondary intention ✅- Wound resulting from surgery causing tissue loss is
considered ?? ?? (healing process)
stage 1 ✅- Pressure ulcer showing intact skin with nonblanchable redness of a localized
area
stage 2 ✅- Pressure ulcer showing partial-thickness skin loss involving epidermis, dermis,
or both
stage 3 ✅- Pressure ulcer where full-thickness skin loss; subcutaneous fat may be visible,
but bone, tendon, or muscles are not
stage 4 ✅- Pressure ulcer where full-thickness tissue loss with exposed bone, tendon, or
muscle
unstageable ✅- Pressure ulcer where wound cannot be visualized; ulcer is full-thickness
tissue loss in which base of the ulcer is covered by slough, typically has eschar
subjective findings ✅- S of SOAP ?? ??
objective findings ✅- O of SOAP ?? ??
assessment ✅- A of SOAP
interventions ✅- I of SOAPIE
evaluations ✅- E of SOAPIE
planning ✅- P of SOAP
sit facing the client ✅- S of SOLER (listening skills) ?? ?? ?? ??
observe an open posture ✅- O of SOLER (listening skills) ?? ?? ?? ??
lean toward the client ✅- L of SOLER (listening skills) ?? ?? ?? ??
establish and maintain intermittent eye contact ✅- E of SOLER (listening
skills) ?? ?? ?? ?? ?? ??
relax ✅- R of SOLER (listening skills) ??
assessment diagnose plan implement evaluate ✅- The 5 phases of the nursing process - ??,
??, ??, ??, and ??
NANDA ✅- Nursing diagnoses must come from the ?? approved list
diagnostic label ✅- ?? ?? is another term for the nursing diagnosis (from NANDA)
related factor ✅- The condition identified in the client's assessment data is called the ?? ??
(R/T)
etiology ✅- ?? is what which is within the nursing domain of practice
definition ✅- ?? helps describe the characteristics of the condition
risk factors ✅- ?? ?? are cues or clues which indicate diagnosis is applicable to the clients
condition
support ✅- ?? the diagnostic statement with specific assessment data which has defining
characteristics proving the accurate nursing diagnosis
as evidenced by ✅- AEB means
as manifested by ✅- AMB means
Acute pain ✅- -temporary
-occurs after an injury to the body
-includes postoperative pain, labor pain, renal calculus pain
Chronic pain ✅- -nonmalignant (low back pain, rheumatoid arthritis etc.)
-intermittent (migraine headaches etc.)
-malignant, associated w/ neoplastic diseases
Gate control theory ✅- pain impulses travel from the periphery to the gray matter in the
dorsal horn of the spinal cord along small nerve fibers
acupuncture ✅- the insertion of needles at various points on the body to relieve pain
-invasive
-associated with the gate control theory
-thought to increase the production of endogenous opiates
preparation for death ✅- -Denial: coping style used to protect self/ego; non compliance,
refusal to seek treatment, ignoring symptoms; changing the subject when speaking about
illness; stating, "not me, it must be a mistake."
-Anger:
often directing it a t family or health care team members; stating, "why me? it's not fair."
-Bargaining: making a deal with God to prolong life; usually not sharing this with anyone,
keeping it a very private experience
-Depression: results from the losses experienced because of health status & hospitalization;
anticipating the loss of life
-Acceptance:
accepting the inevitable; beginning to separate emotionally
dealing with delayed grief ✅- -unresolved grief (determine level of dysfunction)
-physical symptoms similar to those of the deceased
-clinical depression
-social isolation
-failure to acknowledge loss
Temperature range for adults ✅- 36-38 C (96.8-100.4 F)
Average oral temp ✅- 37 (98.6)
Average rectal temp ✅- 37.5 (99.5)
Average axillary temp ✅- 36.5 (97.7)
Pulse range ✅- 60-100 bpm
Respiration range ✅- 12-20 bpm
Prehypertension range ✅- 120-139/80-89
Stage 1 Hypertension ✅- 140-159/90-99
Stage 2 Hypertension ✅- Over 160/ over 100
Where should a blood pressure cuff NOT be placed? ✅- Not on site of IV, fistula,
mastectomy
What should a patient do before having their blood pressure taken? ✅- Avoid
caffeine/smoking, rest 5 minutes before taking BP
What sounds represent blood pressure noises? ✅- Korotkoff's sounds (1st-systolic,
4thdiastolic)
What is the most BP can vary between arms and still be considered normal? ✅- 10
Normal respirations in newborns ✅- 35-40
Normal respirations for infants ✅- 30-50
Normal respirations for toddlers ✅- 25-32
Normal respirations for children ✅- 20-30
Normal respirations for adolescents ✅- 16-20
Normal respirations for adults ✅- 12-20
Intervention for insomnia ✅- Sleep and exercise; encourage client to begin walking
routinely during the day, but not 2-3 hours before bedtime
Who can perform catheter insertions? ✅- RNs. UAP can only position patient, report
discomfort, report characterization of urine
How far should a catheter be inserted? ✅- 2-3 inches for female; 7-9 inches for male
Chain of infection ✅- Infectious agent/pathogen --> reservoir/source for growth --> portal
of exit from reservoir --> mode of transmission --> portal of entry to host --> susceptible
host
Showering with an IV ✅- Adjust IV flow rate to KVO and remove IV tubing from pump.
Reset after shower is over.
Logrolling ✅- Obtain assistance; place pillow between client's knees (prevents tension on
the spinal column). Cross client's arms (prevents injury).
Measuring intake and output ✅- I-O= Total; when you flush a GI tube, have an IV running,
or wash the perineum, yo have subtract this from your output. Check I&O every 8 hours.
Weight can tell if fluid retention
Two types of contact transmission ✅- Direct and indirect
Direct contact transmission ✅- Applied to care and handling of contaminated body fluids
Indirect contact transmission ✅- Involves transfer of an infectious agent through a
contaminated intermediate object
Droplet precautions ✅- Used for diseases that are transmitted by large droplets that are
expelled into the air 3-6 feet. Mask, hand hygiene, dedicated care equipment. Ex. influenza
Airborne precautions ✅- Used for diseases that are transmitted by smaller droplets that
remain in the hair for long periods of time. Requires negative air flow; air filtered through
HEPA filter
Protective environment ✅- Focuses on clients w/ transplants or gene therapy; positive
airflow (>12 exchanges/hour).
Basic contact precautions for protective environments ✅- Hand hygiene before and after
entering room; dispose of contaminated supplies in a way that prevents the spread of
germs; use protective barriers; protect all persons who might be exposed during transport
Heat application guidelines ✅- Must have health care provider's orders
Do's for applying heat/cold therapy ✅- Explain sensations to be felt; report changes
immediately; provide timer and call light; look up safe temps
Don'ts for applying heat/cold therapy ✅- Don't let client adjust temp; don't allow client to
move application or place hands on wound; make sure client can move away from temp
source; don't leave client who can't feel temp changes
How long can a restraint order be good for? ✅- 4 hours for adults, 2 hours for children (917) and 1 hour for under 9
IM site/ ventrogluteal ✅- Deep site situated away from major nerves and blood vessels;
less chance of contamination; easily ID by bony landmarks; total IM volume is 3mL
6 Rights of Medication Administration ✅- Right dose, right time, right patient, right route,
right documentation, right medication
Syringe sizes used for IM and subQ injections ✅- 1-3ml
When are syringes larger than 5 mL used? ✅- Administer IV meds, add meds to IV
solutions, irrigate wounds
Insulin syringes ✅- .3-1 mL (calibrated in units). Most are 100 U
Tuberculin syringe ✅- 16ths of minim and 100ths of a mL. (capacity of 1mL). intradermal
or subQ
Incident pain ✅- Pain that is predictable and elicited by a specific behaviors such as
physical therapy or wound dressing changes
End-of-dose failure pain ✅- Pain that occurs toward the end of the usual dosing interval of
a regularly scheduled analgesic
Spontaneous pain ✅- Pain that is unpredictable and not associated with any activity or
event
Pulse Ox site ✅- Finger (remove nailpolish) or earlobe
Oxygen flow meter ✅- Meter that controls the amount of oxygen when using a nasal
cannula or mask
What level should O2 stats remain above? ✅- 90%
What is prune juice used for? ✅- Bowel stimulation
Diarrhea nursing diagnosis ✅- Diarrhea related to...
NG tubes ✅- Cannot be delegated; have patient sip water; can go into lungs; clients w;
impaired LOC are at risk for aspiration
Intermittent tube feedings ✅- Done periodically
Bolus tube feeding ✅- Large feeding done over 20-30 minutes
Continuous tube feeding ✅- Done continuously
Elimination in bedside chair ✅- Can be delegated; remind assistant to report any abnormal
findings
C. diff ✅- Can't use hand sanitizer; must wash with soap and water
SBAR ✅- Situation, background, assessment, recommendation
Noctural emissions ✅- Normal
Cultural/spiritual nursing process ✅- You must know yourself/your values before you can
help the patient. Always.
Penrose drain ✅- Lies under dressing; pin placed in drain to prevent it from slipping into
the wound
Skin break down ✅- Related to shear, friction, altered LOC, impaired mobility/sensory
perception and moisture; lead to ulcers
How should darker skinned individuals be assessed for skin breakdown? ✅- Use
natural/halogen light; will appear darker than surrounding tissue with purplish/bluish
hue; have initial warmth with coolness as tissue devitalizes; may appear taut, shiny, scaly
Wound dressings ✅- Protect, aid in homeostasis, promotes healing, supports, promotes
thermal insulation, protects client from seeing it; provides moist environment
Hypokalemia ✅- Low K; normally 3.6 to 5.2 mmol/L; lower than 2.5 mmol/L can be
lifethreateningin
Nursing Fundamentals HESI Prep
Which assessment data would provide the most accurate determination of proper
placement of a nasogastric tube?
A) Aspirating gastric contents to assure a pH value of 4 or less.
B) Hearing air pass in the stomach after injecting air into the tubing.
C) Examining a chest x-ray obtained after the tubing was inserted.
D) Checking the remaining length of tubing to ensure that the correct length was inserted.
✅- C) Examining a chest x-ray obtained after the tubing was inserted
Both (A and B) are methods used to determine proper placement of the NG tubing.
However, the best indicator that the tubing is properly placed is (C). (D) is not an indicator
of proper placement
When assisting an 82-year-old client to ambulate, it is important for the nurse to realize
that the center of gravity for an elderly person is the
A) Arms.
B) Upper torso.
C) Head.
D) Feet ✅- B) Upper torso
The center of gravity for adults is the hips. However, as the person grows older, a stooped
posture is common because of the changes from osteoporosis and normal bone
degeneration, and the knees, hips, and elbows flex. This stooped posture results in the
upper torso (B) becoming the center of gravity for older persons. Although (A) is a part, or
an extension of the upper torso, this is not the best and most complete answer.
Which action is most important for the nurse to implement when donning sterile gloves?
A) Maintain thumb at a ninety degree angle.
B) Hold hands with fingers down while gloving.
C) Keep gloved hands above the elbows.
D) Put the glove on the dominant hand first. ✅- C) Keep gloved hands above the elbows
Gloved hands held below waist level are considered unsterile (C). (A and B) are not
essential to maintaining asepsis. While it may be helpful to put the glove on the dominant
hand first, it is not necessary to ensure asepsis (D).
An adult male client with a history of hypertension tells the nurse that he is tired of taking
antihypertensive medications and is going to try spiritual meditation instead. What should
be the nurse's first response?
A) It is important that you continue your medication while learning to meditate.
B) Spiritual meditation requires a time commitment of 15 to 20 minutes daily.
C) Obtain your healthcare provider's permission before starting meditation.
D) Complementary therapy and western medicine can be effective for you. ✅- A) It is
important that you continue your medication while learning to meditate
The prolonged practice of meditation may lead to a reduced need for antihypertensive
medications. However, the medications must be continued (A) while the physiologic
response to meditation is monitored. (B) is not as important as continuing the medication.
The healthcare provider should be informed, but permission is not required to meditate
(C). Although it is true that this complimentary therapy might be effective (D), it is essential
that the client continue with antihypertensive medications until the effect of meditation can
be measured
The nurse plans to obtain health assessment information from a primary source. Which
option is a primary source for the completion of the health assessment?
A) Client.
B) Healthcare provider.
C) A family member.
D) Previous medical records ✅- A) Client
A primary source of information for a health assessment is the client (A). (B, C, and D) are
considered secondary sources about the client's health history, but other details, such as
subjective data, can only be provided directly from the client.
The nurse is instructing a client with high cholesterol about diet and life style modification.
What comment from the client indicates that the teaching has been effective?
A) If I exercise at least two times weekly for one hour, I will lower my cholesterol.
B) I need to avoid eating proteins, including red meat.
C) I will limit my intake of beef to 4 ounces per week.
D) My blood level of low density lipoproteins needs to increase. ✅- C) I will limit my intake
of beef to 4 ounces per week
Limiting saturated fat from animal food sources to no more than 4 ounces per week (C) is
an important diet modification for lowering cholesterol. To be effective in reducing
cholesterol, the client should exercise 30 minutes per day, or at least 4 to 6 times per week
(A). Red meat and all proteins do not need to be eliminated (B) to lower cholesterol, but
should be restricted to lean cuts of red meat and smaller portions (2-ounce servings). The
low density lipoproteins (D) need to decrease rather than increase
Examination of a client complaining of itching on his right arm reveals a rash made up of
multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the
nurse record this finding?
A) Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm.
B) Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter.
C) Several areas of red, papular lesions from pinpoint to 0.5 cm in size.
D) Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter. ✅- B)
Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter
Macules are localized flat skin discolorations less than 1 cm in diameter. However, when
recording such a finding the nurse should describe the appearance (B) rather than simply
naming the condition. (A) identifies vesicles -- fluid filled blisters -- an incorrect description
given the symptoms listed. (C) identifies papules -- solid elevated lesions, again not
correctly identifying the symptoms. (D) identifies petechiae -- pinpoint red to purple skin
discolorations that do not itch, again an incorrect identification
A client who is 5' 5" tall and weighs 200 pounds is scheduled for surgery the next day. What
question is most important for the nurse to include during the preoperative assessment?
A) What is your daily calorie consumption?
B) What vitamin and mineral supplements do you take?
C) Do you feel that you are overweight?
D) Will a clear liquid diet be okay after surgery? ✅- A) What is your daily calorie
consumption?
Vitamin and mineral supplements (B) may impact medications used during the operative
period. (A and C) are appropriate questions for long-term dietary counseling. The nature of
the surgery and anesthesia will determine the need for a clear liquid diet (D), rather than
the client's preference
The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for
fifteen seconds, large amounts of thick yellow secretions return. What action should the
nurse implement next?
A) Encourage the client to cough to help loosen secretions.
B) Advise the client to increase the intake of oral fluids.
C) Rotate the suction catheter to obtain any remaining secretions.
D) Re-oxygenate the client before attempting to suction again. ✅- D) Re-oxygenate the
client before attempting to suction again
Suctioning should not be continued for longer than ten to fifteen seconds, since the client's
oxygenation is compromised during this time (D). (A, B, and C) may be performed after the
client is re-oxygenated and additional suctioning is performed.
A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a
continuous pump infusion. He reports that he had a bad bout of severe coughing a few
minutes ago, but feels fine now. What action is best for the nurse to take?
A) Record the coughing incident. No further action is required at this time.
B) Stop the feeding, explain to the family why it is being stopped, and notify the healthcare
provider.
C) After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube.
D) Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling. ✅- C)
After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube
Coughing, vomiting, and suctioning can precipitate displacement of the tip of the small bore
feeding tube upward into the esophagus, placing the client at increased risk for aspiration.
Checking the sample of fluid withdrawn from the tube (after clearing the tube with 30 ml of
air) for acidic (stomach) or alkaline (intestine) values is a more sensitive method for these
tubes, and the nurse should assess tube placement in this way prior to taking any other
action (C). (A and B) are not indicated. The auscultating method (D) has been found to be
unreliable for small-bore feeding tubes.
A female client with a nasogastric tube attached to low suction states that she is nauseated.
The nurse assesses that there has been no drainage through the nasogastric tube in the last
two hours. What action should the nurse take first?
A) Irrigate the nasogastric tube with sterile normal saline.
B) Reposition the client on her side.
C) Advance the nasogastric tube an additional five centimeters.
D) Administer an intravenous antiemetic prescribed for PRN use. ✅- B) Reposition the
client on her side
The immediate priority is to determine if the tube is functioning correctly, which would
then relieve the client's nausea. The least invasive intervention, (B), should be attempted
first, followed by (A and C), unless either of these interventions is contraindicated. If these
measures are unsuccessful, the client may require an antiemetic (D).
The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest
way to transfer an elderly client with left-sided weakness from the bed to the chair. What
method describes the correct transfer procedure for this client?
A) Place the chair at a right angle to the bed on the client's left side before moving.
B) Assist the client to a standing position, then place the right hand on the armrest.
C) Have the client place the left foot next to the chair and pivot to the left before sitting.
D) Move the chair parallel to the right side of the bed, and stand the client on the right foot
✅- D) Move the chair parallel to the right side of the bed, and stand the client on the
right foot
(D) uses the client's stronger side, the right side, for weight-bearing during the transfer, and
is the safest approach to take. (A, B, and C) are unsafe methods of transfer and include the
use of poor body mechanics by the caregiver.
When conducting an admission assessment, the nurse should ask the client about the use of
complimentary healing practices. Which statement is accurate regarding the use of these
practices?
A) Complimentary healing practices interfere with the efficacy of the medical model of
treatment.
B) Conventional medications are likely to interact with folk remedies and cause adverse
effects.
C) Many complimentary healing practices can be used in conjunction with conventional
practices.
D) Conventional medical practices will ultimately replace the use of complimentary healing
practices. ✅- C) Many complimentary healing practices can be used in conjunction with
conventional practices
Conventional approaches to health care can be depersonalizing and often fail to take into
consideration all aspects of an individual, including body, mind, and spirit. Often
complimentary healing practices can be used in conjunction with conventional medical
practices (C), rather than interfering (A) with conventional practices, causing adverse
effects (B), or replacing conventional medical care (D).
After completing an assessment and determining that a client has a problem, which action
should the nurse perform next?
A) Determine the etiology of the problem.
B) Prioritize nursing care interventions.
C) Plan appropriate interventions.
D) Collaborate with the client to set goals. ✅- A) Determine the etiology of the problem
Before planning care, the nurse should determine the etiology, or cause, of the problem (A),
because this will help determine (B, C, and D).
The nurse notices that the Hispanic parents of a toddler who returns from surgery offer the
child only the broth that comes on the clear liquid tray. Other liquids, including gelatin,
popsicles, and juices, remain untouched. What explanation is most appropriate for this
behavior?
A) The belief is held that the "evil eye" enters the child if anything cold is ingested.
B) After surgery the child probably has refused all foods except broth.
C) Eating broth strengthens the child's innate energy called "chi."
D) Hot remedies restore balance after surgery, which is considered a "cold" condition. ✅D) Hot remedies restore balance after surgery, which is considered a "cold" condition
Common parental practices and health beliefs among Hispanic, Chinese, Filipino, and Arab
cultures classify diseases, areas of the body, and illnesses as "hot" or "cold" and must be
balanced to maintain health and prevent illness. The perception that surgery is a "cold"
condition implies that only "hot" remedies, such as soup, should be used to restore the
healthy balance within the body, so (D) is the correct interpretation. (A, B, and C) are not
correct interpretations of the noted behavior. "Chi" is a Chinese belief that an innate energy
enters and leaves the body via certain locations and pathways and maintains health. The
"evil eye," or "mal ojo," is believed by many cultures to be related to the balance of health
and illness but is unrelated to dietary practice.
Three days following surgery, a male client observes his colostomy for the first time. He
becomes quite upset and tells the nurse that it is much bigger than he expected. What is the
best response by the nurse?
A) Reassure the client that he will become accustomed to the stoma appearance in time. B)
Instruct the client that the stoma will become smaller when the initial swelling diminishes.
C) Offer to contact a member of the local ostomy support group to help him with his concerns.
D) Encourage the client to handle the stoma equipment to gain confidence with the procedure
✅- B) Instruct the client that the stoma will become smaller when the initial swelling
diminishes
Postoperative swelling causes enlargement of the stoma. The nurse can teach the client
that the stoma will become smaller when the swelling is diminished (B). This will help
reduce the client's anxiety and promote acceptance of the colostomy. (A) does not provide
helpful teaching or support. (C) is a useful action, and may be taken after the nurse
provides pertinent teaching. The client is not yet demonstrating readiness to learn
colostomy care (D).
An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to
administering a soap suds enema. Which instruction should the nurse provide the UAP?
A) Position the client on the right side of the bed in reverse Trendelenburg.
B) Fill the enema container with 1000 ml of warm water and 5 ml of castile soap.
C) Reposition in a Sim's position with the client's weight on the anterior ilium.
D) Raise the side rails on both sides of the bed and elevate the bed to waist level. ✅- C)
Reposition in a Sim's position with the client's weight on the anterior ilium
The left sided Sims' position allows the enema solution to follow the anatomical course of
the intestines and allows the best overall results, so the UAP should reposition the client in
the Sims' position, which distributes the client's weight to the anterior ilium (C). (A) is
inaccurate. (B and D) should be implemented once the client is positioned
The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO.
Zaroxolyn is available in 5 mg tablets. How much should the nurse plan to administer?
A) ½ tablet.
B) 1 tablet.
C) 1½ tablets.
D) 2 tablets. ✅- C) 1½ tablets
An elderly male client who suffered a cerebral vascular accident is receiving tube feedings
via a gastrostomy tube. The nurse knows that the best position for this client during
administration of the feedings is
A) prone.
B) Fowler's.
C) Sims'.
D) supine ✅- B) Fowler's
The client should be positioned in a semi-sitting (Fowler's) (B) position during feeding to
decrease the occurrence of aspiration. A gastrostomy tube, known as a PEG tube, due to
placement by a percutaneous endoscopic gastrostomy procedure, is inserted directly into
the stomach through an incision in the abdomen for long-term administration of nutrition
and hydration in the debilitated client. In (A and/or C), the client is placed on the abdomen,
an unsafe position for feeding. Placing the client in (D) increases the risk of aspiration
A resident in a skilled nursing facility for short-term rehabilitation after a hip replacement
tells the nurse, "I don't want any more blood taken for those useless tests." Which narrative
documentation should the nurse enter in the client's medical record?
A) Healthcare provider notified of failure to collect specimens for prescribed blood studies.
B) Blood specimens not collected because client no longer wants blood tests performed. C)
Healthcare provider notified of client's refusal to have blood specimens collected for
testing.
D) Client irritable, uncooperative, and refuses to have blood collected. Healthcare provider
notified ✅- C) Healthcare provider notified of client's refusal to have blood specimens
collected for testing
When a client refuses a treatment, the exact words of the client regarding the client's
refusal of care should be documented in a narrative format (C). (A, B, and D) do not address
the concepts of informatics and legal issues
While instructing a male client's wife in the performance of passive range-of-motion
exercises to his contracted shoulder, the nurse observes that she is holding his arm above
and below the elbow. What nursing action should the nurse implement?
A) Acknowledge that she is supporting the arm correctly.
B) Encourage her to keep the joint covered to maintain warmth.
C) Reinforce the need to grip directly under the joint for better support.
D) Instruct her to grip directly over the joint for better motion. ✅- A) Acknowledge that
she is supporting the arm correctly
The wife is performing the passive ROM correctly, therefore the nurse should acknowledge
this fact (A). The joint that is being exercised should be uncovered (B) while the rest of the
body should remain covered for warmth and privacy. (C and D) do not provide adequate
support to the joint while still allowing for joint movement
A young mother of three children complains of increased anxiety during her annual
physical exam. What information should the nurse obtain first?
A) Sexual activity patterns.
B) Nutritional history.
C) Leisure activities.
D) Financial stressors ✅- B) Nutritional history
Caffeine, sugars, and alcohol can lead to increased levels of anxiety, so a nutritional history
(C) should be obtained first so that health teaching can be initiated if indicated. (A and C)
can be used for stress management. Though (D) can be a source of anxiety, a nutritional
history should be obtained first
The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via
a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN
solution has run out and the next TPN solution is not available. What immediate action
should the nurse take?
A) Infuse normal saline at a keep vein open rate.
B) Discontinue the IV and flush the port with heparin.
C) Infuse 10 percent dextrose and water at 54 ml/hr
D) Obtain a stat blood glucose level and notify the healthcare provider. ✅- C) Infuse 10
percent dextrose and water at 54 ml/hr
TPN is discontinued gradually to allow the client to adjust to decreased levels of glucose.
Administering 10% dextrose in water at the prescribed rate (C) will keep the client from
experiencing hypoglycemia until the next TPN solution is available. The client could
experience a hypoglycemic reaction if the current level of glucose (A) is not maintained or if
the TPN is discontinued abruptly (B). There is no reason to obtain a stat blood glucose level
(D) and the healthcare provider cannot do anything about this situation
A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the
infusion site. The nurse observes erythema, swelling, and a red streak along the vessel
above the IV access site. Which action should the nurse take at this time?
A) Administer the medication more rapidly using the same IV site.
B) Initiate an alternate site for the IV infusion of the medication.
C) Notify the healthcare provider before administering the next dose.
D) Give the client a PRN dose of aspirin while the medication infuses ✅- B) Initiate an
alternate site for the IV infusion of the medication
A cephalosporin antibiotic that is administered IV may cause vessel irritation. Rotating the
infusion site minimizes the risk of thrombophlebitis, so an alternate infusion site should be
initiated (B) before administering the next dose. Rapid administration (A) of intravenous
cephalosporins can potentiate vessel irritation and increase the risk of thrombophlebitis.
(C) is not necessary to initiate an alternative IV site. Although aspirin has antiinflammatory
actions, (D) is not indicated
The nurse is using a genogram while conducting a client's health assessment and past
medical history. What information should the genogram provide?
A) Genetic and familial health disorders.
B) Chronic health problems.
C) Reason for seeking health care.
D) Undetected disorders. ✅- A) Genetic and familial health disorders
A genogram that is used during the health assessment process identifies genetic and
familial health disorders (A). It may not identify the client's chronic health problems (B), so
it is not a reason to seek health care (C). A genogram is not a diagnostic tool to detect
disorders (D), such as those based on pathological findings or DNA.
Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5½ hours. How
much heparin has the client received?
A) 11,000 units. B)
13,000 units.
C) 15,000 units.
D) 17,000 units ✅- A) 11,000 units
A male client tells the nurse that he does not know where he is or what year it is. What data
should the nurse document that is most accurate?
A) demonstrates loss of remote memory.
B) exhibits expressive dysphasia.
C) has a diminished attention span.
D) is disoriented to place and time. ✅- D) is disoriented to place and time
The client is exhibiting disorientation (D). (A) refers to memory of the distant past. The
client is able to express himself without difficulty (B), and does not demonstrate a
diminished attention span (C).
An obese male client discusses with the nurse his plans to begin a long-term weight loss
regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise
program 3 to 4 times a week and to take stress management classes. After praising the
client for his decision, which instruction is most important for the nurse to provide?
A) Be sure to have a complete physical examination before beginning your planned exercise
program.
B) Be careful that the exercise program doesn't simply add to your stress level, making you
want to eat more.
C) Increased exercise helps to reduce stress, so you may not need to spend money on a stress
management class.
D) Make sure to monitor your weight loss regularly to provide a sense of accomplishment and
motivation. ✅- A) Be sure to have a complete physical examination before beginning your
planned exercise program
The most important teaching is (A), so that the client will not begin a dangerous level of
exercise when he is not sufficiently fit. This might result in chest pain, a heart attack, or
stroke. (B, C, and D) are important instructions, but are of less priority than (A).
At the beginning of the shift, the nurse assesses a client who is admitted from the
postanesthesia care unit (PACU). When should the nurse document the client's findings?
A) At the beginning, middle, and end of the shift.
B) After client priorities are identified for the development of the nursing care plan.
C) At the end of the shift so full attention can be given to the client's needs.
D) Immediately after the assessments are completed ✅- D) Immediately after the
assessments are completed
Documentation should occur immediately after any component of the nursing process, so
assessments should be entered in the client's medical record as readily as findings are
obtained (D). (A, B, and C) do not address the concepts of legal recommendations for
information management and informatics.
The nurse assigns a UAP to obtain vital signs from a very anxious client. What instructions
should the nurse give the UAP?
A) Remain calm with the client and record abnormal results in the chart.
B) Notify the medication nurse immediately if the pulse or blood pressure is low.
C) Report the results of the vital signs to the nurse.
D) Reassure the client that the vital signs are normal. ✅- C) Report the results of the vital
signs to the nurse.
Interpretation of vital signs is the responsibility of the nurse, so the UAP should report vital
sign measurements to the nurse (C). (A, B, and D) require the UAP to interpret the vital
signs, which is beyond the scope of the UAP's authority
The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix 20
mg/2 ml. How many milliliters should the nurse administer?
A) 1 ml.
B) 1.5 ml.
C) 1.75 ml.
D) 2 ml. ✅- B) 1.5 ml
An elderly resident of a long-term care facility is no longer able to perform self-care and is
becoming progressively weaker. The resident previously requested that no resuscitative
efforts be performed, and the family requests hospice care. What action should the nurse
implement first?
A) Reaffirm the client's desire for no resuscitative efforts.
B) Transfer the client to a hospice inpatient facility.
C) Prepare the family for the client's impending death.
D) Notify the healthcare provider of the family's request. ✅- D) Notify the healthcare
provider of the family's request
The nurse should first communicate with the healthcare provider (D). Hospice care is
provided for clients with a limited life expectancy, which must be identified by the
healthcare provider. (A) is not necessary at this time. Once the healthcare provider
supports the transfer to hospice care, the nurse can collaborate with the hospice staff and
healthcare provider to determine when (B and C) should be implemented
The nurse is evaluating client learning about a low-sodium diet. Selection of which meal
would indicate to the nurse that this client understands the dietary restrictions?
A) Tossed salad, low-sodium dressing, bacon and tomato sandwich.
B) New England clam chowder, no-salt crackers, fresh fruit salad.
C) Skim milk, turkey salad, roll, and vanilla ice cream.
D) Macaroni and cheese, diet Coke, a slice of cherry pie. ✅- C) Skim milk, turkey salad, roll,
and vanilla ice cream
Skim milk, turkey, bread, and ice cream (C), while containing some sodium, are considered
low-sodium foods. Bacon (A), canned soups (B), especially those with seafood, hard
cheeses, macaroni, and most diet drinks (D) are very high in sodium
A client who has been NPO for 3 days is receiving an infusion of D5W 0.45 normal saline
(NS) with potassium chloride (KCl) 20 mEq at 83 ml/hour. The client's eight-hour urine
output is 400 ml, blood urea nitrogen (BUN) is 15 mg/dl, lungs are clear bilaterally, serum
glucose is 120 mg/dl, and the serum potassium is 3.7 mEq/L. Which action is most
important for the nurse to implement?
A) Notify healthcare provider and request to change the IV infusion to hypertonic D10W.
B) Decrease in the infusion rate of the current IV and report to the healthcare provider.
C) Document in the medical record that these normal findings are expected outcomes.
D) Obtain potassium chloride 20 mEq in anticipation of a prescription to add to present IV.
✅- C) Document in the medical record that these normal findings are expected outcomes
The results are all within normal range.(C) No changes are needed. (A,B, and D)
The nurse is teaching a client proper use of an inhaler. When should the client administer
the inhaler-delivered medication to demonstrate correct use of the inhaler?
A) Immediately after exhalation.
B) During the inhalation.
C) At the end of three inhalations.
D) Immediately after inhalation ✅- B) During the inhalation
The client should be instructed to deliver the medication during the last part of inhalation
(B). After the medication is delivered, the client should remove the mouthpiece, keeping
his/her lips closed and breath held for several seconds to allow for distribution of the
medication. The client should not deliver the dose as stated in (A or D), and should deliver
no more than two inhalations at a time (C).
A male client being discharged with a prescription for the bronchodilator theophylline tells
the nurse that he understands he is to take three doses of the medication each day. Since, at
the time of discharge, timed-release capsules are not available, which dosing schedule
should the nurse advise the client to follow?
A) 9 a.m., 1 p.m., and 5 p.m.
B) 8 a.m., 4 p.m., and midnight.
C) Before breakfast, before lunch and before dinner.
D) With breakfast, with lunch, and with dinner. ✅- B) 8 a.m., 4 p.m., and midnight
Theophylline should be administered on a regular around-the-clock schedule (B) to provide
the best bronchodilating effect and reduce the potential for adverse effects. (A, C, and D) do
not provide around-the-clock dosing. Food may alter absorption of the medication (D).
Seconal 0.1 gram PRN at bedtime is prescribed to a client for rest. The scored tablets are
labeled grain 1.5 per tablet. How many tablets should the nurse plan to administer?
A) 0.5 tablet.
B) 1 tablet.
C) 1.5 tablets.
D) 2 tablets. ✅- B) 1 tablet
15 gr=1 Gm. Converting the prescribed dose of 0.1 grams to grains requires multiplying 0.1
× 15 = 1.5 grains. The tablets come in 1.5 grains, so the nurse should plan to administer 1
tablet (B).
What is the most important reason for starting intravenous infusions in the upper
extremities rather than the lower extremities of adults?
A) It is more difficult to find a superficial vein in the feet and ankles.
B) A decreased flow rate could result in the formation of a thrombosis.
C) A cannulated extremity is more difficult to move when the leg or foot is used.
D) Veins are located deep in the feet and ankles, resulting in a more painful procedure ✅B) A decreased flow rate could result in the formation of a thrombosis
Venous return is usually better in the upper extremities. Cannulation of the veins in the
lower extremities increases the risk of thrombus formation (B) which, if dislodged, could be
life-threatening. Superficial veins are often very easy (A) to find in the feet and legs.
Handling a leg or foot with an IV (C) is probably not any more difficult than handling an
arm or hand. Even if the nurse did believe moving a cannulated leg was more difficult, this
is not the most important reason for using the upper extremities. Pain (D) is not a
consideration
The nurse is assessing the nutritional status of several clients. Which client has the greatest
nutritional need for additional intake of protein?
A) A college-age track runner with a sprained ankle.
B) A lactating woman nursing her 3-day-old infant.
C) A school-aged child with Type 2 diabetes.
D) An elderly man being treated for a peptic ulcer. ✅- B) A lactating woman nursing her
3day-old infant
A lactating woman (B) has the greatest need for additional protein intake. (A, C, and D) are
all conditions that require protein, but do not have the increased metabolic protein
demands of lactation
A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should
the nurse have for planning care in terms of the client's beliefs?
A) Autopsy of the body is prohibited.
B) Blood transfusions are forbidden.
C) Alcohol use in any form is not allowed.
D) A vegetarian diet must be followed ✅- B) Blood transfusions are forbidden
Blood transfusions are forbidden (B) in the Jehovah's Witness religion. Judaism prohibits
(A). Buddhism forbids the use of (C) and drugs. Many of these sects are vegetarian (D), but
the direct impact on nursing care is (B).
A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood
cells) as rapidly as possible. Which intervention is most important for the nurse to
implement?
A) Obtain the pre-transfusion hemoglobin level.
B) Prime the tubing and prepare a blood pump set-up.
C) Monitor vital signs q15 minutes for the first hour.
D) Ensure the accuracy of the blood type match. ✅- D) Ensure the accuracy of the blood
type match
All interventions should be implemented prior to administering blood, but (D) has the
highest priority. Any time blood is administered, the nurse should ensure the accuracy of
the blood type match in order to prevent a possible hemolytic reaction
On admission, a client presents a signed living will that includes a Do Not Resuscitate
(DNR) prescription. When the client stops breathing, the nurse performs cardiopulmonary
resuscitation (CPR) and successfully revives the client. What legal issues could be brought
against the nurse?
A) Assault.
B) Battery.
C) Malpractice.
D) False imprisonment. ✅- B) Battery
Civil laws protect individual rights and include intentional torts, such as assault (an
intentional threat to engage in harmful contact with another) or battery (unwanted
touching). Performing any procedure against the client's wishes can potentially poise a
legal issue, such as battery (B), even if the procedure is of questionable benefit to the client.
(A, C, and D) are not examples against the client's request
During the daily nursing assessment, a client begins to cry and states that the majority of
family and friends have stopped calling and visiting. What action should the nurse take?
A) Listen and show interest as the client expresses these feelings. B)
Reinforce that this behavior means they were not true friends.
C) Ask the healthcare provider for a psychiatric consult.
D) Continue with the assessment and tell the client not to worry. ✅- A) Listen and show
interest as the client expresses these feelings
When a client begins to cry and express feelings, a therapeutic nursing intervention is to
listen and show interest as the client expresses feelings (A). (B) is not therapeutic option
and the nurse does not know the dynamics of their relationships. (C) is not indicated at this
time. (D) is non-therapeutic and offers false hope
An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is
receiving bolus enteral feedings though a gastrostomy tube. What is the best client position
for administration of the bolus tube feedings?
A) Prone.
B) Fowler's.
C) Sims'.
D) Supine. ✅- B) Fowler's
The client should be positioned in a semi-sitting (Fowler's) (B) position during feeding to
decrease the occurrence of aspiration. A gastrostomy tube, known as a PEG tube, due to
placement by a percutaneous endoscopic gastrostomy procedure, is inserted directly into
the stomach through an incision in the abdomen for long-term administration of nutrition
and hydration in the debilitated client. In (A and/or C), the client is placed on the abdomen,
an unsafe position for feeding. Placing the client in (D) increases the risk of aspiration
Which nutritional assessment data should the nurse collect to best reflect total muscle
mass in an adolescent?
A) Height in inches or centimeters.
B) Weight in kilograms or pounds.
C) Triceps skin fold thickness.
D) Upper arm circumference. ✅- D) Upper arm circumference
Upper arm circumference (D) is an indirect measure of muscle mass. (A and B) do not
distinguish between fat (adipose) and muscularity. (C) is a measure of body fat.
An older client who is a resident in a long term care facility has been bedridden for a week.
Which finding should the nurse identify as a client risk factor for pressure ulcers?
A) Generalized dry skin.
B) Localized dry skin on lower extremities.
C) Red flush over entire skin surface.
D) Rashes in the axillary, groin, and skin fold regions ✅- D) Rashes in the axillary, groin,
and skin fold regions
Immobility, constant contact with bed clothing, and excessive heat and moisture in areas
where air flow is limited contributes to bacterial and fungal growth, which increases the
risk for rashes (D), skin breakdown, and the development of pressure ulcers. (A, B, and C)
do not address the concepts of inflammation and tissue integrity
During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis
using a goniometer. Which finding should the nurse expect to measure?
A) Adequate venous blood flow to the lower extremities.
B) Estimated amount of body fat by an underarm skinfold.
C) Degree of flexion and extension of the client's knee joint.
D) Change in the circumference of the joint in centimeters ✅- C) Degree of flexion and
extension of the client's knee joint
The goniometer is a two-piece ruler that is jointed in the middle with a protractor-type
measuring device that is placed over a joint as the individual extends or flexes the joint to
measure the degrees of flexion and extension on the protractor (C). A doppler is used to
measure blood flow (A). Calipers are used to measure body fat (B). A tape measure is used
to measure circumference of body parts (D).
The healthcare provider prescribes 1,000 ml of Ringer's Lactate with 30 Units of Pitocin to
run in over 4 hours for a client who has just delivered a 10 pound infant by cesarean
section. The tubing has been changed to a 20 gtt/ml administration set. The nurse plans to
set the flow rate at how many gtt/min?
A) 42 gtt/min. B)
83 gtt/min.
C) 125 gtt/min.
D) 250 gtt/min ✅- B. 83 gtt/min
An Arab-American woman, who is a devout traditional Muslim, lives with her married son's
family, which includes several adult children and their children. What is the best plan to
obtain consent for surgery for this client?
A) Obtain an interpreter to explain the procedure to the client.
B) Encourage the client to make her own decision regarding surgery.
C) Ask the family members to provide an interpretation of the surgeon's explanation to the
client.
D) Tell the surgeon that the son will decide after explanation of the proposed surgery is
provided. ✅- D) Tell the surgeon that the son will decide after explanation of the
proposed surgery is provided
Traditional Muslim women live in a patriarchal family where decisions are made by men.
Most likely, the son will make the decision for his mother, so (D) provides the surgeon with
culturally sensitive information. (A) may be necessary if a language barrier exists, but the
son is the patriarch in the client's family at this time. It is culturally insensitive to encourage
the woman to go against her religious and cultural worldview, as in (B). Family members
are more likely to misinterpret medical information, but the son should be the primary
decision-maker for his mother (C).
In developing a plan of care for a client with dementia, the nurse should remember that
confusion in the elderly
A) is to be expected, and progresses with age.
B) often follows relocation to new surroundings.
C) is a result of irreversible brain pathology.
D) can be prevented with adequate sleep ✅- B) often follows relocation to new
surroundings
Relocation (B) often results in confusion among elderly clients--moving is stressful for
anyone. (A) is a stereotypical judgment. Stress in the elderly often manifests itself as
confusion, so (C) is wrong. Adequate sleep is not a prevention (D) for confusion
A female client asks the nurse to find someone who can translate into her native language
her concerns about a treatment. Which action should the nurse take?
A) Explain that anyone who speaks her language can answer her questions.
B) Provide a translator only in an emergency situation.
C) Ask a family member or friend of the client to translate.
D) Request and document the name of the certified translator. ✅- D) Request and
document the name of the certified translator
A certified translator should be requested to ensure the exchanged information is reliable
and unaltered. To adhere to legal requirements in some states, the name of the translator
should be documented (D). Client information that is translated is private and protected
under HIPAA rules, so (A) is not the best action. Although an emergency situation may
require extenuating circumstances (B), a translator should be provided in most situations.
Family members may skew information and not translate the exact information, so (C) is
not preferred.
The nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at
a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml,
how many drops per minute should the client receive?
A) 31 gtt/min. B)
62 gtt/min.
C) 93 gtt/min.
D) 124 gtt/min ✅- D) 124 gtt/min
A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what
rate should the nurse set the client's intravenous infusion pump?
A) 13 ml/hour. B)
63 ml/hour.
C) 80 ml/hour.
D) 125 ml/hour ✅- B) 63 ml/hour
During a physical assessment, a female client begins to cry. Which action is best for the
nurse to take?
A) Request another nurse to complete the physical assessment.
B) Ask the client to stop crying and tell the nurse what is wrong.
C) Acknowledge the client's distress and tell her it is all right to cry.
D) Leave the room so that the client can be alone to cry in private. ✅- C) Acknowledge the
client's distress and tell her it is all right to cry
Acknowledging the client's distress and giving the client the opportunity to verbalize her
distress (C) is a supportive response. (A, B, and D) are not supportive and do not facilitate
the client's expression of feelings
Which response by a client with a nursing diagnosis of Spiritual distress, indicates to the
nurse that a desired outcome measure has been met?
A) Expresses concern about the meaning and importance of life
B) Remains angry at God for the continuation of the illness.
C) Accepts that punishment from God is not related to illness.
D) Refuses to participate in religious rituals that have no meaning. ✅- C) Accepts that
punishment from God is not related to illness
Acceptance that she is not being punished by God indicates a desired outcome (C) for some
degree of resolution of spiritual distress. (A, B, and D) do not support the concept of grief,
loss, and cultural/spiritual acceptance.
A client with chronic renal failure selects a scrambled egg for his breakfast. What action
should the nurse take?
A) Commend the client for selecting a high biologic value protein.
B) Remind the client that protein in the diet should be avoided.
C) Suggest that the client also select orange juice, to promote absorption.
D) Encourage the client to attend classes on dietary management of CRF ✅- A) Commend
the client for selecting a high biologic value protein
Foods such as eggs and milk (A) are high biologic proteins which are allowed because they
are complete proteins and supply the essential amino acids that are necessary for growth
and cell repair. Although a low-protein diet is followed (B), some protein is essential.
Orange juice is rich in potassium, and should not be encouraged (C). The client has made a
good diet choice, so (D) is not necessary
A postoperative client will need to perform daily dressing changes after discharge. Which
outcome statement best demonstrates the client's readiness to manage his wound care
after discharge? The client
A) asks relevant questions regarding the dressing change.
B) states he will be able to complete the wound care regimen.
C) demonstrates the wound care procedure correctly.
D) has all the necessary supplies for wound care. ✅- C) demonstrates the wound care
procedure correctly
A return demonstration of a procedure (C) provides an objective assessment of the client's
ability to perform a task, while (A and B) are subjective measures. (D) is important, but is
less of a priority prior to discharge than the nurse's assessment of the client's ability to
complete the wound care
Immediate defibrillation Explanation:
Defibrillation is used during pulseless ventricular tachycardia, ventricular fibrillation, and
asystole (cardiac arrest) when no identifiable R wave is present. ✅- You enter your client's
room and find him pulseless and unresponsive. What would be the treatment of choice for
this client?
0.24 seconds Explanation:
In adults, the normal range for the PR is 0.12 to 0.20 seconds. A PR internal of 0.24 seconds
would indicate a first-degree heart block. ✅- Which PR interval presents a first-degree
heart block?
Sinus bradycardia is a dysrhythmia that proceeds normally through the conduction
pathway but at a slower than usual (≤60 beats/minute) rate. Sinus bradycardia is a slower
than usual (≤60 beats/minute) heart rate. ✅- A 66-year-old female client is having cardiac
diagnostic tests to determine the cause of her symptoms. In her follow-up visit to the
cardiologist, she is told that she has a dysrhythmia at a rate slower than 60 beats/minute.
What type of dysrhythmia did the tests reveal?
The P wave depicts atrial depolarization, or spread of the electrical impulse from the
sinoatrial node through the atria. ✅- P Wave
The PR interval represents spread of the impulse through the interatrial and internodal
fibers, atrioventricular node, bundle of His, and Purkinje fibers. ✅- PR Interval
The QRS complex represents ventricular depolarization. ✅- QRS Complex
The T wave depicts the relative refractory period, representing ventricular repolarization
✅- T Wave
The duration of regular insulin is 4 to 6 hours; 3 to 5 hours is the duration for rapid-acting
insulin such as Novolog. The duration of NPH insulin is 12 to 16 hours. The duration of
Lantus insulin is 24 hours
Humalog is a rapid-acting insulin. NPH is an intermediate-acting insulin. A short-acting
insulin is Humulin-R. An example of a long-acting insulin is Glargine (Lantus) ✅- Duration
of Insulin is:
Once digested, 100% of carbohydrates are converted to glucose. However, approximately
40% of protein foods are also converted to glucose, but this has minimal effect on blood
glucose levels ✅- Once digested, what percentage of carbohydrates is converted to glucose
Immediate bystander CPR Explanation:
The treatment of choice for v-fib is immediate bystander cardiopulmonary resuscitation
(CPR), defibrillation as soon as possible, and activation of emergency services ✅- Which of
the following is the treatment of choice for ventricular fibrillation
used to treat ventricular fibrillation and unstable ventricular tachycardia ✅- Amiodarone
used to treat ventricular ectopy, ventricular tachycardia, and ventricular fibrillation ✅Lidocaine
used to treat symptomatic bradycardia ✅- atropine
Desmopressin
Why? ✅- The nurse is caring for a client with diabetes insipidus. The nurse should
anticipate the administration of:
Serum Potassium ✅- After being sick for 3 days, a client with a history of diabetes mellitus
is admitted to the hospital with diabetic ketoacidosis (DKA). The nurse should evaluate
which diagnostic test results to prevent arrhythmias?
Hypoglycemia ✅- Glucagon is used primarily to treat a patient with
Early morning hyperglycemia resulting from increased growth hormone circulation ✅dawn phenomenon
"It shows the time needed for the SA node impulse to depolarize the atria and travel
through the AV node." Explanation:
The PR interval is measured from the beginning of the P wave to the beginning of the QRS
complex and represents the time needed for sinus node stimulation, atrial depolarization,
and conduction through the AV node before ventricular depolarization. In a normal heart
the impulses do not travel backward. The PR interval does not include the time it take to
travel through the Purkinje fibers ✅- P-R interval
Ketones accumulate in the blood and urine when fat breaks down. Ketones signal a
deficiency of insulin that will cause the body to start to break down stored fat for energy.
Explanation:
Ketones (or ketone bodies) are byproducts of fat breakdown, and they accumulate in the
blood and urine. Ketones in the urine signal a deficiency of insulin and control of type 1
diabetes is deteriorating. When almost no effective insulin is available, the body starts to
break down stored fat for energy ✅- A nurse is teaching a patient recovering from diabetic
ketoacidosis (DKA) about management of "sick days." The patient asks the nurse why it is
important to monitor the urine for ketones. Which of the following statements is the
nurse's best response?
subset of type 2 due to hormone release from placenta resist insulin
2nd & 3rd Trimester, give glucose challenge, dx if over 126 ✅- Gestational Diabetes
TX: insulin, meal spacing ✅- Type I
Treat: Sulfonurea (Increase insulin) + biguanide (incr. isnulin sensitivity), diet & exercise
✅- Type 2
Disease in blood vessels, in SMALLER (eyes, diabetic retinapothy) ✅- Microangiopathy
Larger vessel damage ✅- Macroangiopathy
clots build up, accelorates athro sclerosis, which can lead to myocardial infarction ✅Macrovascualr Angiopathy
blood seeps & protein leaks out, leads to blindness (diabetic retinapothy) ✅Microvascualr Angiopathy
Impaired glucose tolerance 140-199
impaired fasting glucose 110-126 screen
at 40 is FHx present
encourage weightloss ✅- pre-diabetes
Central Obesity, in a prothrombotic state (prone to clots), proinflammatory state,
dyslipidemia, elevated BP 135/85
These people WILL get heart disease & diabetes ✅- Metabolic Syndrome
Symptoms + BG >=200ml/dl at any time w/o regard to meal
2hr post-load glucose >200 (oral gluc test) fasting
>126 ✅- Diagnostic Criteria
Onset: 10-15 m
Duration:2-4 hours
Peak:1 hours
Lispro (Humalog), Aspart, Apidra
Give with breakfast ✅- Rapid Acting
Regular(Humalin), Semilente
Onset: 1-1.5 hr
Duration: 4-6 hours
Peak: 2-3 hours ✅- Short Acting
Lente, NPH
Onset: 2-4 hrs
Duration: 16-20 hours
Peak: 4-12 hours ✅- Intermediate
Ultra Lente, Glargine (LANTUS)
Onset: 1 hr
Duration: 24 hrs
NO PEAK ✅- Long Acting
Hr is 150-250
no p wave (cant determine atrial rate) No
Pulse: defibrillator, amiodarone, cpr, acls
Pulse: cardiovert/amioderano ✅- Vtach
Rate is verrrry fast
Defib, acls, amiodarone ✅- Vfib
Heart isnt beating fast enough to circulate O2, atropine ✅- Sinus brady
Vagus stimulate, adenisone, cardiovert
Narrow QRS ✅- Svt
QRS always widened
Treat with lidocaine Irregular rythm
Can lead to vtach or vfib ✅- Pvc
Sawtooth
Atrial rate 250-350
Ventricular rate is steady
Cardioversion, cardizem (verapamil), amiodarone ✅- Atrial flutter
Spasms in atrial (many pwaves), blood pools-- tx with anticoagulant (warfarin), cardizem,
digoxin & cardiovert if symptoms present ✅- A fib
Acls and cpr asap! ✅- Asystole
When to use?
Morphine, O2, nitroglycerin, aspirin ✅- MONA
Atropine
Conduction is slow, rate can be normal ✅- 1st degree av block
Which drug does a nurse anticipate may be prescribed to produce diuresis and inhibit
formation of aqueous humor for a client with glaucoma?
1
Chlorothiazide (Diuril)
2
Acetazolamide (Diamox)
3
Bendroflumethiazide (Naturetin)
4
Demecarium bromide (Humorsol) ✅- 2
A client receiving steroid therapy states, "I have difficulty controlling my temper which is so
unlike me, and I don't know why this is happening." What is the nurse's best response?
1
Tell the client it is nothing to worry about.
2
Talk with the client further to identify the specific cause of the problem.
3
Instruct the client to attempt to avoid situations that cause irritation.
4
Interview the client to determine whether other mood swings are being experienced. ✅- 4
A client receiving steroid therapy states, "I have difficulty controlling my temper which is so
unlike me, and I don't know why this is happening." What is the nurse's best response?
1
Tell the client it is nothing to worry about.
2
Talk with the client further to identify the specific cause of the problem.
3
Instruct the client to attempt to avoid situations that cause irritation.
4
Interview the client to determine whether other mood swings are being experienced. ✅- 4
The nurse is caring for a client with a temperature of 104.5 degrees Fahrenheit. The nurse
applies a cooling blanket and administers an antipyretic medication. The nurse explains
that the rationale for these interventions is to:
1
Promote equalization of osmotic pressures.
2
Prevent hypoxia associated with diaphoresis.
3
Promote integrity of intracerebral neurons.
4
Reduce brain metabolism and limit hypoxia. ✅- 4
A health care provider prescribes 500 mg of an antibiotic intravenous piggyback (IVPB)
every 12 hours. The vial of antibiotic contains 1 g and indicates that the addition of 2.5 mL
of sterile water will yield 3 mL of reconstituted solution. How many milliliters of the
antibiotic should be added to the 50 mL IVPB bag? Record your answer using one decimal
place. mL ✅- 1.5
The nurse is caring for a non-ambulatory client with a reddened sacrum that is unrelieved
by repositioning. What nursing diagnosis should be included on the client's plan of care?
1
Risk for pressure ulcer
2
Risk for impaired skin integrity
3
Impaired skin integrity, related to infrequent turning and repositioning
4
Impaired skin integrity, related to the effects of pressure and shearing force ✅- 4
A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous
tissue down to the underlying fascia. The nurse should document the assessment finding as
which stage of pressure ulcer?
1
Stage I
2
Stage II
3
Stage III
4
Unstageable ✅- 4
A pressure ulcer with necrotic tissue is unstageable. The necrotic tissue must be removed
before the wound can be staged. A stage I pressure ulcer is defined as an area of persistent
redness with no break in skin integrity. A stage II pressure ulcer is a partial-thickness
wound with skin loss involving the epidermis, dermis, or both; the ulcer is superficial and
may present as an abrasion, blister, or shallow crater. A stage III pressure ulcer involves full
thickness tissue loss with visible subcutaneous fat. Bone, tendon, and muscle are not
exposed.
A client is being admitted for a total hip replacement. When is it necessary for the nurse to
ensure that a medication reconciliation is completed? Select all that apply.
1
After reporting severe pain
2
On admission to the hospital
3
Upon entering the operating room
4
Before transfer to a rehabilitation facility
5
At time of scheduling for the surgical procedure ✅- 2, 4
Medication reconciliation involves the creation of a list of all medications the client is taking
and comparing it to the health care provider's prescriptions on admission or when there is
a transfer to a different setting or service, or discharge. A change in status does not require
medication reconciliation. A medication reconciliation should be completed long before
entering the operating room. Total hip replacement is elective surgery, and scheduling
takes place before admission; medication reconciliation takes place when the client is
admitted.
A client is taking lithium sodium (Lithium). The nurse should notify the health care
provider for which of the following laboratory values?
1
White blood cell (WBC) count of 15,000 mm3
2
Negative protein in the urine
3
Blood urea nitrogen (BUN) of 20 mg/dL
4
Prothrombin of 12.0 seconds ✅- 1
White cell counts can increase with this drug. The expected range of the WBC count is 5000
to 10,000 mm3 for a healthy adult. Urinalysis, BUN, and prothrombin are not necessary and
these are normal values.
Often when a family member is dying, the client and the family are at different stages of
grieving. During which stage of a client's grieving is the family likely to require more
emotional nursing care than the client?
1
Anger
2
Denial
3
Depression
4
Acceptance ✅- 4
In the stage of acceptance, the client frequently detaches from the environment and may
become indifferent to family members. In addition, the family may take longer to accept the
inevitable death than does the client. Although the family may not understand the anger,
dealing with the resultant behavior may serve as a diversion. Denial often is exhibited by
the client and family members at the same time. During depression, the family often is able
to offer emotional support, which meets their needs.
The client asks the nurse to recommend foods that might be included in a diet for
diverticular disease. Which foods would be appropriate to include in the teaching plan?
Select all that apply.
1
Whole grains
2
Cooked fruit and vegetables
3
Nuts and seeds
4
Lean red meats
5
Milk and eggs ✅- 1,2,5
With diverticular disease the patient should avoid foods that may obstruct the diverticuli.
Therefore the fiber should be digestible, such as whole grains, and cooked fruits and
vegetables. Milk and eggs have no fiber content but are good sources of protein. In clients
with diverticular disease, nuts and seeds are contraindicated as they may be retained and
cause inflammation and infection, which is known as diverticulitis. The client should also
decrease intake of fats and red meats.
A nurse is obtaining a health history from the newly admitted client who has chronic pain
in the knee. What should the nurse include in the pain assessment? Select all that apply.
1
Pain history, including location, intensity, and quality of pain
2
Client's purposeful body movement in arranging the papers on the bedside table
3
Pain pattern, including precipitating and alleviating factors
4
Vital signs such as increased blood pressure and heart rate
5
The client's family statement about increases in pain with ambulation ✅- 1,3 Accurate
pain assessment includes pain history with the client's identification of pain location,
intensity, and quality and helps the nurse to identify what pain means to the client. The
pattern of pain includes time of onset, duration, and recurrence of pain and its assessment
helps the nurse anticipate and meet the needs of the client. Assessment of the
precipitating factors helps the nurse prevent the pain and determine it cause. Purposeless
movements such as tossing and turning or involuntary movements such as a reflexive
jerking may indicate pain. Physiological responses such as elevated blood pressure and
heart rate are most likely to be absent in the client with chronic pain. Pain is a subjective
experience and therefore the nurse has to ask the client directly instead of accepting
statement of the family members.
While undergoing a soapsuds enema, the client reports abdominal cramping. What action
should the nurse take?
1
Immediately stop the infusion.
2
Lower the height of the enema bag.
3
Advance the enema tubing 2 to 3 inches.
4
Clamp the tube for 2 minutes, then restart the infusion. ✅- 2
Abdominal cramping during a soapsuds enema may be due to too rapid administration of
the enema solution. Lowering the height of the enema bag slows the flow and allows the
bowel time to adapt to the distention without causing excessive discomfort. Stopping the
infusion is not necessary. Advancing the enema tubing is not appropriate. Clamping the
tube for several minutes then restarting the infusion may be attempted if slowing the
infusion does not relieve the cramps.
During the initial physical assessment of a newly admitted client with a pressure ulcer, a
nurse observes that the client's skin is dry and scaly. The nurse applies emollients and
reinforces the dressing on the pressure ulcer. Legally, were the nurse's actions adequate?
1
The nurse also should have instituted a plan to increase activity.
2
The nurse provided supportive nursing care for the well-being of the client.
3
Debridement of the pressure ulcer should have been done before the dressing was applied.
4
Treatment should not have been instituted until the health care provider's prescriptions
were received. ✅- 2
According to the Nurse Practice Act, a nurse may independently treat human responses to
actual or potential health problems. An activity level is prescribed by a health care
provider; this is a dependent function of the nurse. There is not enough information to
come to the conclusion that debridement should have been done before the dressing was
applied. Application of an emollient and reinforcing a dressing are independent nursing
functions.
A visitor comes to the nursing station and tells the nurse that a client and his relative had a
fight and that the client is now lying unconscious on the floor. What is the most important
action the nurse needs to take?
1
Ask the client if he is okay.
2
Call security from the room.
3
Find out if there is anyone else in the room.
4
Ask security to make sure the room is safe ✅- 4
Safety is the first priority when responding to a presumably violent situation. The nurse
needs to have security enter the room to ensure it is safe. Then it can be determined if the
client is okay and make sure that any other people in the room are safe
To ensure the safety of a client who is receiving a continuous intravenous normal saline
infusion, the nurse should change the administration set every:
1
4 to 8 hours
2
12 to 24 hours 3
24 to 48 hours
4
72 to 96 hours ✅- 4
Best practice guidelines recommend replacing administration sets no more frequently than
72 to 96 hours after initiation of use in patients not receiving blood, blood products, or fat
emulsions. This evidence-based practice is safe and cost effective. Changing the
administration set every 4 to 48 hours is not a cost-effective practice
A nurse is taking care of a client who has severe back pain as a result of a work injury. What
nursing considerations should be made when determining the client's plan of care? Select
all that apply.
1
Ask the client what is the client's acceptable level of pain.
2
Eliminate all activities that precipitate the pain. 3
Administer the pain medications regularly around the clock.
4
Use a different pain scale each time to promote patient education.
5
Assess the client's pain every 15 minutes ✅- 1,3
The nurse works together with the client in order to determine the tolerable level of pain.
Considering that the client has chronic, not acute pain, the goal of the pain management is
to decrease pain to the tolerable level instead of eliminating pain completely.
Administration of pain medications around the clock will provide the stable level of pain
medication in the blood and relieve the pain. Elimination of all activities that precipitate the
client's pain is not possible even though the nurse will try to minimize such activities. The
same pain scale should be used for assessment of the client's pain level helps to ensure
consistency and accuracy in the pain assessment. Only management of acute pain such as
postoperative pain requires the pain assessment at frequent intervals.
The nurse is preparing to administer eardrops to a client that has impacted cerumen.
Before administering the drops, the nurse will assess the client for which
contraindications? Select all that apply.
1
Allergy to the medication
2
Itching in the ear canal
3
Drainage from the ear canal
4
Tympanic membrane rupture
5
Partial hearing loss in the affected ear ✅- 1,3,4
Contraindications to eardrops include allergy to the medication, drainage from the ear
canal, and tympanic membrane rupture. Partial hearing loss may occur with impacted
cerumen and is not a contraindication to the use of eardrops. Itching may occur with some
ear conditions and is not a contraindication to the use of eardrops.
What clinical indicators should the nurse expect a client with hyperkalemia to exhibit?
Select all that apply.
1
Tetany
2
Seizures
3
Diarrhea
4
Weakness
5
Dysrhythmias ✅- 3,4,5
Tetany is caused by hypocalcemia. Seizures caused by electrolyte imbalances are associated
with low calcium or sodium levels. Because of potassium's role in the sodium/potassium
pump, hyperkalemia will cause diarrhea, weakness, and cardiac dysrhythmias.
A health care provider has prescribed isoniazid (Laniazid) for a client. Which instruction
should the nurse give the client about this medication? 1
Prolonged use can cause dark concentrated urine. 2
The medication is best absorbed when taken on an empty stomach.
3
Take the medication with aluminum hydroxide to minimize GI upset.
4
Drinking alcohol daily can cause drug-induced hepatitis ✅- 4
Daily alcohol intake can cause drug induced hepatitis. Prolonged use does not cause dark
concentrated urine. The client should take isoniazid with meals to decrease GI upset.
Clients should avoid taking aluminum antacids at the same time as this medication because
it impairs absorption.
To minimize the side effects of the vincristine (Oncovin) that a client is receiving, what does
the nurse expect the dietary plan to include?
1
Low in fat
2
High in iron
3
High in fluids
4
Low in residue ✅- 3
A common side effect of vincristine is a paralytic ileus that results in constipation.
Preventative measures include high-fiber foods and fluids that exceed minimum
requirements. These will keep the stool bulky and soft, thereby promoting evacuation. Low
in fat, high in iron, and low in residue dietary plans will not provide the roughage and fluids
needed to minimize the constipation associated with vincristine.
A postoperative client says to the nurse, "My neighbor, I mean the person in the next room,
sings all night and keeps me awake." The neighboring client has dementia and is awaiting
transfer to a nursing home. How can the nurse best handle this situation?
1
Tell the neighboring client to stop singing.
2
Close the doors to both clients' rooms at night.
3
Give the complaining client the prescribed as needed sedative.
4
Move the neighboring client to a room at the end of the hall ✅- 4
Moving the client who is singing away from the other clients diminishes the disturbance. A
client with dementia will not remember instructions. It is unsafe to close the doors of
clients' rooms because they need to be monitored. The use of a sedative should not be the
initial intervention
The nurse is providing postoperative care to a client who had a submucosal resection
(SMR) for a deviated septum. The nurse should monitor for what complication associated
with this type of surgery?
Incorrect1
Occipital headache
2
Periorbital crepitus
3
Expectoration of blood
4
Changes in vocalization ✅- 3
After an SMR, hemorrhage from the area should be suspected if the client is swallowing
frequently or expelling blood with saliva. A headache in the back of the head is not a
complication of a submucosal resection. Crepitus is caused by leakage of air into tissue
spaces; it is not an expected complication of SMR. The nerves and structures involved with
speech are not within the operative area. However, the sound of the voice is altered
temporarily by the presence of nasal packing and edema.
A nurse is reviewing a plan of care for a client who was admitted with dehydration as a
result of prolonged watery diarrhea. Which prescription should the nurse question?
1
Oral psyllium (Metamucil)
2
Oral potassium supplement
3
Parenteral half normal saline
4
Parenteral albumin (Albuminar) ✅- 4
Albumin is hypertonic and will draw additional fluid from the tissues into the intravascular
space. Oral psyllium will absorb the watery diarrhea, giving more bulk to the stool. An oral
potassium supplement is appropriate because diarrhea causes potassium loss. Parenteral
half normal saline is a hypotonic solution, which can correct dehydration.
A client is to have mafenide (Sulfamylon) cream applied to burned areas. For which serious
side effect of mafenide therapy should the nurse monitor this client?
1
Curling ulcer
2
Renal shutdown
3
Metabolic acidosis
4
Hemolysis of red blood cells ✅- 3
Mafenide interferes with the kidneys' role in hydrogen ion excretion, resulting in metabolic
acidosis. Curling ulcer, renal shutdown, and hemolysis of red blood cells are not adverse
effects of the drugs.
A nurse is preparing to administer an ophthalmic medication to a client. What techniques
should the nurse use for this procedure? Select all that apply.
1
Clean the eyelid and eyelashes.
2
Place the dropper against the eyelid.
3
Apply clean gloves before beginning of procedure.
4
Instill the solution directly onto cornea.
5
Press on the nasolacrimal duct after instilling the solution. ✅- 1,3,5
Cleaning of the eyelids and eyelashes helps to prevent contamination of the other eye and
lacrimal duct. Application of gloves helps to prevent direct contact of the nurse with the
client's body fluids. Applying pressure to the nasolacrimal duct prevents the medication
from running out of the eye. The dropper should not touch the eyelids or eyelashes in order
to prevent contamination of the medication in the dropper. The medication should not be
instilled directly onto the cornea because cornea has many pain fibers and is therefore very
sensitive. The medication is to be instilled into the lower conjunctival sac.
The nurse recognizes that which are important components of a neurovascular
assessment? Select all that apply.
1
Orientation
2
Capillary refill
3
Pupillary response
4
Respiratory rate
5
Pulse and skin temperature
6
Movement and sensation ✅- 2,5,6,
A neurovascular assessment involves evaluation of nerve and blood supply to an extremity
involved in an injury. The area involved may include an orthopedic and/or soft tissue injury.
A correct neurovascular assessment should include evaluation of capillary refill, pulses,
warmth and paresthesias, and movement and sensation. Orientation, pupillary response,
and respiratory rate are components of a neurological assessment.
A client reaches the point of acceptance during the stages of dying. What response should
the nurse expect the client to exhibit?
1
Apathy
2
Euphoria
3
Detachment
4
Emotionalism ✅- 3
When an individual reaches the point of being intellectually and psychologically able to
accept death, anxiety is reduced and the individual becomes detached from the
environment. Although detached, the client is not apathetic but still may be concerned and
use time constructively. Although resigned to death, the individual is not euphoric. In the
stage of acceptance, the client is no longer angry or depressed.
A dying client is coping with feelings regarding impending death. The nurse bases care on
the theory of death and dying by Kübler-Ross. During which stage of grieving should the
nurse primarily use nonverbal interventions?
1
Anger
2
Denial
3
Bargaining
4
Acceptance ✅- 4
Communication and interventions during the acceptance stage are mainly nonverbal (e.g.,
holding the client's hand). The nurse should be quiet but available. During the anger stage
the nurse should accept that the client is angry. The anger stage requires verbal
communication. During the denial stage the nurse should accept the client's behavior but
not reinforce the denial. The denial stage requires verbal communication. During the
bargaining stage the nurse should listen intently but not provide false reassurance. The
bargaining stage requires verbal communication.
When a client files a lawsuit against a nurse for malpractice, the client must prove that
there is a link between the harm suffered and actions performed by the nurse that were
negligent. This is known as:
1
Evidence
2
Tort discovery
3
Proximate cause
4
Common cause ✅- 3
Proximate cause is the legal concept meaning that the client must prove that the nurse's
actions contributed to or caused the client's injury. Evidence is data presented in proof of
the facts, which may include witness testimony, records, documents, or objects. A tort is a
wrongful act, not including a breach of contract of trust that results in injury to another
person. Common cause means to unite one's interest with another's.
Following a surgery on the neck, the client asks the nurse why the head of the bed is up so
high. The nurse should tell the client that the high-Fowler position is preferred for what
reason?
1
To avoid strain on the incision
2
To promote drainage of the wound
3
To provide stimulation for the client
4
To reduce edema at the operative site ✅- 4
This position prevents fluid accumulation in the tissue, thereby minimizing edema. This
position will neither increase nor decrease strain on the suture line. Drainage from the
wound will not be affected by this position. This position will not affect the degree of
stimulation.
The nurse is preparing discharge instructions for a client who has begun to demonstrate
signs of early Alzheimer dementia. The client lives alone. The client's adult children live
nearby. According to the prescribed medication regimen the client is to take medications
six times throughout the day. What is the priority nursing intervention to assist the client
with taking the medication?
1
Contact the client's children and ask them to hire a private duty aide who will provide
round-the-clock care.
2
Develop a chart for the client, listing the times the medication should be taken.
3
Contact the primary health care provider and discuss the possibility of simplifying the
medication regimen.
4
Instruct the client and client's children to put medications in a weekly pill organizer ✅- 3
Contacting a medical care provider and discussing the possibility of simplifying the client's
medication regimen will make it possible to use a weekly pill organizer : an empty pill box
will remind the client who has a short-term memory deficit due to Alzheimer dementia that
medication was taken and will prevent medication being taken multiple times. The client
does not require 24-hour supervision because the client is in the outset of the Alzheimer
dementia and the major issue is a short-term memory loss. A chart may be complex and
difficult to understand for the client and will require the client to perform cognitive tasks
multiple times on daily basis that may be beyond the client's ability. Use of the weekly pill
organizers will be difficult with the current medication regimen when the client has to take
medications six times a day; the medication regimen has to be simplified first.
The nurse expects a client with an elevated temperature to exhibit what indicators of
pyrexia? Select all that apply.
Incorrect 1
Dyspnea
2
Flushed face
3
Precordial pain
4
Increased pulse rate
5
Increased blood pressure ✅- 2,4
Increased body heat dilates blood vessels, causing a flushed face. The pulse rate increases
to meet increased tissue demands for oxygen in the febrile state. Fever may not cause
difficult breathing. Pain is not related to fever. Blood pressure is not expected to increase
with fever.
The nurse should instruct a client with an ileal conduit to empty the collection device
frequently because a full urine collection bag may:
1
Force urine to back up into the kidneys.
2
Suppress production of urine.
3
Cause the device to pull away from the skin.
4
Tear the ileal conduit ✅- 3
If the device becomes full and is not emptied, it may pull away from the skin and leak urine.
Urine in contact with unprotected skin will irritate and cause skin breakdown. A full urine
collection bag will not cause urine to back up into the kidneys, suppress the production of
urine, or tear the ileal conduit.
A nurse is reviewing studies to answer a clinical question as part of an evidence-based
practice project. The study design determines the level of evidence. Place each
methodology in order from the most reliable to the least reliable. Correct
1.
Meta-analysis
2.
Randomized controlled trial
3.
Expert opinion based on scientific principles
4.
Cohort study
5.
Controlled trial without randomization ✅- Meta-analysis is a synthesis of evidence from
associated randomized controlled trials. Meta-analysis is more reliable than a randomized
controlled trial. Randomized controlled trials are studies where subjects randomly are
assigned to a treatment or control group. A randomized control trial is more reliable than a
controlled trial without randomization. Controlled trials without randomization are studies
in which subjects are assigned nonrandomly to a treatment or control group. A controlled
trial without randomization is more reliable than a cohort study. Cohort studies observe a
group to determine the development of an outcome. Expert opinion based on principles is
not based on actual evidence; it is relied on when there is no evidence from research.
Topics
client expresses concern about being exposed to radiation therapy because it can cause
cancer. What should the nurse emphasize when informing the client about exposure to
radiation?
1
The dosage is kept at a minimum.
2
Only a small part of the body is irradiated.
3
The client's physical condition is not a risk factor.
4
Nutritional environment of the affected cells is a risk factor. ✅- Current radiation therapy
accurately targets malignant lesions with pinpoint precision, minimizing the detrimental
effects of radiation to healthy tissue. The dose is not as significant as the extent of tissue
being irradiated. When radiation therapy is prescribed, the health care provider takes into
consideration the ability of the client to tolerate the therapy, determining that the benefit
outweighs the risk. Nutritional environment of the affected cells does not influence
radiation's effect.
The triage nurse in the emergency department receives four clients simultaneously. Which
of the clients should the nurse determine can be treated last? 1
Multipara in active labor
2
Middle-aged woman with substernal chest pain 3
Older adult male with a partially amputated finger
4
Adolescent boy with an oxygen saturation of 91% ✅- 3
Although a client with a partially amputated finger needs control of bleeding, the injury is
not life threatening and the client can wait for care. A woman in active labor should be
assessed immediately because birth may be imminent. A woman with chest pain may be
experiencing a life-threatening illness and should be assessed immediately. An adolescent
with significant hypoxia may be experiencing a life-threatening illness and should be
assessed immediately.
Health promotion efforts with the chronically ill client should include interventions related
to primary prevention. What should this include?
1
Encouraging daily physical exercise
2
Performing yearly physical examinations
3
Providing hypertension screening programs
4
Teaching a person with diabetes how to prevent complications ✅- 1
Primary prevention activities are directed toward promoting healthful lifestyles and
increasing the level of well-being. Performing yearly physical examinations is a secondary
prevention. Emphasis is on early detection of disease, prompt intervention, and health
maintenance for those experiencing health problems. Providing hypertension screening
programs is a secondary prevention. Emphasis is on early detection of disease, prompt
intervention, and health maintenance for those experiencing health problems. Teaching a
person with diabetes how to prevent complications is a tertiary prevention. Emphasis is on
rehabilitating individuals and restoring them to an optimum level of functioning.
A nurse who is working on a medical-surgical unit receives a phone call requesting
information about a client who has undergone surgery. The nurse observes that the client
requested a do not publish (DNP) order on any information regarding condition or
presence in the hospital. What is the best response by the nurse?
1
"We have no record of that client on our unit. Thank you for calling." 2
"The new privacy laws prevent me from providing any client information over the phone." 3
"The client has requested that no information be given out. You'll need to call the client
directly."
4
"It is against the hospital's policy to provide you with any information regarding any of our
clients." ✅- 1
The response "We have no record of that client on our unit. Thank you for calling."
conforms to the request that no information be given regarding the client's condition or
presence in the hospital. HIPAA laws do not prohibit the provision of information to others
as long as the client consents. The response "The client has requested that no information
be given out. You'll need to call the client directly." implies that the client is admitted to the
facility; this violates the client's request that no information should be shared with others.
Hospital policies do not prohibit the provision of information to others as long as the client
consents. The response "It is against the hospital's policy to provide you with any
information regarding any of our clients." also implies that the client is admitted to the
facility.
When being interviewed for a position as a registered professional nurse, the applicant is
asked to identify an example of an intentional tort. What is the appropriate response? 1
Negligence
2
Malpractice
3
Breach of duty
4
False imprisonment ✅- 4
False imprisonment is a wrong committed by one person against another in a willful,
intentional way without just cause or excuse. Negligence is an unintentional tort.
Malpractice, which is professional negligence, is classified as an unintentional tort. Breach
of duty is an unintentional tort.
The nurse plans care for a client with a somatoform disorder based on the understanding
that the disorder is:
1
A physiological response to stress
2
A conscious defense against anxiety
3
An intentional attempt to gain attention
4
An unconscious means of reducing stress ✅- 4
When emotional stress overwhelms an individual's ability to cope, the unconscious seeks to
reduce stress. A conversion reaction removes the client from the stressful situation, and the
conversion reaction's physical/sensory manifestation causes little or no anxiety in the
individual. This lack of concern is called la belle indifference. No physiologic changes are
involved with this unconscious resolution of a conflict. The conversion of anxiety to
physical symptoms operates on an unconscious level.
A nurse is caring for a client diagnosed with methicillin-resistant Staphylococcus aureus
(MRSA) in the urine. The health care provider orders an indwelling urinary catheter to be
inserted. Which precaution should the nurse take during this procedure?
1
Droplet precautions
2
Reverse isolation
3
Surgical asepsis
4
Medical asepsis ✅- 3
Catheter insertion requires the procedure to be performed under sterile technique . Droplet
precautions are used with certain respiratory illnesses. Reverse isolation is used with
clients who may be immunocompromised. Medical asepsis involves clean
technique/gloving.
Alternative therapy measures have become increasingly accepted within the past decade,
especially in the relief of pain. Which methods qualify as alternative therapies for pain?
Select all that apply.
1
Prayer
2
Hypnosis
3
Medication
4
Aromatherapy
5
Guided imagery ✅- Prayer is an alternative therapy that may relax the client and provide
strength, solace, or acceptance. The relief of pain through hypnosis is based on suggestion;
also, it focuses attention away from the pain. Some clients learn to hypnotize themselves.
Aromatherapy can help relax and distract the individual and thus increase tolerance for
pain, as well as relieve pain. Guided imagery can help relax and distract the individual and
thus increase tolerance for pain, as well as relieve pain. Analgesics, both opioid and
nonopioid, long have been part of the standard medical regimen for pain relief, so they are
not considered an alternative therapy.
A nurse is teaching an adolescent about type 1 diabetes and self-care. Which questions
from the client indicate a need for additional teaching in the cognitive domain? Select all
that apply.
1
"What is diabetes?"
2
"What will my friends think?"
3
"How do I give myself an injection?"
4
"Can you tell me how the glucose monitor works?"
5
"How do I get the insulin from the vial into the syringe? ✅- 1,4
Acquiring knowledge or understanding aids in developing concepts, rather than skills or
attitudes, and is a basic learning task in the cognitive domain. Values and self-realization
are in the affective domain. Skills acquisition is in the psychomotor domain.
Place each step of the nursing process in the order that it should be used.
Correct
1.
Obtain client's nursing history.
Correct
2.
State client's nursing needs.
Correct
3.
Identify goals for care.
Correct
4.
Develop a plan of care.
Correct
5.
Implement nursing interventions. ✅- First the nurse should gather data. Based on the
data, the client's needs are assessed. After the needs have been determined, the goals for
care are established. The next step is planning care based on the knowledge gained from
the previous steps. Implementation follows the development of the plan of care.
In what position should the nurse place a client recovering from general anesthesia? 1
Supine
Correct2
Side-lying
3
High Fowler
4
Trendelenburg ✅- 2
Turning the client to the side promotes drainage of secretions and prevents aspiration,
especially when the gag reflex is not intact. This position also brings the tongue forward,
preventing it from occluding the airway when it is in the relaxed state. The risk for
aspiration is increased when the supine position is assumed by a semi-alert client. High
Fowler position may cause the neck to flex in a client who is not alert, interfering with
respirations. Trendelenburg position is not used for a postoperative client because it
interferes with breathing.
Which age-related change should the nurse consider when formulating a plan of care for an
older adult? Select all that apply.
Incorrect 1
Difficulty in swallowing
2
Increased sensitivity to heat
3
Increased sensitivity to glare
4
Diminished sensation of pain
5
Heightened response to stimuli
. ✅- 3,4
Changes in the ciliary muscles, decrease in pupil size, and a more rigid pupil sphincter
contribute to an increased sensitivity to glare. Diminished sensation of pain may make an
older individual unaware of a serious illness, thermal extremes, or excessive pressure.
There should be no interference with swallowing in older individuals. Older individuals
tend to feel the cold and rarely complain of the heat. There is a decreased response to
stimuli in the older individual
The spouse of a comatose client who has severe internal bleeding refuses to allow
transfusions of whole blood because they are Jehovah's Witnesses. The client does not have
a Durable Power of Attorney for Healthcare. What action should the nurse take?
1
Institute the prescribed blood transfusion because the client's survival depends on volume
replacement.
2
Clarify the reason why the transfusion is necessary and explain the implications if there is
no transfusion.
3
Phone the health care provider for an administrative prescription to give the transfusion
under these circumstances.
4
Give the spouse a treatment refusal form to sign and notify the health care provider that a
court order now can be sought ✅- 4
The client is unconscious. Although the spouse can give consent, there is no legal power to
refuse a treatment for the client unless previously authorized to do so by a power of
attorney or a health care proxy; the court can make a decision for the client. Explanations
will not be effective at this time and will not meet the client's needs. Instituting the
prescribed blood transfusion and phoning the health care provider for an administrative
prescription are without legal basis, and the nurse may be held liable.
Twenty-four hours after a cesarean birth, a client elects to sign herself and her baby out of
the hospital. Staff members are unable to contact her health care provider. The client
arrives at the nursery and asks that her infant be given to her to take home. What is the
most appropriate nursing action?
1
Give the infant to the client and instruct her regarding the infant's care.
2
Explain to the client that she can leave, but her infant must remain in the hospital.
3
Emphasize to the client that the infant is a minor and legally must remain until
prescriptions are received.
4
Tell the client that hospital policy prevents the staff from releasing the infant until ready for
discharge ✅- 1
When a client signs herself and her infant out of the hospital, she is legally responsible for
her infant. The infant is the responsibility of the mother and can leave with the mother
when she signs them out.
A client reports fatigue and dyspnea and appears pale. The nurse questions the client about
medications currently being taken. In light of the symptoms, which medication causes the
nurse to be most concerned?
1
Famotidine (Pepcid)
2
Methyldopa (Aldomet)
3
Ferrous sulfate (Feosol)
4
Levothyroxine (Synthroid) ✅- Methyldopa is associated with acquired hemolytic anemia
and should be discontinued to prevent progression and complications. Famotidine will not
cause these symptoms; it decreases gastric acid secretion, which will decrease the risk of
gastrointestinal bleeding. Ferrous sulfate is an iron supplement to correct, not cause,
symptoms of anemia. Levothyroxine is not associated with red blood cell destruction.
The nurse assesses a client's pulse and documents the strength of the pulse as 3+. The
nurse understands that this indicates the pulse is:
1
faint, barely
detectable.
2
slightly weak,
palpable.
3
normal. 4 bounding. ✅- The strength of a pulse is a measurement of the force at which
blood is ejected against the arterial wall. Palpation should be done using the fingertips and
intensity of the pulse graded on a scale of 0 to 4 + with 0 indicating no palpable pulse, 1 +
indicating a faint, but detectable pulse, 2 + suggesting a slightly more diminished pulse than
normal, 3 + is a normal pulse, and 4 + indicating a bounding pulse.
A toddler screams and cries noisily after parental visits, disturbing all the other children.
When the crying is particularly loud and prolonged, the nurse puts the crib in a separate
room and closes the door. The toddler is left there until the crying ceases, a matter of 30 or
45 minutes. Legally, how should this behavior be interpreted?
1
Limits had to be set to control the child's crying.
2
The child had a right to remain in the room with the other children.
3
The child had to be removed because the other children needed to be considered.
4
Segregation of the child for more than half an hour was too long a period of time ✅- 2
Legally, a person cannot be locked in a room (isolated) unless there is a threat of danger
either to the self or to others. Limit setting in this situation is not warranted. This is a
reaction to separation from the parent, which is common at this age. Crying, although
irritating, will not harm the other children. A child should never be isolated
An older client who is receiving chemotherapy for cancer has severe nausea and vomiting
and becomes dehydrated. The client is admitted to the hospital for rehydration therapy.
Which interventions have specific gerontologic implications the nurse must consider?
Select all that apply.
1
Assessment of skin turgor
2
Documentation of vital signs
3
Assessment of intake and output
4
Administration of antiemetic drugs
5
Replacement of fluid and electrolytes ✅- 1,4,5
When skin turgor is assessed, the presence of tenting may be related to loss of
subcutaneous tissue associated with aging rather than to dehydration; skin over the
sternum should be used instead of skin on the arm for checking turgor. Older adults are
susceptible to central nervous system side effects, such as confusion, associated with
antiemetic drugs; dosages must be reduced, and responses must be evaluated closely.
Because many older adults have delicate fluid balance and may have cardiac and renal
disease, replacement of fluid and electrolytes may result in adverse consequences, such as
hypervolemia, pulmonary edema, and electrolyte imbalance. Vital signs can be obtained as
with any other adult. Intake and output can be measured accurately in older adults.
What should the nurse consider when obtaining an informed consent from a 17-year-old
adolescent?
1
If the client is allowed to give consent
2
The client cannot make informed decisions about health care.
3
If the client is permitted to give voluntary consent when parents are not available
4
The client probably will be unable to choose between alternatives when asked to consent
✅- 1
A person is legally unable to sign a consent until the age of 18 years unless the client is an
emancipated minor or married. The nurse must determine the legal status of the
adolescent. Although the adolescent may be capable of intelligent choices, 18 is the legal
age of consent unless the client is emancipated or married. Parents or guardians are legally
responsible under all circumstances unless the adolescent is an emancipated minor or
married. Adolescents have the capacity to choose, but not the legal right in this situation
unless they are legally emancipated or married.
Which nursing activities are examples of primary prevention? Select all that apply.
1
Preventing disabilities
2
Correcting dietary deficiencies
3
Establishing goals for rehabilitation
4
Assisting with immunization programs
5
t ✅- 4,5
Immunization programs prevent the occurrence of disease and are considered primary
interventions. Stopping smoking prevents the occurrence of disease and is considered a
primary intervention. Preventing disabilities is a tertiary intervention. Correcting dietary
deficiencies is a secondary intervention. Establishing goals for rehabilitation is a tertiary
intervention.
An 85-year-old client has just been admitted to a nursing home. When designing a plan of
care for this older adult the nurse recalls what expected sensory losses associated with
aging? Select all that apply.
1
Difficulty in swallowing
2
Diminished sensation of pain
3
Heightened response to stimuli
4
Impaired hearing of high-frequency sounds 5
Increased ability to tolerate environmental heat ✅- 2,4
Because of aging of the nervous system an older adult has a diminished sensation of pain
and may be unaware of a serious illness, thermal extremes, or excessive pressure. As people
age they experience atrophy of the organ of Corti and cochlear neurons, loss of the sensory
hair cells, and degeneration of the stria vascularis, which affects an older person's ability to
perceive high-frequency sounds. An interference with swallowing is a motor, not a sensory,
loss, nor is it an expected response to aging. There is a decreased, not heightened, response
to stimuli in older adults. There is a decreased, not increased, ability to physiologically
adjust to extremes in environmental temperature.
A nurse receives a subpoena in a court case involving a child. The nurse is preparing to
appear in court. In addition to the state Nurse Practice Act and the American Nursing
Association (ANA) Code for Nurses, what else should the nurse review?
1
Nursing's Social Policy Statement
2
State law regarding protection of minors
3
ANA Standards of Clinical Nursing Practice
4
References regarding a child's right to consent ✅- 3
The ANA Standards of Clinical Nursing Practice guidelines govern safe nursing practice;
nurses are legally responsible to perform according to these guidelines. Nursing's Social
Policy Statement explains what the public can expect from nurses, but it is not used to
govern nursing practice. There are no data that indicate state law regarding protection of
minors and references regarding a child's right to consent are necessary.
A client is receiving albuterol (Proventil) to relieve severe asthma. For which clinical
indicators should the nurse monitor the client? Select all that apply. 1
Tremors
2
Lethargy
3
Palpitations
4
Visual disturbances
5
Decreased pulse rate ✅- 1,3
Albuterol's sympathomimetic effect causes central nervous stimulation, precipitating
tremors, restlessness, and anxiety. Albuterol's sympathomimetic effect causes cardiac
stimulation that may result in tachycardia and palpitations. Albuterol may cause
restlessness, irritability, and tremors, not lethargy. Albuterol may cause dizziness, not
visual disturbances. Albuterol will cause tachycardia, not bradycardia.
A client asks about the purpose of a pulse oximeter. The nurse explains that it is used to
measure the:
1
Respiratory rate.
2
Amount of oxygen in the blood.
3
Percentage of hemoglobin-carrying oxygen.
4
Amount of carbon dioxide in the blood ✅- 3
The pulse oximeter measures the oxygen saturation of blood by determining the percentage
of hemoglobin-carrying oxygen. A pulse oximeter does not interpret the amount of oxygen
or carbon dioxide carried in the blood, nor does it measure respiratory rate.
A client comes to the clinic complaining of a productive cough with copious yellow sputum,
fever, and chills for the past two days. The first thing the nurse should do when caring for
this client is to:
1
Encourage fluids.
2
Administer oxygen.
3
Take the temperature.
4
Collect a sputum specimen ✅- 3
Baseline vital signs are extremely important; physical assessment precedes diagnostic
measures and intervention. This is done after the health care provider makes a medical
diagnosis; this is not an independent function of the nurse. Encouraging fluids might be
done after it is determined whether a specimen for blood gases is needed; this is not
usually an independent function of the nurse. Oxygen is administered independently by the
nurse only in an emergency situation. A sputum specimen should be obtained after vital
signs and before administration of antibiotics.
A nurse is preparing a community health program for senior citizens. The nurse teaches the
group that the physical findings that are typical in older people include:
1
A loss of skin elasticity and a decrease in libido
2
Impaired fat digestion and increased salivary secretions
3
Increased blood pressure and decreased hormone production
4
An increase in body warmth and some swallowing difficulties ✅- 3
With aging, narrowing of the arteries causes some increase in the systolic and diastolic
blood pressures; hormone production decreases after menopause. There may or may not
be changes in libido; there is a loss of skin elasticity. Salivary secretions decrease, not
increase, causing more difficulty with swallowing; there is some impairment of fat
digestion. There may be a decrease in subcutaneous fat and decreasing body warmth; some
swallowing difficulties occur because of decreased oral secretions.
A client has been diagnosed as brain dead. The nurse understands that this means that the
client has:
1
No spontaneous reflexes
2
Shallow and slow breathing
3
No cortical functioning with some reflex breathing
4
Deep tendon reflexes only and no independent breathing ✅- 4
A client who is declared as being brain dead has no function of the cerebral cortex and a flat
EEG. The client may have some spontaneous breathing and a heartbeat. The guidelines
established by the American Association of Neurology include coma or unresponsiveness,
absence of brainstem reflexes, and apnea. There are specific assessments to validate the
findings. The other answer options do not fit the definition of brain dead.
A nurse cares for a client that has been bitten by a large dog. A bite by a large dog can cause
which type of trauma?
1
Abrasion
2
Fracture
3
Crush injury
4
Incisional laceration ✅- 3
The bite of a large dog can exert between 150 and 400 psi of pressure, causing a crush
injury. A crush injury may or may not include a fracture. Abrasions and incisional
lacerations are not caused by this form of trauma.
A client who was exposed to hepatitis A asks why an injection of gamma globulin is needed.
Before responding, what should the nurse consider about how gamma globulin provides
passive immunity?
1
It increases production of short-lived antibodies.
2
It accelerates antigen-antibody union at the hepatic sites.
3
The lymphatic system is stimulated to produce antibodies.
4
The antigen is neutralized by the antibodies that it supplies ✅- 4
Gamma globulin, which is an immune globulin, contains most of the antibodies circulating
in the blood. When injected into an individual, it prevents a specific antigen from entering a
host cell. Gamma globulin does not stimulate antibody production. It does not affect
antigen-antibody function.
A nurse is caring for a client with an impaired immune system. Which blood protein
associated with the immune system is important for the nurse to consider? 1
Albumin
2
Globulin
3
Thrombin
4
Hemoglobin ✅- 2
The gamma-globulin fraction in the plasma is the fraction that includes the antibodies.
Albumin helps regulate fluid shifts by maintaining plasma oncotic pressure. Thrombin is
involved with clotting. Hemoglobin carries oxygen.
A nurse discusses the philosophy of Alcoholics Anonymous (AA) with the client who has a
history of alcoholism. What need must self-help groups such as AA meet to be successful? 1
Trust
2
Growth
3
Belonging
4
Independence ✅- 3
Self-help groups are successful because they support a basic human need for acceptance. A
feeling of comfort and safety and a sense of belonging may be achieved in a nonjudgmental,
supportive, sharing experience with others. AA meets dependency needs rather than
focusing on independence, trust, and growth.
What type of interview is most appropriate when a nurse admits a client to a clinic?
1
Directive
2
Exploratory
3
Problem solving
4
Information giving ✅- 1
The first step in the problem-solving process is data collection so that client needs can be
identified. During the initial interview a direct approach obtains specific information, such
as allergies, current medications, and health history. The exploratory approach is too broad
because in a nondirective interview the client controls the subject matter. Problem solving
and information giving are premature at the initial visit.
A client who is suspected of having tetanus asks a nurse about immunizations against
tetanus. Before responding, what should the nurse consider about the benefits of tetanus
antitoxin?
1
It stimulates plasma cells directly.
2
A high titer of antibodies is generated.
3
It provides immediate active immunity.
4 ✅- 2
A long-lasting passive immunity is produced.
Tetanus antitoxin provides antibodies, which confer immediate passive immunity. Antitoxin
does not stimulate production of antibodies. It provides passive, not active, immunity.
Passive immunity, by definition, is not long-lasting.
What is a basic concept associated with rehabilitation that the nurse should consider when
formulating discharge plans for clients?
1
Rehabilitation needs are met best by the client's family and community resources.
Incorrect2
Rehabilitation is a specialty area with unique methods for meeting clients' needs.
Correct3
Immediate or potential rehabilitation needs are exhibited by clients with health problems.
4
Clients who are returning to their usual activities following hospitalization do not require
rehabilitation. ✅- 3
Rehabilitation refers to a process that assists clients to obtain optimal functioning. Care
should be initiated immediately when a health problem exists to avoid complications and
facilitate recuperation. All resources that can be beneficial to client rehabilitation, including
the private health care provider and acute care facilities, should be used. Rehabilitation is a
commonality in all areas of nursing practice. Rehabilitation is necessary to help clients
return to a previous or optimal level of functioning.
A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse should
monitor for what clinical manifestations of the electrolyte deficiency? Select all that apply. 1
Diplopia
2
Skin rash
3
Leg cramps
4
Tachycardia
5
Muscle weakness ✅- 3,5
Leg cramps occur with hypokalemia because of potassium deficit. Muscle weakness occurs
with hypokalemia because of the alteration in the sodium potassium pump mechanism.
Diplopia does not indicate an electrolyte deficit. A skin rash does not indicate an electrolyte
deficit. Tachycardia is not associated with hypokalemia, bradycardia is.
A nurse in the surgical intensive care unit is caring for a client with a large surgical incision.
The nurse reviews a list of vitamins and expects that which medication will be prescribed
because of its major role in wound healing?
1
Vitamin A (Aquasol A)
2
Cyanocobalamin (Cobex)
3
Phytonadione (Mephyton)
4
Ascorbic acid (Ascorbicap) ✅- 4
Vitamin C (ascorbic acid) plays a major role in wound healing . It is necessary for the
maintenance and formation of collagen, the major protein of most connective tissues.
Vitamin A is important for the healing process; however, vitamin C is the priority because it
cements the ground substance of supportive tissue. Cyanocobalamin is a vitamin B12
preparation needed for red blood cell synthesis and a healthy nervous system.
Phytonadione is vitamin K, which plays a major role in blood coagulation.
A client is receiving an intravenous (IV) infusion of 5% dextrose in water. The client loses
weight and develops a negative nitrogen balance. The nurse concludes that what likely
contributed to this client's weight loss?
1
Excessive carbohydrate intake
2
Lack of protein supplementation
3
Insufficient intake of water-soluble vitamins
4
Increased concentration of electrolytes in cells ✅- 2
An infusion of dextrose in water does not provide proteins required for tissue growth,
repair, and maintenance; therefore, tissue breakdown occurs to supply the essential amino
acids. Each liter provides approximately 170 calories, which is insufficient to meet minimal
energy requirements; tissue breakdown will result. Weight loss is caused by insufficient
nutrient intake; vitamins do not prevent weight loss. An infusion of 5% dextrose in water
may decrease electrolyte concentration.
A client has undergone a subtotal thyroidectomy. The client is being transferred from the
post anesthesia care unit/recovery area to the inpatient nursing unit. What emergency
equipment is most important for the nurse to have available for this client?
1
A defibrillator
2
An IV infusion pump
3
A tracheostomy tray
4
An electrocardiogram (ECG) monitor ✅- 3
The client who has undergone a subtotal thyroidectomy is at high risk for airway occlusion
resulting from postoperative edema. With this in mind, emergency airway equipment such
as a tracheostomy set and intubation supplies should be immediately available to the client.
A defibrillator, an IV infusion pump, and an electrocardiogram (ECG) monitor are all
equipment items that should be available to all postoperative clients.
The nurse reviews a medical record and is concerned that the client may develop
hyperkalemia. Which disease increases the risk of hyperkalemia?
1
Crohn's
2
Cushing's
3
End-stage renal
4
Gastroesophageal reflux
. ✅- 3
One of the kidneys' functions is to eliminate potassium from the body; diseases of the
kidneys often interfere with this function, and hyperkalemia may develop, necessitating
dialysis. Clients with Crohn's disease have diarrhea, resulting in potassium loss. Clients
with Cushing's disease will retain sodium and excrete potassium. Clients with
gastroesophageal reflux disease are prone to vomiting that may lead to sodium and
chloride loss with minimal loss of potassium
A nurse assesses a client's serum electrolyte levels in the laboratory report. What
electrolyte in intracellular fluid should the nurse consider most important? 1
Sodium
2
Calcium
3
Chloride
4
Potassium ✅- 4
The concentration of potassium is greater inside the cell and is important in establishing a
membrane potential, a critical factor in the cell's ability to function. Sodium is the most
abundant cation of the extracellular compartment, not the intracellular compartment.
Calcium is the most abundant electrolyte in the body; 99% is concentrated in the teeth and
bones, and only 1% is available for bodily functions. Chloride is an extracellular, not
intracellular, anion.
What is the maximum length of time a nurse should allow an intravenous (IV) bag of
solution to infuse?
1
6 hours
2
12 hours 3
18 hours
4
24 hours ✅- 4
After 24 hours there is increased risk for contamination of the solution and the bag should
be changed. It is unnecessary to change the bag any less often.
An intravenous piggyback (IVPB) of cefazolin (Kefzol) 500 mg in 50 mL of 5% dextrose in
water is to be administered over a 20-minute period. The tubing has a drop factor of 15
drops/mL. At what rate per minute should the nurse regulate the infusion to run? Record
the answer using a whole number.
gtts/min
Solve the problem by using the following formula: Drops per minute = total number of
drops / total time in minutes Drops per minute = 50 mL x 15 (drop factor) / 20 mintes =
750 / 20 = 37.5. Round the answer to 38 drops per minute. ✅- 38
Solve the problem by using the following formula: Drops per minute = total number of
drops / total time in minutes Drops per minute = 50 mL x 15 (drop factor) / 20 mintes =
750 / 20 = 37.5. Round the answer to 38 drops per minute
The nurse manager is planning to assign an unlicensed assistive personnel (UAP) to care for
clients. What care can be delegated on a medical-surgical unit to a UAP? Select all that
apply.
Correct 1
Performing a bed bath for a client on bed rest
2
Evaluating the effectiveness of acetaminophen and codeine (Tylenol #3)
3
Obtaining an apical pulse rate before oral digoxin (Lanoxin) is administered
Correct 4
Assisting a client who has patient-controlled analgesia (PCA) to the bathroom
5
Assessing the wound integrity of a client recovering from an abdominal laparotomy ✅- 1,4
Performing a bed bath for a client on bed rest is within the scope of practice of the UAP.
Assisting a client who has PCA to the bathroom does not require professional nursing
judgment and is within the job description of the UAP. Evaluating human responses to
medications requires the expertise of a licensed professional nurse. Obtaining an apical
pulse rate requires a professional nursing judgment to determine whether or not the
medication should be administered. Evaluating human responses to health care
interventions requires the expertise of a licensed professional nurse.
A client has an anaphylactic reaction after receiving intravenous penicillin. What does the
nurse conclude is the cause of this reaction?
1
An acquired atopic sensitization occurred.
2
There was passive immunity to the penicillin allergen.
3
Antibodies to penicillin developed after a previous exposure.
4
Potent antibodies were produced when the infusion was instituted ✅- 3
Hypersensitivity results from the production of antibodies in response to exposure to
certain foreign substances (allergens). Earlier exposure is necessary for the development of
these antibodies. This is not a sensitivity reaction to penicillin; hay fever and asthma are
atopic conditions. It is an active, not passive, immune response. Antibodies developed when
there was a previous, not current, exposure to penicillin.
A nurse is providing care to a client eight hours after the client had surgery to correct an
upper urinary tract obstruction. Which assessment finding should the nurse report to the
surgeon?
1
Incisional pain
2
Absent bowel sounds
3
Urine output of 20 mL/hour
4
Serosanguineous drainage on the dressing
. ✅- 3
A urinary output of 50 mL/hr or greater is necessary to prevent stasis and consequent
infections after this type of surgery. The nurse should notify the surgeon of the assessment
findings, since this may indicate a urinary tract obstruction. Incisional pain, absent bowel
sounds, and serosanguineous drainage are acceptable assessment findings for this client
after this procedure and require continued monitoring but do not necessarily require
reporting to the surgeon
A nurse is caring for an older adult who is taking acetaminophen (Tylenol) for the relief of
chronic pain. Which substance is most important for the nurse to determine if the client is
taking because it intensifies the most serious adverse effect of acetaminophen? 1
Alcohol
2
Caffeine
3
Saw palmetto
4
St. John's wort ✅- 1
Too much ingestion of alcohol can cause scarring and fibrosis of the liver. Eighty-five to
95% of acetaminophen is metabolized by the liver. Acetaminophen and alcohol are both
hepatotoxic substances. Metabolites of acetaminophen along with alcohol can cause
irreversible liver damage. Caffeine affects (stimulates) the cardiovascular system, not the
liver. In addition, caffeine does not interact with acetaminophen. Saw palmetto is not
associated with increased liver damage when taking acetaminophen. It often is taken for
benign prostatic hypertrophy because of its antiinflammatory and antiproliferative
properties in prostate tissue. St. John's wort is classified as an antidepressant and is not
associated with increased liver damage when taking acetaminophen. However, it does
decrease the effectiveness of acetaminophen.
An arterial blood gas report indicates the client's pH is 7.25, PCO2 is 35 mm Hg, and HCO3
is 20 mEq/L. Which disturbance should the nurse identify based on these results?
1
Metabolic acidosis
2
Metabolic alkalosis
3
Respiratory acidosis
4
Respiratory alkalosis
A low pH and low bicarbonate level are consistent with metabolic acidosis. The pH
indicates acidosis. The CO2 concentration is within normal limits, which is inconsistent
with respiratory acidosis; it is elevated with respiratory acidosis. ✅- 1
A low pH and low bicarbonate level are consistent with metabolic acidosis. The pH
indicates acidosis. The CO2 concentration is within normal limits, which is inconsistent
with respiratory acidosis; it is elevated with respiratory acidosis.
Ph-7.35-7.45
PCO2 - 35-45
HCO3 - 22-30
A health care provider prescribes 10 mL of a 10% solution of calcium gluconate for a client
with a severely depressed serum calcium level. The client also is receiving digoxin
(Lanoxin) 0.25 mg daily and an intravenous (IV) solution of D5W. The nurse's next action is
based on the fact that calcium gluconate:
1
Can be added to any IV solution
Incorrect2
Must be administered via an intravenous piggyback (IVPB)
3
Is non-irritating to surrounding tissues
Correct4
Potentiates the action of the digoxin preparation ✅- 4
Toxicity can result because the action of calcium ions is similar to that of digoxin. Calcium
gluconate cannot be added to a solution containing carbonate or phosphate because a
dangerous precipitation will occur. Calcium gluconate can be added to the IV solution the
client is receiving. If calcium infiltrates, sloughing of tissue will result.
A nurse is preparing to administer an oil-retention enema and understands that it works
primarily by:
1
Stimulating the urge to defecate.
2
Lubricating the sigmoid colon and rectum.
3
Dissolving the feces.
4
Softening the feces ✅- 2
The primary purpose of an oil-retention enema is to lubricate the sigmoid colon and
rectum. Secondary benefits of an oil-retention enema include stimulating the urge to
defecate and softening feces. An oil-retention enema does not dissolve feces.
After gastric surgery a client has a nasogastric tube in place. What should the nurse do
when caring for this client?
1
Monitor for signs of electrolyte imbalance.
2
Change the tube at least once every 48 hours.
3
Connect the nasogastric tube to high continuous suction.
4
Assess placement by injecting 10 mL of water into the tube ✅- 1
Gastric secretions, which are electrolyte rich, are lost through the nasogastric tube; the
imbalances that result can be life threatening. Changing the nasogastric tube every 48
hours is unnecessary and can damage the suture line. High continuous suction can cause
trauma to the suture line. Injecting 10 mL of water into the nasogastric tube to test for
placement is unsafe; if respiratory intubation has occurred aspiration will result
A nurse administers an intravenous solution of 0.45% sodium chloride. In what category of
fluids does this solution belong?
1
Isotonic
2
Isomeric
3
Hypotonic
4
Hypertonic ✅- 1
Hypotonic solutions are less concentrated (contain less than 0.85 g of sodium chloride in
each 100 mL) than body fluids. Isotonic solutions are those that cause no change in the
cellular volume or pressure, because their concentration is equivalent to that of body fluid.
This relates to two compounds that possess the same molecular formula but that differ in
their properties or in the position of atoms in the molecules (isomers). Hypertonic
solutions contain more than 0.85 g of solute in each 100 mL.
The nurse is caring for a client that is on a low carbohydrate diet. With this diet, there is
decreased glucose available for energy, and fat is metabolized for energy resulting in an
increased production of which substance in the urine?
1
Protein
2
Glucose
3
Ketones
4
Uric Acid ✅- 3
As a result of fat metabolism, ketone bodies are formed and the kidneys attempt to
decrease the excess by filtration and excretion. Excessive ketones in the blood can cause
metabolic acidosis. A low carbohydrate diet does not cause increased protein, glucose, or
uric acid in the urine.
Study Tip: The old standbys of enough sleep and adequate nutritional intake also help keep
excessive stress at bay. Although nursing students learn about the body's energy needs in
anatomy and physiology classes, somehow they tend to forget that glucose is necessary for
brain cells to work. Skipping breakfast or lunch or surviving on junk food puts the brain at a
disadvantage.
What is a nurse's responsibility when administering prescribed opioid analgesics? Select all
that apply.
1
Count the client's respirations.
2
Document the intensity of the client's pain.
3
Withhold the medication if the client reports pruritus.
4
Verify the number of doses in the locked cabinet before administering the prescribed dose.
✅- 1,2,4
Opioid analgesics can cause respiratory depression; the nurse must monitor respirations.
The intensity of pain must be documented before and after administering an analgesic to
evaluate its effectiveness. Because of the potential for abuse, the nurse is legally required to
verify an accurate count of doses before taking a dose from the locked source and at the
change of the shift. Pruritus is a common side effect that can be managed with
antihistamines. It is not an allergic response, so it does not preclude administration. The
nurse should not discard an opioid in a client's room. Any waste of an opioid must be
witnessed by another nurse.
A client has been admitted with a urinary tract infection. The nurse receives a urine culture
and sensitivity report that reveals the client has vancomycin-resistant Entercoccus (VRE).
After notifying the physician, which action should the nurse take to decrease the risk of
transmission to others?
1
Insert a urinary catheter.
2
Initiate droplet precautions.
3
Move the client to a private room.
4
Use a high efficiency particulate air (HEPA) respirator during care. ✅- 3
Contact precautions are used for clients with known or suspected infections transmitted by
direct contact or contact with items in the environment; therefore infectious clients must
be placed in a private room. There is no need to insert an indwelling catheter, as this can
increase the risk for additional infection. Droplet precautions are used for clients known or
suspected to have infections transmitted by the droplet route. These infections are caused
by organisms in droplets that may travel 3 feet, but are not suspended for long periods.
A client who had abdominal surgery is receiving patient-controlled analgesia (PCA)
intravenously to manage pain. The pump is programmed to deliver a basal dose and bolus
doses that can be accessed by the client with a lock-out time frame of 10 minutes. The
nurse assesses use of the pump during the last hour and identifies that the client attempted
to self-administer the analgesic 10 times. Further assessment reveals that the client is
experiencing pain still. What should the nurse do first?
1
Monitor the client's pain level for another hour.
2
Determine the integrity of the intravenous delivery system. 3
Reprogram the pump to deliver a bolus dose every eight minutes.
4
Arrange for the client to be evaluated by the health care provider. ✅- Initially, integrity of
the intravenous system should be verified to ensure that the client is receiving medication.
The intravenous tubing may be kinked or compressed, or the catheter may be dislodged.
Continued monitoring will result in the client experiencing unnecessary pain. The nurse
may not reprogram the pump to deliver larger or more frequent doses of medication
without a health care provider's prescription. The health care provider should be notified if
the system is intact and the client is not obtaining relief from pain. The prescription may
have to be revised; the basal dose may be increased, the length of the delay may be reduced,
or another medication or mode of delivery may be prescribed.
An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is
essential to the client's nursing care?
A. Massage any reddened areas for at least five minutes.
B. Encourage active range of motion exercises on extremities.
C. Position the client laterally, prone, and dorsally in sequence.
D. Gently lift the client when moving into a desired position. ✅- To avoid shearing forces
when repositioning, the client should be lifted gently across a surface (D). Reddened
areas should not be massaged (A) since this may increase the damage to already
traumatized skin. To control pain and muscle spasms, active range of motion (B) may be
limited on the affected leg. The position described in (C) is contraindicated for a client
with a fractured left hip.
Correct Answer: D
The nurse is administering medications through a nasogastric tube (NGT) which is
connected to suction. After ensuring correct tube placement, what action should the nurse
take next?
A. Clamp the tube for 20 minutes.
B. Flush the tube with water.
C. Administer the medications as prescribed.
D. Crush the tablets and dissolve in sterile water. ✅- The NGT should be flushed before,
after and in between each medication administered (B). Once all medications are
administered, the NGT should be clamped for 20 minutes (A). (C and D) may be
implemented only after the tubing has been flushed.
Correct Answer: B
A client who is in hospice care complains of increasing amounts of pain. The healthcare
provider prescribes an analgesic every four hours as needed. Which action should the
nurse implement?
A. Give an around-the-clock schedule for administration of analgesics.
B. Administer analgesic medication as needed when the pain is severe.
C. Provide medication to keep the client sedated and unaware of stimuli.
D. Offer a medication-free period so that the client can do daily activities. ✅- The most
effective management of pain is achieved using an around-the-clock schedule that
provides analgesic medications on a regular basis (A) and in a timely manner. Analgesics
are less effective if pain persists until it is severe, so an analgesic medication should be
administered before the client's pain peaks (B). Providing comfort is a priority for the
client who is dying, but sedation that impairs the client's ability to interact and
experience the time before life ends should be minimized (C). Offering a medication-free
period allows the serum drug level to fall, which is not an effective method to manage
chronic pain (D). Correct Answer: A
When assessing a client with wrist restraints, the nurse observes that the fingers on the
right hand are blue. What action should the nurse implement first? A. Loosen the right
wrist restraint.
B. Apply a pulse oximeter to the right hand.
C. Compare hand color bilaterally.
D. Palpate the right radial pulse. ✅- The priority nursing action is to restore circulation by
loosening the restraint (A), because blue fingers (cyanosis) indicates decreased
circulation.
(C and D) are also important nursing interventions, but do not have the priority of (A).
Pulse oximetry (B) measures the saturation of hemoglobin with oxygen and is not indicated
in situations where the cyanosis is related to mechanical compression (the restraints).
Correct Answer: A
The nurse is assessing the nutritional status of several clients. Which client has the greatest
nutritional need for additional intake of protein?
A. A college-age track runner with a sprained ankle.
B. A lactating woman nursing her 3-day-old infant.
C. A school-aged child with Type 2 diabetes.
D. An elderly man being treated for a peptic ulcer. ✅- A lactating woman (B) has the
greatest need for additional protein intake. (A, C, and D) are all conditions that require
protein, but do not have the increased metabolic protein demands of lactation. Correct
Answer: B
A client is in the radiology department at 0900 when the prescription levofloxacin
(Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit
at 1300. What is the best intervention for the nurse to implement?
A. Contact the healthcare provider and complete a medication variance form.
B. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning.
C. Notify the charge nurse and complete an incident report to explain the missed dose.
D. Give the missed dose at 1300 and change the schedule to administer daily at 1300. ✅To ensure that a therapeutic level of medication is maintained, the nurse should
administer the missed dose as soon as possible, and revise the administration schedule
accordingly to prevent dangerously increasing the level of the medication in the
bloodstream (D). The nurse should document the reason for the late dose, but (A and C)
are not warranted. (B) could result in increased blood levels of the drug.
Correct Answer: D
While instructing a male client's wife in the performance of passive range-of-motion
exercises to his contracted shoulder, the nurse observes that she is holding his arm above
and below the elbow. What nursing action should the nurse implement? A. Acknowledge
that she is supporting the arm correctly.
B. Encourage her to keep the joint covered to maintain warmth.
C. Reinforce the need to grip directly under the joint for better support.
D. Instruct her to grip directly over the joint for better motion. ✅- The wife is performing
the passive ROM correctly, therefore the nurse should acknowledge this fact (A). The
joint that is being exercised should be uncovered (B) while the rest of the body should
remain covered for warmth and privacy. (C and D) do not provide adequate support to
the joint while still allowing for joint movement.
Correct Answer: A
What is the most important reason for starting intravenous infusions in the upper
extremities rather than the lower extremities of adults?
A. It is more difficult to find a superficial vein in the feet and ankles.
B. A decreased flow rate could result in the formation of a thrombosis.
C. A cannulated extremity is more difficult to move when the leg or foot is used.
D. Veins are located deep in the feet and ankles, resulting in a more painful procedure. ✅Venous return is usually better in the upper extremities. Cannulation of the veins in the
lower extremities increases the risk of thrombus formation (B) which, if dislodged, could
be life-threatening. Superficial veins are often very easy (A) to find in the feet and legs.
Handling a leg or foot with an IV (C) is probably not any more difficult than handling an
arm or hand. Even if the nurse did believe moving a cannulated leg was more difficult,
this is not the most important reason for using the upper extremities. Pain (D) is not a
consideration.
Correct Answer: B
The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood
pressure with a cuff that is too small, but the blood pressure reading obtained is within the
client's usual range. What action is most important for the nurse to implement? A. Tell the
UAP to use a larger cuff at the next scheduled assessment.
B. Reassess the client's blood pressure using a larger cuff.
C. Have the unit educator review this procedure with the UAPs.
D. Teach the UAP the correct technique for assessing blood pressure. ✅- The most
important action is to ensure that an accurate BP reading is obtained. The nurse should
reassess the BP with the correct size cuff (B). Reassessment should not be postponed
(A). Though (C and D) are likely indicated, these actions do not have the priority of (B).
Correct Answer: B
A client is to receive cimetidine (Tagamet) 300 mg q6h IVPB. The preparation arrives from
the pharmacy diluted in 50 ml of 0.9% NaCl. The nurse plans to administer the IVPB dose
over 20 minutes. For how many ml/hr should the infusion pump be set to deliver the
secondary infusion? ✅- The infusion rate is calculated as a ratio proportion problem, i.e.,
50 ml/ 20 min : x ml/ 60 min. Multiply extremes and means 50 × 60 /20x 1= 300/20=150
Correct Answer: 150
Twenty minutes after beginning a heat application, the client states that the heating pad no
longer feels warm enough. What is the best response by the nurse?
A. That means you have derived the maximum benefit, and the heat can be removed.
B. Your blood vessels are becoming dilated and removing the heat from the site.
C. We will increase the temperature 5 degrees when the pad no longer feels warm.
D. The body's receptors adapt over time as they are exposed to heat. ✅- (D) describes
thermal adaptation, which occurs 20 to 30 minutes after heat application. (A and B)
provide false information. (C) is not based on a knowledge of physiology and is an unsafe
action that may harm the client.
Correct Answer: D
The nurse is instructing a client with high cholesterol about diet and life style modification.
What comment from the client indicates that the teaching has been effective?
A. If I exercise at least two times weekly for one hour, I will lower my cholesterol.
B. I need to avoid eating proteins, including red meat.
C. I will limit my intake of beef to 4 ounces per week.
D. My blood level of low density lipoproteins needs to increase. ✅- Limiting saturated fat
from animal food sources to no more than 4 ounces per week (C) is an important diet
modification for lowering cholesterol. To be effective in reducing cholesterol, the client
should exercise 30 minutes per day, or at least 4 to 6 times per week (A). Red meat and
all proteins do not need to be eliminated (B) to lower cholesterol, but should be
restricted to lean cuts of red meat and smaller portions (2-ounce servings). The low
density lipoproteins (D) need to decrease rather than increase.
Correct Answer: C
The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest
way to transfer an elderly client with left-sided weakness from the bed to the chair. What
method describes the correct transfer procedure for this client?
A. Place the chair at a right angle to the bed on the client's left side before moving.
B. Assist the client to a standing position, then place the right hand on the armrest.
C. Have the client place the left foot next to the chair and pivot to the left before sitting.
D. Move the chair parallel to the right side of the bed, and stand the client on the right foot.
✅- (D) uses the client's stronger side, the right side, for weight-bearing during the
transfer, and is the safest approach to take. (A, B, and C) are unsafe methods of transfer
and include the use of poor body mechanics by the caregiver.
Correct Answer: D
An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to
administering a soap suds enema. Which instruction should the nurse provide the UAP? A.
Position the client on the right side of the bed in reverse Trendelenburg.
B. Fill the enema container with 1000 ml of warm water and 5 ml of castile soap.
C. Reposition in a Sim's position with the client's weight on the anterior ilium.
D. Raise the side rails on both sides of the bed and elevate the bed to waist level. ✅- The
left sided Sims' position allows the enema solution to follow the anatomical course of the
intestines and allows the best overall results, so the UAP should reposition the client in
the Sims' position, which distributes the client's weight to the anterior ilium (C). (A) is
inaccurate. (B and D) should be implemented once the client is positioned. Correct
Answer: C
A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should
the nurse have for planning care in terms of the client's beliefs? A. Autopsy of the body is
prohibited.
B. Blood transfusions are forbidden.
C. Alcohol use in any form is not allowed.
D. A vegetarian diet must be followed. ✅- Blood transfusions are forbidden (B) in the
Jehovah's Witness religion. Judaism prohibits (A). Buddhism forbids the use of (C) and
drugs. Many of these sects are vegetarian (D), but the direct impact on nursing care is
(B). Correct Answer: B
The nurse observes that a male client has removed the covering from an ice pack applied to
his knee. What action should the nurse take first?
A. Observe the appearance of the skin under the ice pack.
B. Instruct the client regarding the need for the covering.
C. Reapply the covering after filling with fresh ice.
D. Ask the client how long the ice was applied to the skin. ✅- The first action taken by the
nurse should be to assess the skin for any possible thermal injury (A). If no injury to the
skin has occurred, the nurse can take the other actions (B, C, and D) as needed. Correct
Answer: A
The nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at
a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml,
how many drops per minute should the client receive? A. 31 gtt/min. B. 62 gtt/min.
C. 93 gtt/min.
D. 124 gtt/min. ✅- (D) is the correct calculation: Convert lbs to kg: 182/2.2 = 82.73 kg.
Determine the dosage for this client: 5 mcg × 82.73 = 413.65 mcg/min. Determine how
many mcg are contained in 1 ml: 250/50,000 mcg = 200 mcg per ml. The client is to
receive 413.65 mcg/min, and there are 200 mcg/ml; so the client is to receive 2.07ml per
minute. With a drip factor of 60 gtt/ml, then 60 × 2.07 = 124.28 gtt/min (D) OR, using
dimensional analysis: gtt/min = 60 gtt/ml X 250 ml/50 mg X 1 mg/1,000 mcg X 5
mcg/kg/min X 1 kg/2.2 lbs X 182 lbs.
Correct Answer: D
A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a
continuous pump infusion. He reports that he had a bad bout of severe coughing a few
minutes ago, but feels fine now. What action is best for the nurse to take?
A. Record the coughing incident. No further action is required at this time.
B. Stop the feeding, explain to the family why it is being stopped, and notify the healthcare
provider.
C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube.
D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling. ✅Coughing, vomiting, and suctioning can precipitate displacement of the tip of the small
bore feeding tube upward into the esophagus, placing the client at increased risk for
aspiration. Checking the sample of fluid withdrawn from the tube (after clearing the tube
with 30 ml of air) for acidic (stomach) or alkaline (intestine) values is a more sensitive
method for these tubes, and the nurse should assess tube placement in this way prior to
taking any other action (C). (A and B) are not indicated. The auscultating method (D) has
been found to be unreliable for small-bore feeding tubes.
Correct Answer: C
A male client being discharged with a prescription for the bronchodilator theophylline tells
the nurse that he understands he is to take three doses of the medication each day. Since, at
the time of discharge, timed-release capsules are not available, which dosing schedule
should the nurse advise the client to follow? A. 9 a.m., 1 p.m., and 5 p.m.
B. 8 a.m., 4 p.m., and midnight.
C. Before breakfast, before lunch and before dinner.
D. With breakfast, with lunch, and with dinner. ✅- Theophylline should be administered on
a regular around-the-clock schedule (B) to provide the best bronchodilating effect and
reduce the potential for adverse effects. (A, C, and D) do not provide around-the-clock
dosing. Food may alter absorption of the medication (D).
Correct Answer: B
A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what
rate should the nurse set the client's intravenous infusion pump? A. 13 ml/hour. B. 63
ml/hour.
C. 80 ml/hour.
D. 125 ml/hour. ✅- (B) is the correct calculation: To calculate this problem correctly,
remember that the dose of KCl is not used in the calculation. 250 ml/4 hours = 63
ml/hour. Correct Answer: B
An obese male client discusses with the nurse his plans to begin a long-term weight loss
regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise
program 3 to 4 times a week and to take stress management classes. After praising the
client for his decision, which instruction is most important for the nurse to provide?
A. Be sure to have a complete physical examination before beginning your planned exercise
program.
B. Be careful that the exercise program doesn't simply add to your stress level, making you
want to eat more.
C. Increased exercise helps to reduce stress, so you may not need to spend money on a stress
management class.
D. Make sure to monitor your weight loss regularly to provide a sense of accomplishment and
motivation. ✅- The most important teaching is (A), so that the client will not begin a
dangerous level of exercise when he is not sufficiently fit. This might result in chest pain, a
heart attack, or stroke. (B, C, and D) are important instructions, but are of less priority than
(A).
Correct Answer: A
The nurse is teaching a client proper use of an inhaler. When should the client administer
the inhaler-delivered medication to demonstrate correct use of the inhaler? A.
Immediately after exhalation.
B. During the inhalation.
C. At the end of three inhalations.
D. Immediately after inhalation. ✅- The client should be instructed to deliver the
medication during the last part of inhalation (B). After the medication is delivered, the
client should remove the mouthpiece, keeping his/her lips closed and breath held for
several seconds to allow for distribution of the medication. The client should not deliver
the dose as stated in (A or D), and should deliver no more than two inhalations at a time
(C).
Correct Answer: B
The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO.
Zaroxolyn is available in 5 mg tablets. How much should the nurse plan to administer? A.
½ tablet.
B. 1 tablet.
C. 1½ tablets.
D. 2 tablets. ✅- (C) is the correct calculation: D/H × Q = 7.5/5 × 1 tablet = 1½ tablets.
Correct Answer: C
The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix 20
mg/2 ml. How many milliliters should the nurse administer? A. 1 ml.
B. 1.5 ml.
C. 1.75 ml.
D. 2 ml. ✅- (B) is the correct calculation: Dosage on hand/amount on hand = Dosage
desired/x amount. 20 mg : 2 ml = 15 mg : x . 20x = 30. x = 30/20; = 1½ or 1.5 ml. Correct
Answer: B
Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5½ hours. How
much heparin has the client received? A. 11,000 units. B. 13,000 units.
C. 15,000 units.
D. 17,000 units. ✅- (A) is the correct calculation: 20,000 units/500 ml = 40 units (the
amount of units in one ml of fluid). 40 units/ml x 50 ml/hr = 2,000 units/hour (1,000
units in 1/2 hour). 5.5 x 2,000 = 11,000 (A). OR, multiply 5 x 2,000 and add the 1/2 hour
amount of 1,000 to reach the same conclusion = 11,000 units.
Correct Answer: A
The healthcare provider prescribes morphine sulfate 4mg IM STAT. Morphine comes in 8
mg per ml. How many ml should the nurse administer?
A. 0.5 ml.
B. 1 ml.
C. 1.5 ml.
D. 2 ml. ✅- Using ratio and proportion:
8mg: 1ml :: 4mg:Xml
8X=4
X=0.5
Correct Answer: A
The nurse prepares a 1,000 ml IV of 5% dextrose and water to be infused over 8 hours. The
infusion set delivers 10 drops per milliliter. The nurse should regulate the IV to administer
approximately how many drops per minute?
A. 80
B. 8
C. 21
D. 25 ✅- The accepted formula for figuring drops per minute is: amount to be infused in
one hour × drop factor/time for infusion (min)= drops per minute. Using this formula:
1,000/8 hours = 125 ml/ hour 125 × 10 (drip factor) = 1,250 drops in one hour. 1,250/
60 (number of minutes in one hour) = 20.8 or 21 gtt/min (C).
Correct Answer: C
Which action is most important for the nurse to implement when donning sterile gloves?
A. Maintain thumb at a ninety degree angle.
B. Hold hands with fingers down while gloving.
C. Keep gloved hands above the elbows.
D. Put the glove on the dominant hand first. ✅- Gloved hands held below waist level are
considered unsterile (C). (A and B) are not essential to maintaining asepsis. While it may
be helpful to put the glove on the dominant hand first, it is not necessary to ensure
asepsis (D). Correct Answer: C
A client's infusion of normal saline infiltrated earlier today, and approximately 500 ml of
saline infused into the subcutaneous tissue. The client is now complaining of excruciating
arm pain and demanding "stronger pain medications." What initial action is most important
for the nurse to take?
A. Ask about any past history of drug abuse or addiction.
B. Measure the pulse volume and capillary refill distal to the infiltration.
C. Compress the infiltrated tissue to measure the degree of edema.
D. Evaluate the extent of ecchymosis over the forearm area. ✅- Pain and diminished pulse
volume (B) are signs of compartment syndrome, which can progress to complete loss of
the peripheral pulse in the extremity. Compartment syndrome occurs when external
pressure (usually from a cast), or internal pressure (usually from subcutaneous infused
fluid), exceeds capillary perfusion pressure resulting in decreased blood flow to the
extremity. (A) should not be pursued until physical causes of the pain are ruled out. (C) is
of less priority than determining the effects of the edema on circulation and nerve
function. Further assessment of the client's ecchymosis can be delayed until the signs of
edema and compression that suggest compartment syndrome have been examined (D).
Correct Answer: B
An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is
receiving bolus enteral feedings though a gastrostomy tube. What is the best client position
for administration of the bolus tube feedings? A. Prone.
B. Fowler's.
C. Sims'.
D. Supine. ✅- The client should be positioned in a semi-sitting (Fowler's) (B) position
during feeding to decrease the occurrence of aspiration. A gastrostomy tube, known as a
PEG tube, due to placement by a percutaneous endoscopic gastrostomy procedure, is
inserted directly into the stomach through an incision in the abdomen for long-term
administration of nutrition and hydration in the debilitated client. In (A and/or C), the
client is placed on the abdomen, an unsafe position for feeding. Placing the client in (D)
increases the risk of aspiration.
Correct Answer: B
A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due to a
fracture resulting from a fall. In reviewing hip precautions with the client, which instruction
should the nurse include in this client's teaching plan?
A. In 8 weeks you will be able to bend at the waist to reach items on the floor.
B. Place a pillow between your knees while lying in bed to prevent hip dislocation.
C. It is safe to use a walker to get out of bed, but you need assistance when walking.
D. Take pain medication 30 minutes after your physical therapy sessions. ✅- The client's
affected hip joint following a hemiarthroplasty (partial hip replacement) is at risk of
dislocation for 6 months to a year following the procedure. Hip precautions to prevent
dislocation include placing a pillow between the knees to maintain abduction of the hips
(B). Clients should be instructed to avoid bending at the waist (A), to seek assistance for
both standing and walking until they are stable on a walker or cane (C), and to take pain
medication 20 to 30 minutes prior to physical therapy sessions, rather than waiting until
the pain level is high after their therapy.
Correct Answer: B
A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while
ambulating. Based on these findings, which intervention should the nurse implement first?
A. Assist the ambulating client back to the bed.
B. Encourage the client to ambulate to resolve pneumonia.
C. Obtain a prescription for portable oxygen while ambulating.
D. Move the oximetry probe from the finger to the earlobe. ✅- An oxygen saturation below
90% indicates inadequate oxygenation. First, the client should be assisted to return to
bed (A) to minimize oxygen demands. Ambulation increases aeration of the lungs to
prevent pooling of respiratory secretions, but the client's activity at this time is depleting
oxygen saturation of the blood, so (B) is contraindicated. Increased activity increases
respiratory effort, and oxygen may be necessary to continue ambulation (C), but first the
client should return to bed to rest. Oxygen saturation levels at different sites should be
evaluated after the client returns to bed (D).
Correct Answer: A
A client with chronic renal failure selects a scrambled egg for his breakfast. What action
should the nurse take?
A. Commend the client for selecting a high biologic value protein.
B. Remind the client that protein in the diet should be avoided.
C. Suggest that the client also select orange juice, to promote absorption.
D. Encourage the client to attend classes on dietary management of CRF. ✅- Foods such as
eggs and milk (A) are high biologic proteins which are allowed because they are
complete proteins and supply the essential amino acids that are necessary for growth
and cell repair. Although a low-protein diet is followed (B), some protein is essential.
Orange juice is rich in potassium, and should not be encouraged (C). The client has made
a good diet choice, so (D) is not necessary.
Correct Answer: A
A client who is 5' 5" tall and weighs 200 pounds is scheduled for surgery the next day. What
question is most important for the nurse to include during the preoperative assessment? A.
What is your daily calorie consumption?
B. What vitamin and mineral supplements do you take?
C. Do you feel that you are overweight?
D. Will a clear liquid diet be okay after surgery? ✅- Vitamin and mineral supplements (B)
may impact medications used during the operative period. (A and C) are appropriate
questions for long-term dietary counseling. The nature of the surgery and anesthesia will
determine the need for a clear liquid diet (D), rather than the client's preference. Correct
Answer: B
During the initial morning assessment, a male client denies dysuria but reports that his
urine appears dark amber. Which intervention should the nurse implement? A. Provide
additional coffee on the client's breakfast tray.
B. Exchange the client's grape juice for cranberry juice.
C. Bring the client additional fruit at mid-morning.
D. Encourage additional oral intake of juices and water. ✅- Dark amber urine is
characteristic of fluid volume deficit, and the client should be encouraged to increase
fluid intake (D). Caffeine, however, is a diuretic (A), and may worsen the fluid volume
deficit. Any type of juice will be beneficial (B), since the client is not dysuric, a sign of an
urinary tract infection. The client needs to restore fluid volume more than solid foods
(C). Correct Answer: D
Which intervention is most important for the nurse to implement for a male client who is
experiencing urinary retention? A. Apply a condom catheter.
B. Apply a skin protectant.
C. Encourage increased fluid intake.
D. Assess for bladder distention. ✅- Urinary retention is the inability to void all urine
collected in the bladder, which leads to uncomfortable bladder distention (D). (A and B)
are useful actions to protect the skin of a client with urinary incontinence. (C) may
worsen the bladder distention.
Correct Answer: D
A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood
cells) as rapidly as possible. Which intervention is most important for the nurse to
implement?
A. Obtain the pre-transfusion hemoglobin level.
B. Prime the tubing and prepare a blood pump set-up.
C. Monitor vital signs q15 minutes for the first hour.
D. Ensure the accuracy of the blood type match. ✅- All interventions should be
implemented prior to administering blood, but (D) has the highest priority. Any time
blood is administered, the nurse should ensure the accuracy of the blood type match in
order to prevent a possible hemolytic reaction.
Correct Answer: D
Which snack food is best for the nurse to provide a client with myasthenia gravis who is at
risk for altered nutritional status? A. Chocolate pudding.
B. Graham crackers.
C. Sugar free gelatin.
D. Apple slices. ✅- The client with myasthenia gravis is at high risk for altered nutrition
because of fatigue and muscle weakness resulting in dysphagia. Snacks that are
semisolid, such as pudding (A) are easy to swallow and require minimal chewing effort,
and provide calories and protein. (C) does not provide any nutritional value. (B and D)
require energy to chew and are more difficult to swallow than pudding.
Correct Answer: A
The nurse is evaluating client learning about a low-sodium diet. Selection of which meal
would indicate to the nurse that this client understands the dietary restrictions? A.
Tossed salad, low-sodium dressing, bacon and tomato sandwich.
B. New England clam chowder, no-salt crackers, fresh fruit salad.
C. Skim milk, turkey salad, roll, and vanilla ice cream.
D. Macaroni and cheese, diet Coke, a slice of cherry pie. ✅- Skim milk, turkey, bread, and
ice cream (C), while containing some sodium, are considered low-sodium foods. Bacon
(A), canned soups (B), especially those with seafood, hard cheeses, macaroni, and most
diet drinks (D) are very high in sodium.
Correct Answer: C
Which nutritional assessment data should the nurse collect to best reflect total muscle
mass in an adolescent?
A. Height in inches or centimeters.
B. Weight in kilograms or pounds.
C. Triceps skin fold thickness.
D. Upper arm circumference. ✅- Upper arm circumference (D) is an indirect measure of
muscle mass. (A and B) do not distinguish between fat (adipose) and muscularity. (C) is a
measure of body fat.
Correct Answer: D
An elderly resident of a long-term care facility is no longer able to perform self-care and is
becoming progressively weaker. The resident previously requested that no resuscitative
efforts be performed, and the family requests hospice care. What action should the nurse
implement first?
A. Reaffirm the client's desire for no resuscitative efforts.
B. Transfer the client to a hospice inpatient facility.
C. Prepare the family for the client's impending death.
D. Notify the healthcare provider of the family's request. ✅- The nurse should first
communicate with the healthcare provider (D). Hospice care is provided for clients with
a limited life expectancy, which must be identified by the healthcare provider. (A) is not
necessary at this time. Once the healthcare provider supports the transfer to hospice
care, the nurse can collaborate with the hospice staff and healthcare provider to
determine when (B and C) should be implemented.
Correct Answer: D
After completing an assessment and determining that a client has a problem, which action
should the nurse perform next?
A. Determine the etiology of the problem.
B. Prioritize nursing care interventions.
C. Plan appropriate interventions.
D. Collaborate with the client to set goals. ✅- Before planning care, the nurse should
determine the etiology, or cause, of the problem (A), because this will help determine (B,
C, and D).
Correct Answer: A
An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse is
at greatest risk for a malpractice judgment?
A. A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes.
B. The nurse assigned to care for the client who was at lunch at the time of the fall.
C. The nurse who transferred the client to the chair when the fall occurred.
D. The charge nurse who completed rounds 30 minutes before the fall occurred. ✅- The
four elements of malpractice are: breach of duty owed, failure to adhere to the
recognized standard of care, direct causation of injury, and evidence of actual injury. The
hip fracture is the actual injury and the standard of care was "frequent monitoring." (C)
implies that duty was owed and the injury occurred while the nurse was in charge of the
client's care. There is no evidence of negligence in (A, B, and D).
Correct Answer: C
A postoperative client will need to perform daily dressing changes after discharge. Which
outcome statement best demonstrates the client's readiness to manage his wound care
after discharge? The client
A. asks relevant questions regarding the dressing change.
B. states he will be able to complete the wound care regimen.
C. demonstrates the wound care procedure correctly.
D. has all the necessary supplies for wound care. ✅- A return demonstration of a
procedure (C) provides an objective assessment of the client's ability to perform a task,
while (A and B) are subjective measures. (D) is important, but is less of a priority prior to
discharge than the nurse's assessment of the client's ability to complete the wound care.
Correct Answer: C
When evaluating a client's plan of care, the nurse determines that a desired outcome was
not achieved. Which action will the nurse implement first? A. Establish a new nursing
diagnosis.
B. Note which actions were not implemented.
C. Add additional nursing orders to the plan.
D. Collaborate with the healthcare provider to make changes. ✅- First, the nurse reviews
which actions in the original plan were not implemented (B) in order to determine why
the original plan did not produce the desired outcome. Appropriate revisions can then be
made, which may include revising the expected outcome, or identifying a new nursing
diagnosis (A). (C) may be needed if the nursing actions were unsuccessful, or were
unable to be implemented. (D) other members of the healthcare team may be necessary
to collaborate changes once the nurse determines why the original plan did not produce
the desired outcome.
Correct Answer: B
The healthcare provider prescribes 1,000 ml of Ringer's Lactate with 30 Units of Pitocin to
run in over 4 hours for a client who has just delivered a 10 pound infant by cesarean
section. The tubing has been changed to a 20 gtt/ml administration set. The nurse plans to
set the flow rate at how many gtt/min? A. 42 gtt/min. B. 83 gtt/min.
C. 125 gtt/min.
D. 250 gtt/min. ✅- gtt/min = 20gtts/ml X 1000 ml/4hrs X 1 hr/60 min
Correct Answer: B
Seconal 0.1 gram PRN at bedtime is prescribed to a client for rest. The scored tablets are
labeled grain 1.5 per tablet. How many tablets should the nurse plan to administer? A.
0.5 tablet.
B. 1 tablet.
C. 1.5 tablets.
D. 2 tablets. ✅- 15 gr=1 Gm. Converting the prescribed dose of 0.1 grams to grains requires
multiplying 0.1 × 15 = 1.5 grains. The tablets come in 1.5 grains, so the nurse should plan
to administer 1 tablet (B).
Correct Answer: B
Which assessment data would provide the most accurate determination of proper
placement of a nasogastric tube?
A. Aspirating gastric contents to assure a pH value of 4 or less.
B. Hearing air pass in the stomach after injecting air into the tubing.
C. Examining a chest x-ray obtained after the tubing was inserted.
D. Checking the remaining length of tubing to ensure that the correct length was inserted.
✅- Both (A and B) are methods used to determine proper placement of the NG tubing.
However, the best indicator that the tubing is properly placed is (C). (D) is not an indicator
of proper placement.
Correct Answer: C
The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via
a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN
solution has run out and the next TPN solution is not available. What immediate action
should the nurse take?
A. Infuse normal saline at a keep vein open rate.
B. Discontinue the IV and flush the port with heparin.
C. Infuse 10 percent dextrose and water at 54 ml/hr.
D. Obtain a stat blood glucose level and notify the healthcare provider. ✅- TPN is
discontinued gradually to allow the client to adjust to decreased levels of glucose.
Administering 10% dextrose in water at the prescribed rate (C) will keep the client from
experiencing hypoglycemia until the next TPN solution is available. The client could
experience a hypoglycemic reaction if the current level of glucose (A) is not maintained
or if the TPN is discontinued abruptly (B). There is no reason to obtain a stat blood
glucose level (D) and the healthcare provider cannot do anything about this situation.
Correct Answer: C
When assisting an 82-year-old client to ambulate, it is important for the nurse to realize
that the center of gravity for an elderly person is the A. Arms.
B. Upper torso.
C. Head.
D. Feet. ✅- The center of gravity for adults is the hips. However, as the person grows older,
a stooped posture is common because of the changes from osteoporosis and normal
bone degeneration, and the knees, hips, and elbows flex. This stooped posture results in
the upper torso (B) becoming the center of gravity for older persons. Although (A) is a
part, or an extension of the upper torso, this is not the best and most complete answer.
Correct Answer: B
In developing a plan of care for a client with dementia, the nurse should remember that
confusion in the elderly
A. is to be expected, and progresses with age.
B. often follows relocation to new surroundings.
C. is a result of irreversible brain pathology.
D. can be prevented with adequate sleep. ✅- Relocation (B) often results in confusion
among elderly clients--moving is stressful for anyone. (A) is a stereotypical judgment.
Stress in the elderly often manifests itself as confusion, so (C) is wrong. Adequate sleep is
not a prevention (D) for confusion.
Correct Answer: B
An elderly male client who suffered a cerebral vascular accident is receiving tube feedings
via a gastrostomy tube. The nurse knows that the best position for this client during
administration of the feedings is A. prone.
B. Fowler's.
C. Sims'.
D. supine. ✅- The client should be positioned in a semi-sitting or Fowler's (B) position
during feeding, in order to decrease the chance of aspiration. A gastrostomy tube, often
referred to as a PEG tube, is inserted directly into the stomach through an incision in the
abdomen and is used when long-term tube feedings are needed. In (A and/or C)
positions, the client would be lying on his abdomen and on the tubing. In (D), the client
would be lying flat on his back which would increase the chance of aspiration.
Correct Answer: B
The nurse notices that the mother a 9-year-old Vietnamese child always looks at the floor
when she talks to the nurse. What action should the nurse take? A. Talk directly to the
child instead of the mother.
B. Continue asking the mother questions about the child.
C. Ask another nurse to interview the mother now.
D. Tell the mother politely to look at you when answering. ✅- Eye contact is a
culturallyinfluenced form of non-verbal communication. In some non-Western cultures,
such as the Vietnamese culture, a client or family member may avoid eye contact as a
form of respect, so the nurse should continue to ask the mother questions about the child
(B). (A, C, and D) are not indicated. Correct Answer: B
When conducting an admission assessment, the nurse should ask the client about the use of
complimentary healing practices. Which statement is accurate regarding the use of these
practices?
A. Complimentary healing practices interfere with the efficacy of the medical model of
treatment.
B. Conventional medications are likely to interact with folk remedies and cause adverse
effects.
C. Many complimentary healing practices can be used in conjunction with conventional
practices.
D. Conventional medical practices will ultimately replace the use of complimentary healing
practices. ✅- Conventional approaches to health care can be depersonalizing and often fail
to take into consideration all aspects of an individual, including body, mind, and spirit.
Often complimentary healing practices can be used in conjunction with conventional
medical practices (C), rather than interfering (A) with conventional practices, causing
adverse effects (B), or replacing conventional medical care (D).
Correct Answer: C
A young mother of three children complains of increased anxiety during her annual
physical exam. What information should the nurse obtain first? A. Sexual activity
patterns.
B. Nutritional history.
C. Leisure activities.
D. Financial stressors. ✅- Caffeine, sugars, and alcohol can lead to increased levels of
anxiety, so a nutritional history (C) should be obtained first so that health teaching can
be initiated if indicated. (A and C) can be used for stress management. Though (D) can be
a source of anxiety, a nutritional history should be obtained first.
Correct Answer: B
Three days following surgery, a male client observes his colostomy for the first time. He
becomes quite upset and tells the nurse that it is much bigger than he expected. What is the
best response by the nurse?
A. Reassure the client that he will become accustomed to the stoma appearance in time. B.
Instruct the client that the stoma will become smaller when the initial swelling
diminishes.
C. Offer to contact a member of the local ostomy support group to help him with his concerns.
D. Encourage the client to handle the stoma equipment to gain confidence with the procedure.
✅- Postoperative swelling causes enlargement of the stoma. The nurse can teach the client
that the stoma will become smaller when the swelling is diminished (B). This will help
reduce the client's anxiety and promote acceptance of the colostomy. (A) does not provide
helpful teaching or support. (C) is a useful action, and may be taken after the nurse
provides pertinent teaching. The client is not yet demonstrating readiness to learn
colostomy care (D).
Correct Answer: B
At the time of the first dressing change, the client refuses to look at her mastectomy
incision. The nurse tells the client that the incision is healing well, but the client refuses to
talk about it. What would be an appropriate response to this client's silence?
A. It is normal to feel angry and depressed, but the sooner you deal with this surgery, the
better you will feel.
B. Looking at your incision can be frightening, but facing this fear is a necessary part of your
recovery.
C. It is OK if you don't want to talk about your surgery. I will be available when you are ready.
D. I will ask a woman who has had a mastectomy to come by and share her experiences with
you. ✅- (C) displays sensitivity and understanding without judging the client. (A) is
judgmental in that it is telling the client how she feels and is also insensitive. (B) would give
the client a chance to talk, but is also demanding and demeaning. (D) displays a positive
action, but, because the nurse's personal support is not offered, this response could be
interpreted as dismissing the client and avoiding the problem.
Correct Answer: C
The nurse witnesses the signature of a client who has signed an informed consent. Which
statement best explains this nursing responsibility? A. The client voluntarily signed the
form.
B. The client fully understands the procedure.
C. The client agrees with the procedure to be done.
D. The client authorizes continued treatment. ✅- The nurse signs the consent form to
witness that the client voluntarily signs the consent (A), that the client's signature is
authentic, and that the client is otherwise competent to give consent. It is the healthcare
provider's responsibility to ensure the client fully understands the procedure (B). The
nurse's signature does not indicate (C or D).
Correct Answer: A
The nurse assigns a UAP to obtain vital signs from a very anxious client. What instructions
should the nurse give the UAP?
A. Remain calm with the client and record abnormal results in the chart.
B. Notify the medication nurse immediately if the pulse or blood pressure is low.
C. Report the results of the vital signs to the nurse.
D. Reassure the client that the vital signs are normal. ✅- Interpretation of vital signs is the
responsibility of the nurse, so the UAP should report vital sign measurements to the
nurse (C). (A, B, and D) require the UAP to interpret the vital signs, which is beyond the
scope of the UAP's authority.
Correct Answer: C
An adult male client with a history of hypertension tells the nurse that he is tired of taking
antihypertensive medications and is going to try spiritual meditation instead. What should
be the nurse's first response?
A. It is important that you continue your medication while learning to meditate.
B. Spiritual meditation requires a time commitment of 15 to 20 minutes daily.
C. Obtain your healthcare provider's permission before starting meditation.
D. Complementary therapy and western medicine can be effective for you. ✅- The
prolonged practice of meditation may lead to a reduced need for antihypertensive
medications. However, the medications must be continued (A) while the physiologic
response to meditation is monitored. (B) is not as important as continuing the
medication. The healthcare provider should be informed, but permission is not required
to meditate (C). Although it is true that this complimentary therapy might be effective
(D), it is essential that the client continue with antihypertensive medications until the
effect of meditation can be measured. Correct Answer: A
Examination of a client complaining of itching on his right arm reveals a rash made up of
multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the
nurse record this finding?
A. Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm.
B. Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter.
C. Several areas of red, papular lesions from pinpoint to 0.5 cm in size.
D. Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter. ✅Macules are localized flat skin discolorations less than 1 cm in diameter. However, when
recording such a finding the nurse should describe the appearance (B) rather than
simply naming the condition. (A) identifies vesicles -- fluid filled blisters -- an incorrect
description given the symptoms listed. (C) identifies papules -- solid elevated lesions,
again not correctly identifying the symptoms. (D) identifies petechiae -- pinpoint red to
purple skin discolorations that do not itch, again an incorrect identification.
Correct Answer: B
The nurse is completing a mental assessment for a client who is demonstrating slow
thought processes, personality changes, and emotional lability. Which area of the brain
controls these neuro-cognitive functions? A. Thalamus.
B. Hypothalamus.
C. Frontal lobe.
D. Parietal lobe. ✅- The frontal lobe (C) of the cerebrum controls higher mental activities,
such as memory, intellect, language, emotions, and personality. (A) is an afferent relay
center in the brain that directs impulses to the cerebral cortex. (B) regulates body
temperature, appetite, maintains a wakeful state, and links higher centers with the
autonomic nervous and endocrine systems, such as the pituitary. (D) is the location of
sensory and motor functions.
Correct Answer: C
A male client tells the nurse that he does not know where he is or what year it is. What data
should the nurse document that is most accurate? A. demonstrates loss of remote memory.
B. exhibits expressive dysphasia.
C. has a diminished attention span.
D. is disoriented to place and time. ✅- The client is exhibiting disorientation (D). (A) refers
to memory of the distant past. The client is able to express himself without difficulty (B),
and does not demonstrate a diminished attention span (C).
Correct Answer: D
An IV infusion terbutaline sulfate 5 mg in 500 ml of D5W, is infusing at a rate of 30 mcg/min
prescribed for a client in premature labor. How many ml/hr should the nurse set the
infusion pump?
A. 30
B. 60
C. 120
D. 180 ✅- (D) is correct calculation: 180 ml/hr = 500 ml/5 mg × 1mg/1000 mcg × 30
mcg/min × 60 min/hr.
Correct Answer: D
An African-American grandmother tells the nurse that her 4-year-old grandson is suffering
with "miseries." Based on this statement, which focused assessment should the nurse
conduct?
A. Inquire about the source and type of pain.
B. Examine the nose for congestion and discharge.
C. Take vital signs for temperature elevation.
D. Explore the abdominal area for distension. ✅- Different cultural groups often have their
own terms for health conditions. African-American clients may refer to pain as "the
miseries. " Based on understanding this term, the nurse should conduct a focused
assessment on the source and type of pain (A). (B, C, and D) are important, but do not
focus on "miseries" (pain).
Correct Answer: A
The nurse notices that the Hispanic parents of a toddler who returns from surgery offer the
child only the broth that comes on the clear liquid tray. Other liquids, including gelatin,
popsicles, and juices, remain untouched. What explanation is most appropriate for this
behavior?
A. The belief is held that the "evil eye" enters the child if anything cold is ingested.
B. After surgery the child probably has refused all foods except broth.
C. Eating broth strengthens the child's innate energy called "chi."
D. Hot remedies restore balance after surgery, which is considered a "cold" condition. ✅Common parental practices and health beliefs among Hispanic, Chinese, Filipino, and
Arab cultures classify diseases, areas of the body, and illnesses as "hot" or "cold" and
must be balanced to maintain health and prevent illness. The perception that surgery is a
"cold" condition implies that only "hot" remedies, such as soup, should be used to restore
the healthy balance within the body, so (D) is the correct interpretation. (A, B, and C) are
not correct interpretations of the noted behavior. "Chi" is a Chinese belief that an innate
energy enters and leaves the body via certain locations and pathways and maintains
health. The "evil eye," or "mal ojo," is believed by many cultures to be related to the
balance of health and illness but is unrelated to dietary practice.
Correct Answer: D
A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the
infusion site. The nurse observes erythema, swelling, and a red streak along the vessel
above the IV access site. Which action should the nurse take at this time? A. Administer the
medication more rapidly using the same IV site.
B. Initiate an alternate site for the IV infusion of the medication.
C. Notify the healthcare provider before administering the next dose.
D. Give the client a PRN dose of aspirin while the medication infuses. ✅- A cephalosporin
antibiotic that is administered IV may cause vessel irritation. Rotating the infusion site
minimizes the risk of thrombophlebitis, so an alternate infusion site should be initiated
(B) before administering the next dose. Rapid administration (A) of intravenous
cephalosporins can potentiate vessel irritation and increase the risk of thrombophlebitis.
(C) is not necessary to initiate an alternative IV site. Although aspirin has
antiinflammatory actions, (D) is not indicated.
Correct Answer: B
The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for
fifteen seconds, large amounts of thick yellow secretions return. What action should the
nurse implement next?
A. Encourage the client to cough to help loosen secretions.
B. Advise the client to increase the intake of oral fluids.
C. Rotate the suction catheter to obtain any remaining secretions.
D. Re-oxygenate the client before attempting to suction again. ✅- Suctioning should not be
continued for longer than ten to fifteen seconds, since the client's oxygenation is
compromised during this time (D). (A, B, and C) may be performed after the client is
reoxygenated and additional suctioning is performed.
Correct Answer: D
A female client with a nasogastric tube attached to low suction states that she is nauseated.
The nurse assesses that there has been no drainage through the nasogastric tube in the last
two hours. What action should the nurse take first?
A. Irrigate the nasogastric tube with sterile normal saline.
B. Reposition the client on her side.
C. Advance the nasogastric tube an additional five centimeters.
D. Administer an intravenous antiemetic prescribed for PRN use. ✅- The immediate
priority is to determine if the tube is functioning correctly, which would then relieve the
client's nausea. The least invasive intervention, (B), should be attempted first, followed
by (A and C), unless either of these interventions is contraindicated. If these measures
are unsuccessful, the client may require an antiemetic (D).
Correct Answer: B
During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis
using a goniometer. Which finding should the nurse expect to measure? A. Adequate
venous blood flow to the lower extremities.
B. Estimated amount of body fat by an underarm skinfold.
C. Degree of flexion and extension of the client's knee joint.
D. Change in the circumference of the joint in centimeters. ✅- The goniometer is a
twopiece ruler that is jointed in the middle with a protractor-type measuring device that
is placed over a joint as the individual extends or flexes the joint to measure the degrees
of flexion and extension on the protractor (C). A doppler is used to measure blood flow
(A). Calipers are used to measure body fat (B). A tape measure is used to measure
circumference of body parts (D).
Correct Answer: C
During a physical assessment, a female client begins to cry. Which action is best for the
nurse to take?
A. Request another nurse to complete the physical assessment.
B. Ask the client to stop crying and tell the nurse what is wrong.
C. Acknowledge the client's distress and tell her it is all right to cry.
D. Leave the room so that the client can be alone to cry in private. ✅- Acknowledging the
client's distress and giving the client the opportunity to verbalize her distress (C) is a
supportive response. (A, B, and D) are not supportive and do not facilitate the client's
expression of feelings.
Correct Answer: C
A female client asks the nurse to find someone who can translate into her native language
her concerns about a treatment. Which action should the nurse take?
A. Explain that anyone who speaks her language can answer her questions.
B. Provide a translator only in an emergency situation.
C. Ask a family member or friend of the client to translate.
D. Request and document the name of the certified translator. ✅- A certified translator
should be requested to ensure the exchanged information is reliable and unaltered. To
adhere to legal requirements in some states, the name of the translator should be
documented (D). Client information that is translated is private and protected under
HIPAA rules, so (A) is not the best action. Although an emergency situation may require
extenuating circumstances (B), a translator should be provided in most situations.
Family members may skew information and not translate the exact information, so (C) is
not preferred.
Correct Answer: D
The nurse is teaching a client with numerous allergies how to avoid allergens. Which
instruction should be included in this teaching plan?
A. Avoid any types of sprays, powders, and perfumes.
B. Wearing a mask while cleaning will not help to avoid allergens.
C. Purchase any type of clothing, but be sure it is washed before wearing it.
D. Pollen count is related to hay fever, not to allergens. ✅- The client with allergies should
be instructed to reduce any exposure to pollen, dust, fumes, odors, sprays, powders, and
perfumes (A). The client should be encouraged to wear a mask when working around
dust or pollen (B). Clients with allergies should avoid any clothing that causes itching;
washing clothes will not prevent an allergic reaction to some fabrics (C). Pollen count is
related to allergens (D), and the client should be instructed to stay indoors when the
pollen count is high.
Correct Answer: A
Nursing . . . ✅- predates written history.
Who is the founder behind the profession of nursing? ✅- Florence Nightingale
Florence Nightingale did many significant things in her lifetime, some of those include: ✅Challenged prejudices against women.
Elevated the status of nurses
Established the first "proper" training of nurses.
*Based nursing practice on evidence.* Helped
distinguish nursing from medicine.
Since Florence Nightingale, nursing has . . . ✅- broadened in all areas.
In what ways has nursing evolved? ✅- Nursing is no longer considered a "less than" job
and instead is recognized as a highly respected profession.
Practice has widened to cover a wide variety of health care settings.
Nurses have a specific body of knowledge.
Nurses have an ethical conduct.
Nurses value research and continuously publish scholarly research.
Nurses don't just "care for sick people;" nurse promote health as well.
Nursing is continuously growing as a highly professional discipline.
ICN = ✅- International Council for Nurses
What is the ICN definition of nursing? ✅- Nursing encompasses autonomous and
collaborative care of individuals of all ages, families, groups, & communities, sick or well in
all settings.
The ICN also says that nursing care includes: ✅- the promotion of health, prevention of
illness, & the care of ill, disabled, & dying.
In a nutshell, the ICN's key values of nursing are: ✅- Advocacy, promotion of a safe
environment, research, education, and participation in shaping health policy and in patient
and health systems management.
Autonomy = ✅- Standing alone; independence; right to self-determination
Advocacy = ✅- Standing up for someone, other than oneself, when they are unable, or not
prepared, to make a decision, or action, for themselves.
ANA = ✅- American Nursing Association
What's the ANA's definition of nursing? ✅- The protection, promotion, and optimization of
health and abilities, prevention of illness and injury, alleviation of suffering through the
diagnosis and treatment of human response, and advocacy in the care of individuals,
families, communities, and populations.
Regardless of the various definitions of nursing, what is the central focus of *ALL*
definitions? ✅- The patient.
What are the six essential features of professional nursing? (Generally speaking). ✅- 1.
Caring relationships that facilitate health and healing.
2. Being aware of the range of human responses to health and illness in their various
environments.
3. Integrating objective date with the patient's or groups subjective experience.
4.Applying scientific knowledge to care for the patient, through the use of critical thinking.
5. Learning through scholarly inquiry.
6. Influence on the promotion of social justice.
What are the FOUR aims of nursing? ✅- 1. To promote health.
2. To prevent illness.
3. To restore health (alleviate suffering).
4. To facilitate coping with disability or death.
Blended competencies = ✅- the set of intellectual, interpersonal, technical, and
ethical/legal capacities needed to practice professional nursing
What are the four blended competencies of nursing? ✅- 1. cognitive
2. technical
3. interpersonal
4. ethical/legal
What is healthy people 2020? ✅- Federal government indicative. Sort of like "Guidelines"
for the US health standards.
Healthy people 2020's primary "guidelines" are: ✅- 1. Prevent disease, disability, and
premature death.
2. Having high health equity, *eliminating disparities,* and improving the health of ALL
groups.
3. Create a society that promotes good health for all.
4. Promotes continued high quality of life across all lifespans.
Disparities = ✅- inequality
QSEN = ✅- Quality and safety education for nurses
What are the 6 QSEN competencies? ✅- 1. Patient-centered care
2. Teamwork and collaboration
3. Quality improvement
4. Safety
5. Evidence-based practice
6. Informatics
What are the roles of a nurse? ✅- 1. Caregiver
2. Communicator
3. Educator
4. Counselor
5. Leader
6: Researcher
7. Advocate
8. Collaborator
Nursing is a profession dedicated to . . . ✅- serving others.
Is there one specific route to become an RN? ✅- No! There are various educational routes,
however BSN programs are becoming the way of the profession and will soon surpass other
routes.
What are some of the ANA standards of nursing practice? ✅- The nursing process
Ethics
Education
EBP/Research
Quality of Practice
Communication
Leadership
Collaboration
Professional Practice Eval
Resource Utilization
Environmental Health
Collegiality
What are Nurse Practice Acts? ✅- They are laws established in each state in the United
States to regulate the practice of nursing.
Who defines the legal scope of practice for nursing? ✅- The state board of a specific state.
The ultimate authority of nursing practice is . . . ✅- the state board of nursing
Values = ✅- shape our choices, behavior, and identity
What are the professional values of a nurse? ✅- 1. Altruism
2. Autonomy
3. Human dignity
4. Integrity
5. Social justice
Altruism = ✅- concern for welfare and well-being of others
Human Dignity = ✅- Respect for inherent worth and uniqueness of individuals and
populations
Integrity = ✅- Acting according to code of ethics and standards of practice
Social justice - ✅- Upholding moral, legal, and humanistic rights
What are the two basic theoretical frameworks of ethics? ✅- Utilitarian and Deontologic
Utilitarian = ✅- The rightness or wrongness of an action depends on the consequences of
the action.
Deontologic = ✅- An action is right or wrong independent of its consequences.
Bioethics = ✅- ethics dealing with human lives
What is the principle-based approach to bioethics? ✅- 1. Autonomy
2. Nonmaleficence
3. Beneficence
4. Justice
5. Fidelity
6. Veracity, accountability, privacy, and confidentiality
Autonomy in bioethics = ✅- Respect rights of patients to make health care decisions
Nonmaleficence = ✅- Avoid causing harm
Beneficence = ✅- benefit the patient
Justice = ✅- Give each his or her due and act fairly
Fidelity = ✅- Keeping promises; "Integrity"
What is the purpose of the code of ethics for nurses? ✅- Provide a powerful statement of
the ethical values, obligations, and duties of every individual who enters the nursing
profession. The code of ethics serves as the nonnegotiable ethical standard of practice.
What is provision 1 of the code of ethics? ✅- The nurse practices with compassion and
respect for the inherent dignity, worth, and unique attributes of every person.
What is provision 2 of the code of ethics? ✅- The nurse's primary commitment is to the
patient, whether an individual, family, group, community, or population.
What is provision 3 of the code of ethics? ✅- The nurse promotes, advocates for, and
protects the rights, health, and safety of the patient.
What is provision 4 of the code of ethics? ✅- The nurse has authority, accountability, and
responsibility for nursing practice' makes decisions; and takes action consistent with the
obligation to promote health and to provide optimal care.
What is provision 5 of the code of ethics? ✅- The nurse owes the same duties to self as to
others, including the responsibility to promote health and safety, preserve wholeness of
character, and integrity, maintain competence, and continue personal and professional
growth.
What is provision 6 of the code of ethics? ✅- The nurse, through individual and collective
effort, establishes, maintains, and improves the ethical environment of the work setting and
conditions of employment that are conducive to safe, quality health care.
What is provision 7 of the code of ethics? ✅- The nurse, in all roles and settings, advance
the profession through research and scholarly inquiry, professional standards
development, and the generation of both nursing and health policy.
What is provision 8 of the code of ethics? ✅- The nurse collaborate with other health
professionals and the public to protect human rights, promote health diplomacy, and
reduce health disparities.
What is provision 9 of the code of ethics? ✅- The profession of nursing, collectively
through its professional organizations, must articulate nursing values, maintain the
integrity of the profession, and integrate principles of social justice into nursing and health
policy.
Nurses have a bill of rights that: ✅- Results in advocacy on behalf of the nursing
profession.
Empowers nurses.
Improves workplace.
Ensures nurses' ability to provide safe, quality care.
Allows them to freely advocate for themselves and their patients, without fear of
retribution.
What's an ethical dilemma?
Professor Donadio's example of the PT on the vent. ✅- Two (or more) clear moral
principles apply, but support mutually inconsistent courses of actions.
What is moral distress? ✅- When the nurse knows the right thing to do but either personal
or institutional factors make it difficult to do the right thing.
What is a law? ✅- Standard or rule of conduct established and enforced by government.
Private Law? ✅- AKA: Civil law.
Most law associated with nursing.
-Regulates relationships among people.
Can an RN's license be suspended/revoked? ✅- Yes! If said RN becomes carless, reckless,
and negligent of ones career and patients.
What's a crime? ✅- Wrong against person/property & the public
What's a tort? ✅- A wrong committed by a person against another person or property;
tried in civil court.
Torts may be . . . ✅- intentional or unintentional.
What is unintentional torts? ✅- Negligence & Malpractice
HIPAA = ✅- Health Insurance Portability and Accountability Act
What is the purpose of HIPAA? ✅- To ensure patient rights.
What are some patient rights? ✅- To see and copy their health record.
To update their health record.
To request correction of any mistakes.
To get a list of disclosures.
To request restrictions on certain uses or disclosures.
To choose how to receive health information
What are the four elements of liability? ✅- 1. Duty.
2. Breach of Duty. 3.
Causation
4. Damages.
Competency = ✅- The ability to do something correctly, efficiently, and successfully.
Nursing is ...... ✅- NOTHING without critical thinking!
Nursing is also, ✅- patent-centered, meaning the patient drives the entire process.
Caring in nursing is: ✅- - A way of being, knowing, & doing with the goal of protection,
enhancement, & preservation of human dignity. - Action and competencies that aim toward
the good and welfare of others.
What are the steps of the nursing process? ✅- ASSESS
DIAGNOSE
PLAN
IMPLEMENT
EVALUATE
-DOCUMENTThe nursing process is: ✅- systemic, dynamic, interpersonal, outcome oriented, and
universally applicable.
The nursing process is the
for all nursing activities. ✅- Framework
Reflective practice is ..... ✅- essential to professional practice.
One can practice reflective practice in many different ways ..... ✅- Reflection *IN* action
(present)
Reflection *ON* action (past)
Reflection *FOR* action (future)