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Performance
Exit
Pre-Midterm HESI Fundamentals
Prep: Content - NCLEX-PN Basics of
Nursing Practice
Due Oct 8, 2023 by 11:59 pm
Final Score
100%
100 out of 100 questions answered correctly
Completed on Oct 6, 2023 10:25 am
Incorrect (0)
Correct (100)
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During disaster response, which task is the responsibility of the medical
command physician? One, some, or all responses may be correct.
Determine resource needs of patients.
Rapidly evaluate each patient to determine treatment priorities.
Communicate with the media.
Implement the emergency plan.
Rationale
The responsibilities of the medical command physician include determining number,
acuity, and resources required. The triage officer (a physician or nurse) rapidly
evaluates each patient to determine priorities for treatment. The public information
officer is the media liaison. The hospital incident commander implements the
emergency plan.
Which statement describes the characteristics of the abstract section of
an article? Select all that apply. One, some, or all responses may be
correct.
Summarizes the purpose of the article
Mentions the major themes and implications for nursing practice
Contains brief supporting evidence regarding the importance of the topic
Includes a brief summary that informs the reader whether the article is
research-based or clinically based
Provides detailed information regarding the level of science or clinical
information available on the topic
Rationale
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The abstract section summarizes the purpose of the article. It also mentions the
themes or findings as well as the implications for nursing practice. The abstract section
is a brief summary that informs readers whether the article is based on research or
clinical evidence. The introduction contains brief supporting evidence regarding the
importance of the topic. The literature review section contains detailed information
regarding the level of scientific or clinical information available on the topic.
Which therapy is considered palliative care in the end stage of human
immunodeficiency virus (HIV) disease? Select all that apply. One,
some, or all responses may be correct.
Antibiotic therapy
Blood transfusion
Intravenous therapy
Photochemotherapy
Monoclonal antibody therapy
Rationale
Antibiotic use, blood transfusions, and intravenous therapy help keep clients with HIV
disease comfortable and help maintain quality of life; therefore they may be
considered palliative therapy in the end stage of HIV disease. Photochemotherapy is
used for the management of psoriasis. Monoclonal antibody therapy may be used to
treat metastatic breast cancer in women who overexpress a breast cancer cell antigen
called HER2.
Which physical finding may be seen in a client who is the victim of
intimate partner violence? Select all that apply. One, some, or all
responses may be correct.
Burns
Abrasions
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Excoriation
Hematomas
Human bites
Rationale
Physical findings such as burns, abrasions, and human bites are often seen in victims
of intimate partner violence. Excoriation is most commonly caused by a skin-picking
disorder. Hematomas are more often seen in abused older adults.
Which source of funding would support a city health department that
provides home health services under the governance of a local unit of
government? Select all that apply. One, some, or all responses may be
correct.
Grants
County revenues
Fees from limited sources
Noncharitable contributions
Tax-deductible contributions
Rationale
The city health department is an example of an official home health agency. Its
sources of support are grants, county revenues, charitable contributions, and fees from
limited sources. It will not be supported by noncharitable contributions, and taxdeductible contributions support voluntary home health agencies.
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Which action of the nurse exhibits transactional leadership? Select all
that apply. One, some, or all responses may be correct.
Motivating or inspiring the employees
Meeting the targets within the deadline
Working according to organizational rules
Correcting the errors in a reactive manner
Increasing the employee commitment of an organization
Rationale
The characteristics of transactional leadership include valuing the orders and
structures of an organization. The nurse who exhibits transactional leadership will
meet the targets within the deadline given by the organization. The nurse will also
follow the rules of an organization and will correct the errors of an employee in a
reactive manner. Motivating or inspiring the employees and increasing employee
commitment are the characteristics of transformational leadership.
STUDY TIP: Enhance your organizational skills by developing a checklist and creating
ways to improve your ability to retain information, such as using index cards with
essential data, which are easy to carry and review whenever you have a spare moment.
Which food recommendation would the nurse expect to be made to a
client with an ileostomy during a discussion with a dietician? Select all
that apply. One, some, or all responses may be correct.
Eat larger meals.
Eat a high-protein diet.
Avoid caffeinated beverages.
Avoid extremely hot or cold foods and fluids.
Limit intake of milk and raw vegetables and fruits.
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Rationale
Clients with ileostomies are advised to eat meals high in protein, calories, and
vitamins. Avoidance of caffeinated beverages and extremely hot or cold foods and
fluids are also recommended. Milk and raw vegetables and fruits are to be limited.
Clients are to eat frequent, small meals.
Which member of the health care team is under dependent status when
a task is delegated by the registered nurse (RN)? Select all that apply.
One, some, or all responses may be correct.
Unit secretary
Client attendant
RN
Primary health care provider
Licensed vocational nurse (LVN)
Rationale
A unlicensed nursing personnel (UNP), licensed practical nurse (LPN), or LVN who is
under the direction of an RN is given dependent status. The client attendant and the
LVN are on dependent status when a task is delegated by the RN. The unit secretary is
a member of the health care team but is devoid of formal preparation or legal
recognition. The RN is the leader of the team and has responsibility for other
members of the group. The primary health care provider is a member of the health
care team but may delegate tasks to those with dependent status.
Which normal flora of the skin would a nurse suspect as a cause of an
infected sacral decubitus ulcer when caring for a paraplegic client?
Enterobacter species
Anaerobes
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Staphylococcus aureus
Bacteroides species
Rationale
Normal flora of the skin such as Staphylococcus aureus can be the cause of infected
ulcers. Enterobacter species, anaerobes, and Bacteroides species are normal flora of
the gastrointestinal tract.
Test-Taking Tip: Read the question carefully before looking at the answers: (1)
determine what the question is really asking; look for key words; (2) read each answer
thoroughly and see if it completely covers the material asked by the question; (3)
narrow the choices by immediately eliminating answers you know are incorrect.
A client presents with hearing loss in the right ear. When the nurse
performs a Weber test with a tuning fork, the client hears the sound
better with the right ear. Which condition would the nurse suspect from
these results?
Normal hearing
Mixed hearing loss
Conduction hearing loss
Sensorineural hearing loss
Rationale
During a Weber test, conduction hearing loss often causes the tuning fork to be heard
better and more clearly in the impaired ear. The client does not have normal hearing.
Mixed hearing loss is a combination of both conduction and sensorineural hearing
loss and would not result in the findings observed with the Weber test. People with
sensorineural hearing loss will hear the sound better in the normal (in this case, the
left) ear.
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The health care provider has prescribed meperidine 50 mg
intramuscularly to client. The medication is available in 100 mg/mL
vials. To which mark on the syringe would the nurse draw up the
medication?
2 mL mark
1 mL mark
2 ½ mL mark
½ mL mark
Rationale
The medication is supplied as 100 mg/mL. The prescription is for 50 mg. You would
calculate: Desired/Have times Volume. 50 mg/100 mg/mL x 1 mL = 0.5 mL, or ½ mL.
Using the ratio and proportion method provides the following sequence. 50 mg : x mL
:: 100 mg : 1 mL. 100 x = 50. x = 50/100. x = ½ mL.
Test-Taking Tip: When taking the NCLEX exam, an on-screen calculator will be
available for you to determine your response, which you will then type in the provided
space.
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Which action would the nurse complete if a client’s paper medication
administration record (MAR) shows the previous nurse did not give a
prescribed stat medication?
Sign the MAR for the nurse; the nurse reported giving it during shift
handover.
Give the prescribed medication and document administration.
Report the omission to the charge nurse.
Leave the MAR as is, so the previous nurse can document the administration.
Rationale
The nurse would report the omission to the charge nurse. Signing the MAR for the
previous nurse, giving the prescribed medication, and leaving the MAR as is are not
appropriate actions.
Which intervention would the nurse implement when assessing an
older adult client who has a hearing impairment?
Speak instructions loudly.
Face the client when speaking.
Avoid medical terminology.
Increase processing time by speaking quickly.
Rationale
The nurse would face the client when speaking and ensure a well-lit environment.
These actions allow the client to notice the nurse’s nonverbal communication and
make out words by watching the nurse’s mouth. Speaking loudly does not help a client
who is hearing impaired. The nurse would avoid speaking in simple or childish terms;
medical terminology would be used when appropriate. Speaking slowly provides the
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client time to process what the nurse is saying and to answer.
Test-Taking Tip: Avoid selecting answers that state hospital rules or regulations as a
reason or rationale for action.
Which response by the nurse is appropriate when asked by the client
what active participation in health care means? Select all that apply.
One, some, or all responses may be correct.
"Don’t question the health care provider."
"Follow the treatment plan."
"Act responsibly according to the health care condition."
"Determine which medications can be discontinued."
"Contribute to the planning process."
Rationale
Active participation in health care includes following the agreed treatment plan. The
client would also act responsibly according to the diagnosed health care condition. The
client would contribute to the planning process as part of active participation.
Questioning the health care provider is part of collaboration; not asking questions can
lead to misunderstanding. The client would not determine which medications to
discontinue but would consult the health care provider for any medication-related
concerns.
Which is an independent nursing intervention for a hospitalized client?
Placing oxygen on a client with an arterial oxygen saturation (SaO 2) of 89%
Raising the head of the bed to facilitate lung expansion
Applying a medicated lotion to the client’s dry skin areas
Ambulating the postoperative client
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Rationale
Raising the head of the bed for a client to aid in lung expansion is a nursing
intervention and does not require a health care provider prescription. Oxygen is a
medication and requires a health care provider’s prescription. Medicated lotion
requires a health care provider’s prescription. The nurse would not ambulate the
postoperative client unless the health care provider entered a prescription.
With which health care team member would it be appropriate for the
nurse to share a client’s medical diagnosis?
Unit secretary
Environmental personnel
Charge nurse
Phlebotomist
Rationale
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 provides
protection of health information. Client information is limited to staff who need to
know the client’s information in order to provide care. The charge nurse is allowed this
information in order to collaborate with health care providers and the staff nurse. The
unit secretary does not need to know the client’s medical diagnosis; the role of the
secretary is to manage the unit desk. Environmental personnel who clean the unit do
not need to know sensitive client information. The phlebotomist would not need to be
aware of the client’s medical diagnosis in order to obtain a blood specimen.
Which statement by a nursing student demonstrates the difference
between a nursing diagnosis and a medical diagnosis? Select all that
apply. One, some, or all responses may be correct.
"A medical diagnosis relates to a health problem that can be treated with
health care provider-prescribed therapies."
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"The nursing diagnosis correlates with the client’s health problem prognosis."
"The nursing diagnosis identifies the client’s response to illness."
"The nurse often uses clues in the medical diagnosis to develop the nursing
diagnosis."
"The nurse is not responsible for an accurate nursing diagnosis, but a health
care provider is responsible for an accurate medical diagnosis."
Rationale
The medical diagnosis is concerned with health problems that would be treated with a
health care provider’s prescription. The nursing diagnosis relates to the client’s
response to illness; physical, psychological, and spiritual well-being is considered in
the holistic approach to client care. The nursing diagnosis can often be developed
using the medical diagnosis as a basis for care. The nurse may utilize the client’s
prognosis to identify the nursing diagnosis, but the central theme of the nursing
diagnosis is the client’s response to the prognosis. Both the nurse and health care
provider are responsible for accuracy of the client care plan within their scope of
practice.
Test-Taking Tip: Become familiar with reading questions on a computer screen.
Familiarity reduces anxiety and decreases errors.
Which complication may be reduced when a nurse’s suggestion of a
urology consult is implemented for a client who is incontinent?
Ileus
Atelectasis
Renal failure
Pressure ulcer
Rationale
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Incontinence is a risk factor for development of a pressure ulcer. A urology consult and
management may reduce this risk. Ileus is a type of bowel obstruction and would not
be managed by a urologist. Atelectasis risk would be reduced by an incentive
spirometer. Renal failure is not associated with incontinence.
Which equipment would a nurse request from an unlicensed health care
worker when preparing to transport a client who cannot tolerate the
fatigue associated with transport?
Lift
Gurney
Stretcher
Wheelchair
Rationale
Wheelchairs are used to transport clients who are unable to tolerate fatigue. Lifts are
used for transfers of clients. A stretcher or gurney may be used when a client is unable
to sit and requires transport.
Which statement by the nurse indicates the need for further teaching?
"Logrolling can be done without a lift sheet."
"Logrolling maintains the body in straight alignment at all times."
"Logrolling can be used in a client with suspected spinal cord injuries."
"Logrolling requires one nurse to move the body and one to move the feet in
coordination."
Rationale
Logrolling involves three persons. One nurse would control the head, neck, and
shoulders. One would roll the waist and hips. The third would support the thighs and
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lower legs. Logrolling does not require a lift sheet, maintains alignment at all times,
and is used with suspected spinal cord injuries.
Which position would the nurse place a client in after the health care
provider states that a rectal examination is to be performed?
Sims
Supine
Prone
Fowler
Rationale
The Sims position is useful for rectal examinations, administering enemas, and
inserting suppositories. The supine, prone, and Fowler positions would not be
appropriate. A client in the supine and Fowler positions would be lying on the back.
The prone position would be lying face down but would be uncomfortable and
awkward for a rectal examination.
Which advice would a nurse give to another nurse concerning correct
standing body alignment to prevent injury?
Arms out
Knees straight
Abdominal muscles tucked in
Head down and focused on position of feet
Rationale
To prevent injury, correct standing body alignment includes abdominal muscles
tucked in. Additionally, the arms should be relaxed at the side, knees slightly flexed,
and head up and eyes straight.
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Which muscles would a nurse explain to a client would be targeted by a
therapist trying to strengthen the core?
Trapezius
Triceps
Gastrocnemius
Transversus abdominis
Rationale
The transversus abdominis muscle is an abdominal muscle that would be targeted
when strengthening the core. The trapezius, triceps, and gastrocnemius muscles are
not part of the core.
Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times
when four or five consecutive questions have the same letter or number for the correct
answer.
Which intervention would the nurse manager and the critical incident
stress management team encourage when debriefing nurses after a
mass casualty incident (MCI)?
Sharing feelings
Discussing errors
Providing respite
Organizing volunteers
Rationale
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The critical incident stress management unit works with employees after a disaster to
allow members to share and validate feelings. This allows staff to process the incident
and begin to heal, as well as minimize the incidence of posttraumatic stress disorder.
Errors are not discussed, and respite is not provided during these meetings.
Volunteers are organized during the disaster.
Test-Taking Tip: Be alert for details. Details provided in the stem of the item, such as
behavioral changes or clinical changes (or both) within a certain time period, can
provide a clue to the most appropriate response or, in some cases, responses.
Which task is classified as low priority when planning client care for the
day?
Drawing arterial blood gases on a client in respiratory distress
Turning and positioning a client after hip replacement surgery
Teaching self-administration of insulin injections before discharge
Obtaining and recording vital signs every 2 hours on a postoperative client
Rationale
A low priority, problem classification is an actual or potential problem that is not
directly related to the client’s illness or disease. These problems are often
developmental needs or long-term health care needs and are examples of a lowpriority need as is education before discharge. Even though the education about
insulin injections is important, it is not an immediate or high priority. Drawing arterial
blood gases on a client in respiratory distress is a high-priority problem because the
client is demonstrating an immediate, life-threatening condition. Turning and
positioning a postoperative client is an example of an intermediate priority because it
is done to prevent possible postoperative complications. Obtaining and recording vital
signs every 2 hours on a postoperative client is an intermediate need because it is not
a life-threatening, urgent need, but monitoring it is required for client stability.
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Test-Taking Tip: Have confidence in your initial response to an item because it more
than likely is the correct answer.
During an orientation for new nurses, the nurse leader discusses client
confidentiality and privacy when using the facility’s electronic health
record system. Which safeguard would the nurse leader include as the
best way to protect client privacy?
System end users
Unique passwords
Policies and procedures
Data security agreements
Rationale
The integrity and ethical principles of system end users provide the final safeguard for
client privacy. Unique passwords, policies and procedures, and data security
agreements are all aspects of protecting client confidentiality and privacy but are not
the final safeguard.
Which is a component of the primary survey?
Disability
Abdomen and flanks
Head, neck, and face
History of the illness or injury
Rationale
Assessing disability by conducting a brief neurologic examination is a component of
the primary survey, which aims to identify life-threatening conditions so appropriate
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interventions can be started. Assessment of the abdomen and flanks; the head, neck,
and face; and the history of the illness or injury are all part of the secondary survey,
which begins after addressing each step of the primary survey and starting any
lifesaving interventions.
Test-Taking Tip: You have at least a 25% chance of selecting the correct response in
multiple-choice items with four options. If you are uncertain about a question,
eliminate the choices that you believe are wrong, and then call on your knowledge,
skills, and abilities to choose from the remaining responses.
Which factor would a nurse suggest can be improved to decrease the
susceptibility of infection in an older client?
Age
Sex
Vitamins
Nutritional status
Rationale
Optimization of nutritional status can decrease the susceptibility of infection. This is
especially significant in older adults and those who are malnourished. Age is a factor in
susceptibility to infection but cannot be modified. Sex is not linked to an increase in
infections and cannot be modified. Vitamins are indicated only where there is a
deficiency.
Which statement by a nurse caring for a client with a colostomy
indicates the need for further teaching?
"A dusky color is a sign of compromised blood supply."
"A red stoma needs to be reported to the health care provider."
"The effluent from a colostomy is more formed than from an ileostomy."
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"The stoma and skin should be washed with mild soap when changing the
faceplate."
Rationale
A red or pink stoma is healthy tissue and does not require contacting the health care
provider. A dusky color would necessitate contacting the health care provider as it is a
sign of vascular compromise. Colostomy effluent tends to be more formed, and the
stoma and skin should be washed with mild soap when changing the faceplate.
Test-Taking Tip: Do not worry if you select the same numbered answer repeatedly,
because there usually is no pattern to the answers.
Which food would the nurse expect to be restricted by the dietician for a
client on a low-sodium diet? Select all that apply. One, some, or all
responses may be correct.
Ham
Cheese
Hot dogs
Dried fruit
Lunch meats
Rationale
Ham, cheese, hot dogs, dried fruit, and lunch meats are all high in sodium and to be
restricted in a low-sodium diet.
Which action would be taken by the nurse when a client who is hard of
hearing is scheduled for surgery?
Notify the operating room that the client is hard of hearing.
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Ensure that the client has hearing aids out when being transported.
Allow a family member to consent for surgery on behalf of the client.
Request a sign language interpreter to be present immediately after surgery.
Rationale
The operating room must be notified if a client is hard of hearing. A client can keep
hearing aids in until requested by the anesthesia team to remove them. A client’s
hearing deficit will not diminish the ability to consent. Interpreters are generally
requested as needed. There is no indication that this client will need an interpreter
postoperatively.
Test-Taking Tip: Once you have decided on an answer, look at the stem again. Does
your choice answer the question that was asked? If the question stem asks "why," be
sure the response you have chosen is a reason. If the question stem is singular, be sure
the option is singular, and the same for plural stems and plural responses. Many
times, checking to make sure that the choice makes sense in relation to the stem will
reveal the correct answer.
Which recommendation would a nurse give to parents when asked
about making the household safer for their children? Select all that
apply. One, some, or all responses may be correct.
Cover electrical outlets.
Secure stairways with a safety barrier.
Keep children away from hot surfaces.
Do not drink hot liquids while holding an infant.
Avoid using tablecloths that hang over the table within an infant’s reach.
Rationale
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All of these recommendations can help provide a safer household environment.
Which action would a nurse take to prevent cross-contamination?
Gram staining
Timely administration of antibiotics
Culturing
Hand hygiene
Rationale
Hand hygiene is one of the most important measures to prevent cross-contamination.
Gram staining and cultures provide information about the infective microorganism.
The administration of antibiotics on time is critical to treatment.
Which normal flora of the vagina and skin will a nurse explain is not a
concern to an alarmed female client who is worried by vaginal culture
results?
Neisseria species
Staphylococcus epidermidis
Streptococcus pyogenes (group A)
Haemophilus species
Rationale
Staphylococcus epidermidis is normal flora of the vagina and skin, and a female client
should be reassured that this is not a concerning culture result. Neisseria species,
Streptococcus pyogenes (group A), and Haemophilus species are not normal flora of
the vagina.
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Which normal flora of the gastrointestinal tract will a nurse attempt to
limit by cleaning an incontinent client as soon after a bowel movement
as possible?
Staphylococcus aureus
Staphylococcus epidermidis
Yeast
Enterobacter species
Rationale
Enterobacter species are normal flora of the gastrointestinal tract and are frequently
the cause of urinary tract and other infections. Staphylococcus aureus, Staphylococcus
epidermidis, and yeast are all normal flora of the skin.
Which factor puts the nurse at highest risk of developing acute stress
disorder after working during a mass casualty event?
Took breaks
Talked to clergy
Contacted family
Worked for 24 hours
Rationale
To decrease the risk for acute stress disorder during a mass casualty event, nurses
would not work more than 12 hours per day. The nurse that has worked 24 hours is at
highest risk for acute stress disorder. Using available counseling, taking regular breaks,
and keeping in contact with family and friends decrease the risk for acute stress
disorder.
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Which information would be important for the nurse to provide to the
anesthetist for an older client undergoing major surgery?
Pain score before the morning of the surgery
Temperature for 24 hours before the surgery
Accurate measurement of height and weight
Blood pressure before being transferred to the operating room
Rationale
Accurate measurement of height and weight are critical to calculations for anesthetic
administration. Pain score is not relevant as the client will be under general anesthesia.
Both temperature and blood pressure will be monitored during and after surgery.
Previous measurements are not specifically needed by the anesthetist.
Test-Taking Tip: Never leave a question unanswered. Even if answering is no more
than an educated guess on your part, go ahead and mark an answer. You might be
right, but if you leave it blank, you will certainly be wrong and lose precious points.
How many total mL of fluid will be infused between the hours of 8:00
am and 8:00 pm if a client is receiving 22 mL per hour of intravenous
fluid? Record your answer as a whole number.
264
mL
Rationale
22 mL × 12 hours = 264 mL.
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A client with gastroesophageal reflux is to receive metoclopramide 15
mg orally before meals. The concentrated solution contains 10 mg/mL.
How much solution would the nurse administer? Record your answer
using one decimal place.
1.5
mL
Rationale
The prescribed dose is 15 mg. The available concentration is 10 mg/mL. Use the
dimensional analysis and/or ratio and proportion methods to determine the
appropriate amount of medication to be administered.
Test-Taking Tip: Get a good night's sleep before an exam. Staying up all night to study
before an exam rarely helps anyone. It usually interferes with the ability to concentrate.
Which part of the Subjective, Objective, Assessment, Plan, Intervention,
Evaluation, Revision (SOAPIER) format does laboratory findings
indicate?
Planning
Objective
Evaluation
Assessment
Rationale
In SOAPIER, objective refers to information that the nurse can measure such as
laboratory findings. Planning refers to the general statement of the plan of care to be
given or action to be taken based on the client’s needs. Evaluation refers to an
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appraisal of the client’s response and effectiveness of the plan. Assessment refers to
potential diagnosis of the cause of the client’s problem.
Which statement about the situational leadership role is correct?
"Situational leadership is also called free-run style."
"This style allows the manager to grow professionally."
"This style of leadership works well in highly motivated professional groups."
"The basis of this leadership style is the manager’s flexibility in adapting to the
needs of the group or individual."
Rationale
In situational leadership theory, the manager has flexibility in adapting to the needs
of the group or individual. Laissez-faire leadership is called free-run style. This type of
leadership style fosters professional growth of the manager and staff, and it does not
work well with highly motivated professional groups.
Which is the best communication technique for the nurse to use when
beginning to teach the client about a restricted diet?
Ask about which type of foods the client usually eats.
Tell the client that the diet must be followed exactly as written.
Tell the client that the intake of foods on the list must be limited.
Ask what the client knows about the diet that was prescribed.
Rationale
Asking about what the client knows about the prescribed diet may validate the client's
understanding; the response may indicate the need for further teaching or that the
client understands; understanding and accepting the need for restrictions will increase
adherence to the diet. Assessing the client's food preferences and teaching about diets
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come after an assessment of the client's understanding about the need for a specific
diet; the client must understand the need for and the benefits of the diet before there
is a readiness for learning. Telling the client that the diet must be followed exactly as
written and telling the client that the intake of foods on the list must be limited are
authoritarian and should be avoided.
Which action would the hospice nurse take when a client using fentanyl
transdermal patches passes away?
Tell the family to remove and dispose of the patch.
Leave the patch in place for the mortician to remove.
Have the family return the patch to the pharmacy for disposal.
Remove and dispose of the patch in an appropriate receptacle.
Rationale
The nurse should remove and dispose of the patch in a manner that protects self and
others from exposure to the fentanyl. Having the family remove and dispose of the
patch and having the mortician remove the patch are inappropriate; removing the
patch is not the responsibility of nonprofessionals because they do not know how to
protect themselves and others from exposure to the fentanyl. It is unnecessary to
return a used fentanyl patch.
Which sign or symptom is likely to be found in an adult experiencing
sexual abuse? Select all that apply. One, some, or all responses may be
correct.
Anorexia
Flat affect
Panic attacks
Physical aggression
Excessive daydreaming
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Rationale
Anorexia, a flat affect, and panic attacks are behavioral/nonverbal signs and symptoms
the nurse may observe in an adult victim of sexual abuse. Physical aggression and
excessive daydreaming are behavioral/nonverbal signs and symptoms more likely to be
exhibited by a child victim of sexual abuse.
The nurse delegated a task to a unlicensed assistive personnel (UAP) and
the UAP completed the task effectively. Which statement made by the
nurse is appropriate feedback?
"Nice job."
"Well done."
"Your performance was good."
"You performed that procedure safely and professionally."
Rationale
The statement "You performed that procedure safely and professionally" clearly
identifies what the UAP did well, so it can shape future behavior positively. The nurse
should not include vague statements, such as "Nice job" or "Well done." The statement
"Your performance was good" could have a positive impact, but a specific behavior is
not mentioned in the statement.
Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times
when four or five consecutive questions have the same letter or number for the correct
answer.
The nurse is caring for a client who underwent surgery for a pituitary
tumor. Which task can be delegated to unlicensed assistive personnel
(UAP)?
Teaching the client
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Monitoring vital signs
Assessing laboratory reports
Evaluating the status of the client
Rationale
The UAP can be delegated to care for a client in an acute care setting if the client is
stable. So the vital signs can be monitored by the UAP if the client has stable vital
signs. Client teaching is within the scope of the nurse. Reinforcement of the teaching
can be delegated to the UAP. Assessing laboratory reports is the role of the nurse; this
task may not be delegated to UAPs. Evaluating client status is the role of the nurse;
this task is outside the scope of practice of the UAP.
What is the nurse's accountability when a worn stretcher strap breaks
and the client is injured?
Exempt from any lawsuit because of the Doctrine of Respondeat Superior
Totally responsible for the obvious negligence because of failure to report
defective equipment
Liable, along with the employer, for misapplication of equipment or use of
defective equipment that harms the client
Exonerated because only the hospital, as principal employer, is responsible for
the quality and maintenance of equipment
Rationale
Using a stretcher with worn straps is negligent; this oversight does not reflect the
actions of a reasonably prudent nurse. The nurse is responsible and must ascertain the
adequate functioning of equipment. The hospital shares responsibility for safe,
functioning equipment.
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A woman in premature labor is prescribed betamethasone 12 mg
intramuscularly (IM) daily for 3 days to enhance fetal lung maturity. The
betamethasone comes in a vial labeled "6 mg/mL." How many milliliters
would the nurse administer each day? Record your answer using a
whole number.
2
mL
Rationale
The prescribed dose is 12 mg. The available concentration is 6 mg/mL. Use the
dimensional analysis and ratio and proportion methods to determine how many
milliliters the nurse should administer with each dose. 12 mg : x mL :: 6 mg : 1 mL.
6 x = 12. x = 12 ÷ 6. x = 2.
Test-Taking Tip: When taking the NCLEX exam, an on-screen calculator will be
available for you to determine your response, which you will then type in the provided
space.
Which principle would legally apply when a nurse discovers burns due
to the incorrect setting of a heating pad?
No one could be held liable for new equipment.
The nurse could be held liable for the injury that occurred.
The nurse did what a reasonable, prudent nurse would do.
The manufacturer is liable for new equipment.
Rationale
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A nurse can be held responsible for any action performed that causes a client to be
harmed. Legally, someone will assume liability for the action. If sued in this case, the
nurse would have to prove that the actions were reasonable and prudent under the
circumstances. The manufacturer may also be liable depending on whether the
equipment was used correctly, but initially the actions of the nurse will be reviewed.
Which legal principle is most likely to be applied when a nurse fails to
act in a reasonable, prudent manner?
Malice
Tort law
Malpractice
Case law
Rationale
Malpractice is the unskilled or faulty treatment by a professional that causes injury or
harm to a client. It can result from a lack of professional knowledge or skill that can be
expected in others in the profession, or it can result from a failure to exercise
reasonable care or judgment in the applying of professional knowledge, experience, or
skill. Malice is the desire or intent to inflict injury, harm, or suffering. A tort is a
wrongful act, not including a breach of contract or trust, that results in injury to
another person and for which the injured person is entitled to compensation. Case law
is law established by judicial decisions in particular cases instead of by legislation
action.
Which role describes the American Red Cross in emergency nursing
after a community disaster?
Managing mass fatalities
Establishing fully functional field surgical facilities
Setting up shelters for clients who have lost their homes
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Dealing with emotions of health care providers after a disturbing event
Rationale
American Red Cross is activated by state and federal government authorities for mass
casualty situations or disasters. American Red Cross sets up shelter for clients who lost
their homes in the disaster or are relocated from their homes. Disaster Mortuary
Operational Response Teams (DMORTs) are a health care service that helps manage
mass facilities. International Medical Surgical Response Teams (IMSuRTs) are health
care services that establish fully functional field surgical facilities in a disaster. Critical
Incident Stress Debriefing (CISD) teams are called to deal with emotions of health care
providers after a disturbing event.
Which quality is characteristic of an effective team? Select all that
apply. One, some, or all responses may be correct.
Autocratic leadership
Shared vision and goals
Objectives include personal agendas
Vague role definitions
Ability to handle conflicts by having open discussions
Rationale
An effective team works together with shared vision and goals. An effective team will
handle conflict by openly discussing issues. Autocratic leadership does not allow input
from team members, which creates ineffective teams. Objectives involving personal
agendas do not represent the entire team. Vague role definitions create confusion,
which decreases the effectiveness of a team.
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Which factor would be considered when delegating a task to the
licensed practical nurse (LPN)? Select all that apply. One, some, or all
responses may be correct.
Client's condition
Complexity of the task
Number of LPNs available
Predictability of outcomes
Relationship status between the delegatee and delegator
Rationale
The decisions for delegation should be based on multiple factors such as the client's
condition, complexity of the task, and predictability of outcomes. The number of LPNs
may not be important information while assigning the tasks. Relationship status
between the delegatee and the delegator is not an important consideration for
delegating a task to the LPN effectively.
Which role can assume responsibility for the nurse when the nurse takes
a break?
Charge nurse
Chief nursing officer
Health care provider
Licensed practical nurse (LPN)
Rationale
The charge nurses have knowledge and expertise in critical thinking, clinical practice,
leadership, and communication; therefore, the charge nurse can assume the duties
when the registered nurse (RN) goes for a break. Chief nursing officers are accountable
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for establishing systems to communicate competency requirements related to
delegation. Health care providers may delegate and assign tasks for unlicensed
nursing personnel (UNPs). LPN are not eligible for delegation; the LPNs are
delegatees.
Which statement accurately describes primary prevention?
Directing care toward rehabilitation rather than treatment
Applying care to clients who are physically and emotionally healthy
Providing screening techniques and the treatment of the early stages of a
disease
Focusing on individuals who are ill and have a possibility for developing
complications
Rationale
Primary prevention is true prevention. This prevention is applied to clients who are
considered to be physically and emotionally healthy. The tertiary level of prevention is
directed at providing rehabilitative care to clients. Secondary prevention includes
screening techniques and treatment of early stages of disease. Secondary prevention is
focused on individuals who are ill and are at risk for further complications.
Test-Taking Tip: You have at least a 25% chance of selecting the correct response in
multiple-choice items with four options. If you are uncertain about a question,
eliminate the choices that you believe are wrong and then call on your knowledge,
skills, and abilities to choose from the remaining responses.
Which finding helps the nurse distinguish absolute homelessness from
relative homelessness while conducting a survey about homeless
children in the community?
The children are underimmunized and at a risk for childhood illnesses.
The children are more likely to drop out of school and become unemployable.
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The children have access to health care only through the emergency
department.
The children do not have a physical shelter and may sleep outdoors or in
vehicles.
Rationale
Public health organizations use the term absolute homelessness to describe people
who have no physical shelter. These children sleep outdoors, in vehicles, abandoned
buildings, or other places not intended for human habitation. Relative homelessness
describes those who have a physical shelter but one that does not meet the standards
of health and safety. Children from both sections of the community tend to be
underimmunized and are at risk for childhood illnesses. Both types of homeless
children are unable to meet residency requirements for public schools and are more
likely to drop out of school and be rendered unemployable. A lack of finances leads
both types of homeless children to seek health care only in emergency conditions.
Which phase of disaster management would the nurse be executing
when teaching hygiene practice and symptoms of infections to victims
of a hurricane?
Mitigation
Response
Evaluation
Preparedness
Rationale
Mitigation is the attempt to limit a disaster's impact on human health and community
functions. Educating the client about the rapid spread of infectious diseases and
various hygiene methods that can be adopted in such conditions will help limit the
impact of the disaster. Response is the actual implementation of the disaster plan.
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Evaluation involves identifying successes and failures of the response effort to prepare
for the future. Preparedness is the protective plan designed before the occurrence of a
disaster to assess the risk and evaluate the potential damage.
A nurse administers an intramuscular analgesic against the will of a
terminally ill client. Which crime would the nurse be charged with in
this situation?
Assault
Battery
Invasion of privacy
Lack of informed consent
Rationale
Battery is the intentional touching of one person by another without permission of the
person being touched. Assault is an intentional act without touching that makes a
person fearful or produces reasonable apprehension of bodily harm. Invasion of
privacy refers to abusing the right of clients to have their private affairs protected.
Informed consent applies to permission for procedures and treatments to be
performed.
How many milliliters per hour would the nurse set the volume control
device to deliver an intravenous infusion of 800 mL per 24 hours?
38 mL
33 mL
28 mL
23 mL
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Rationale
The volume control device should be set at 33 mL per hour; 800 mL divided by 24
hours equals 33 mL per hour. A rate of 38 mL per hour is too fast; rates of 23 and 28
mL per hour are too slow.
Filgrastim 5 mcg/kg per day by injection is prescribed for a client who
weighs 132 lb (60 kg). The vial label reads filgrastim 300 mcg/mL. How
many milliliters would the nurse administer? Record your answer using
a whole number.
1
mL
Rationale
The prescribed dose is 5 mcg/kg. The client’s weight is 60 kg. The available
concentration is 300 mcg/mL. Use the dimensional analysis and/or ratio and
proportion methods to determine the appropriate amount of medication to be
administered.
Test-Taking Tip: When taking the NCLEX exam, an on-screen calculator will be
available for you to determine your response, which you will then type in the provided
space.
Which statement by a newly hired nurse indicates that this nurse is
knowledgeable about a computer-based client information system?
"More medication errors are made when this system is used."
"It is disappointing that nurses are not allowed to use this system."
"Client information is immediately available when this system is used."
"I will have less time to provide direct care to my clients with this system."
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Rationale
The intent of these systems is to streamline documentation and record keeping for all
appropriate health team members, including nurses. There is a reduction in
medication errors with this type of system. Data are immediately available to
appropriate health team members without the need to depend on record/chart
availability. The intent of these systems is to streamline documentation and record
keeping, thus, increasing opportunities for more direct client care by nurses.
Which competency does the nurse display when gathering data about
the success of side rails in fall reduction according to the Institute of
Medicine (IOM) competencies of the 21st century?
Using informatics
Applying quality improvement
Using evidence-based practice
Working in interdisciplinary teams
Rationale
According to the IOM competencies of the 21st century, nurses are required to
incorporate quality improvement into their work. A nurse performs this task by
identifying potential hazards, designing interventions to improve quality, and
evaluating the success of the strategies. In the given situation, the nurse is evaluating
the success of a strategy to minimize clients' risks of falls. Using informatics involves
the use of information technology for the purposes of communication, management
of knowledge, and reduction of errors. Using evidence-based practice involves
participating in research activities and integrating results of research with client care. A
nurse is required to work with interdisciplinary teams to provide better care to clients.
This action is done by cooperating and collaborating with the client, caregivers, and
other health care workers.
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Which task would be delegated to the unlicensed assistive personnel
(UAP) when caring for a hospitalized client with a high fever? Select all
that apply. One, some, or all responses may be correct.
Assessing the vital signs
Performing all hygiene tasks
Administering oral medications
Helping the client in changing clothes
Administering intravenous medications
Rationale
The UAP does all the hygiene tasks and also helps in changing the clothes. Vital signs
may be taken by UAP, but they must be reported to the nurse for assessment.
Administering the intravenous medications is performed by the registered nurse.
Administrating oral medication is performed by the licensed practical nurse.
Which action would the triage officer do first when five shooting victims
identified as needing urgent care arrive in the emergency department
(ED)?
Triage the victims.
Conduct laboratory testing.
Type and crossmatch for blood transfusions.
Notify next of kin that the victims are at the emergency department.
Rationale
The triage officer rapidly evaluates each person who presents to the hospital, even
those who come in with triage tags in place. Client acuity is reevaluated for appropriate
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disposition to the area within the ED or hospital best suited to meet the client's
medical needs. The clients will need to be triaged before being sent to the operating
room. The triage officer would not be responsible for conducting laboratory testing
(such as type and crossmatch for blood transfusions) or notifying the next of kin of the
victims.
Which documentation supports the finding of a pulse deficit?
Blood pressure of 130/70 mm Hg, indicating pulse deficit of 60
Capillary refill greater than 3 seconds, indicating pulse deficit
Apical pulse 86 and radial pulse 78, indicating pulse deficit of 8
Radial pulse 80 and pedal pulse 70, indicating pulse deficit of 10
Rationale
The apical rate is more rapid than the radial rate when a pulse deficit exists. An apical
pulse of 86 with a radial pulse of 78 is a pulse deficit of 8. A blood pressure of 130/70
mm Hg is a pulse pressure of 60. Capillary refill greater than 3 seconds indicates
circulation is sluggish. A radial pulse of 80 and a pedal pulse of 70 do not indicate a
pulse deficit; a pulse deficit is the difference between the apical and peripheral pulses.
Which action would the nurse advise an older client to take who reports
feeling light-headed when getting out of bed?
Slide slowly to the floor to prevent a fall and injury.
Sit on the edge of the bed while holding the client upright.
Bend forward to increase blood flow to the brain.
Lie down quickly so the legs can be raised above the heart level.
Rationale
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Sitting allows the nurse to support the client until orthostatic hypotension subsides.
The client's stable pulse and color indicate that the situation does not warrant placing
the client in the supine position. Sliding slowly to the floor to prevent a fall and injury,
bending forward, or lying down quickly will permit flexion of the vertebrae, which may
traumatize the spinal cord. A light-headed feeling usually is transient until the body
adapts to the upright position, so leg elevation is unnecessary.
Which diagnosis would the nurse ensure receives immediate care?
Sprains
Open fractures
Cold symptoms
Closed fractures
Rationale
Clients with open fractures should be provided with immediate care because it is an
emergency situation. Clients with sprains and cold symptoms can be established for a
lower priority of care. Clients with closed fractures should be given second priority for
care.
Which action would the nurse take first when planning to provide a back
massage to a client?
Assist the client into an appropriate position.
Start massaging the client as soon as possible.
Assess the client's preference for touch and massage.
Provide information regarding the massage procedure.
Rationale
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The nurse should first assess the client's preference for touch and massage when
planning to give a back massage. The nurse can assist the client into an appropriate
position, but only after assessing the client's preference for touch and massage. The
nurse can start the massage, but only after knowing the client's perspective on touch.
The nurse can provide information regarding the massage, but only after assessing the
client's preferences.
A nurse overhears an unlicensed assistive personnel (UAP) talking with a
client about the client's marital and family problems. Which statement
would the nurse identify as the UAP providing the client with false
reassurance?
"I agree; I think you should get a divorce."
"Everything will be fine; just wait and see."
"You should be glad that you have such a loving family."
"In the scheme of things, you do not have a major problem."
Rationale
Saying that everything will be fine provides false hope. Agreeing with the client is an
example of offering approval. Commenting on how a client should feel is an example
of being judgmental. Implying that the problem is minor is an example of minimizing.
Which indication best demonstrates that the nurse-client interaction
has been therapeutic after a client becomes hostile from learning that
an amputation of a gangrenous toe is being considered?
Increased physical activity
Absence of emotional outbursts
Relaxation of tensed muscles
Denial of the need for further discussion
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Rationale
Relaxation of muscles and facial expression are examples of nonverbal behavior;
nonverbal behavior is an excellent index of feelings because it is less likely to be
consciously controlled. Increased activity may be an expression of anger or hostility.
Clients may suppress verbal outbursts despite feelings and become withdrawn.
Refusing to talk may be a sign that the client is just not ready to discuss feelings.
Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable
under ordinary circumstances and that the action can be carried out in the given
situation.
Which definition of battery would the nurse include when teaching
about child abuse?
Maligning a person's character while threatening to do bodily harm
A legal wrong committed by one person against property of another
The application of force to another person without lawful justification
Behaving in a way that a reasonable person with the same education would
not
Rationale
Battery means touching in an offensive manner or actually injuring another person.
Battery refers to actual bodily harm rather than threats of physical or psychological
harm. It refers to harm against persons instead of property. Behaving in a way that a
reasonable person with the same education would not is the definition of negligence.
Which interpretation describes the behavior of a nurse who ties the
arms of a toddler with intensely itching arms with eczema to the crib
sides and exclaims "I’m going to teach you one way or another"?
These actions can be construed as assault and battery.
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The problem was resolved with forethought and accountability.
Skin must be protected, and the actions taken were by a reasonably prudent
nurse.
The nurse had tried to reason with the toddler and expected understanding
and cooperation.
Rationale
Assault is a threat or an attempt to do violence to another, and battery means touching
an individual in an offensive manner or actually injuring another person. The nurse's
behavior demonstrates anger and does not take into account the growth and
developmental needs of children in this age group. Although the behavior (scratching)
needs to be decreased, this can be done with mittens, not immobilization. A toddler
does not have the capacity to understand cause (scratching) and effect (bleeding).
Test-Taking Tip: Look for options that are similar in nature. If all are correct, either the
question is poorly written or all options are incorrect, the latter of which is more likely.
Example: If the answer you are seeking is directed to a specific treatment and all but
one option deal with signs and symptoms, you would be correct in choosing the
treatment-specific option.
Which term would the nurse use for soft, crackling, bubbling breath
sounds more obvious on inspiration?
Vesicular
Bronchial
Crackles
Rhonchi
Rationale
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Crackles are abnormal breath sounds described as soft, crackling, bubbling sounds
produced by air moving across fluid in the alveoli. Vesicular breath sounds are normal.
They are quiet, soft, and inspiration sounds that are short and almost silent on
expiration. They are heard over the lung periphery. Bronchial breath sounds are
normal and consist of a full inspiration and expiratory phase with the expiratory phase
being louder. They are heard over the trachea and large bronchi of the lungs. Rhonchi
are abnormal breath sounds heard over the large airways of the lungs. They consist of
a low pitch and are caused by the movement of secretions in the larger airways; they
usually clear with coughing.
Which group is primarily protected under the regulations of the practice
of nursing?
The public
Practicing nurses
The employing agency
People with health problems
Rationale
Each state or province protects the health and welfare of its populace by regulating
nursing practice. Although the members of the nursing profession can benefit also
from a clear description of their role, this is not the primary purpose of the law. The
employing agency does assume responsibility for its employees, and therefore,
benefits from maintenance of standards, but this is not the purpose of the law. People
with health problems are just one portion of the population that is protected; this
answer is too limited.
Which consideration would the nurse take into account when adjusting
the intravenous (IV) drip rate using gravity?
Total volume of fluid in the IV bag
Size of the needle or catheter in the vein
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Drops per milliliter delivered by the infusion set
Diameter of the tubing being used to instill the fluid
Rationale
Different infusion sets deliver different preset numbers of drops per milliliter. Knowing
this is a necessity for calculating the drip rate. Total volume of fluid in the IV bag and
size of the needle or catheter in the vein do not determine the drip rate. Diameter of
the tubing being used to instill the fluid determines the size of the drop, not the drip
rate.
Test-Taking Tip: Do not panic while taking an exam! Panic will only increase your
anxiety. Stop for a moment, close your eyes, take a few deep breaths, and resume
review of the question.
The health care provider has prescribed enoxaparin 1 mg/kg for a client
who had a total knee replacement. The client weighs 187 lb (85 kg). This
medication is available in a concentration of 30 mg per 0.3 mL. Which
dose would the nurse administer in milliliters?
0.8 mL
0.85 mL
0.9 mL
0.95 mL
Rationale
The answer is calculated as follows: 1 kg = 2.2 lb. (187 divided by 2.2 = 85 kg.) 30
mg/0.3 mL = 100 mg/mL. Prescribed dose is 1 mg/kg, so the client needs 85 mg
because the client weighs 85 kg. 100 mg: 1 mL :: 85 mg: x mL. 100x = 85. x = 0.85 mL.
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Test-Taking Tip: Be aware that information from previously asked questions may help
you respond to other exam questions.
During which time period would the nurse advise a client with a long
leg cast for a fractured bone to take the as-needed oxycodone?
Just as a last resort
Before going to sleep
As the pain becomes intense
When the discomfort begins
Rationale
Pain is most effectively relieved when an analgesic is administered at the onset of pain,
before it becomes intense; this prevents a pain cycle from occurring. Analgesics are
less effective if administered when pain is at its peak. Before going to sleep, it may or
may not be necessary; the medication should be taken when the client begins to feel
uncomfortable within the parameters specified by the health care provider's
prescription. Analgesics are less effective if administered when pain is at its peak.
Test-Taking Tip: Being prepared reduces your stress or tension level and helps you
maintain a positive attitude.
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A client had surgery on the shoulder, and the nurse is to obtain a
brachial pulse. Which area in the illustration is best to palpate to obtain
the brachial pulse rate?
a
b
c
d
Rationale
One of the several pulse points in the body is the brachial artery (option b); it is the
main artery of the upper arm, and it bifurcates into the radial and ulnar arteries.
Option a is not a major artery of the arm; it is not a pulse point. Option c is the radial
artery, which is where the radial pulse is palpated. Option d is the ulnar artery, which is
where the ulnar pulse is palpated.
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Which nursing action is inappropriate while caring for different clients
after a disaster?
Teaching and supervising volunteers
Providing on-site first aid and emergency care
Evacuating injured and uninjured people from a danger area
Teaching clients about procedures that are needed for safety
Rationale
After a disaster, evacuating the injured and uninjured people from the danger area and
placing them in a safer place is done by firefighters and other disaster-trained
emergency personnel. Nurses should not perform this action because they are not
provided with specific rescue training. The nurse should teach and supervise
volunteers to effectively perform during disasters. The nurse should provide on-site
first aid treatment to the clients. The nurse should also perform the emergency care at
the disaster site. Teaching the client about safety measures at home is appropriate.
Which statement defines a one-on-one communication between a
nurse and another person?
Small-group communication
Intrapersonal communication
Interpersonal communication
Transpersonal communication
Rationale
Interpersonal communication is a one-on-one interaction between a nurse and
another person that often occurs face to face. Small-group communication is
interaction that occurs when a small number of people meet. Intrapersonal
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communication is a form of communication that occurs within an individual.
Transpersonal communication is an interaction that occurs within a person's spiritual
domain.
Which role is a nurse playing when helping a client to clarify health
problems and choose the appropriate courses of action?
Educator
Caregiver
Counselor
Epidemiologist
Rationale
When a nurse is helping a client to identify and clarify health problems and choose
appropriate courses of action to solve those problems, the nurse is acting as a
counselor. The nurse acts as an educator by establishing relationships with community
service organizations. The nurse acts as an epidemiologist when he or she is involved
in case finding, health teaching, and tracking incident rates of an illness. The nurse
acts as a caregiver when he or she provides appropriate, individualized nursing care for
specific clients and their families.
Test-Taking Tip: Avoid taking a wild guess at an answer. However, should you feel
insecure about a question, eliminate the alternatives that you believe are definitely
incorrect, and reread the information given to make sure you understand the intent of
the question. This approach increases your chances of randomly selecting the correct
answer or having a clearer understanding of what is being asked. Although there is no
penalty for guessing, the subsequent question will be based, to an extent, on the
response you give to the question at hand; that is, if you answer a question incorrectly,
the computer will adapt the next question based on your knowledge and skill
performance on the exam up to that point.
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Which task performed by the nurse would satisfy the Institute of
Medicine’s (IOM) patient-centered care competency? Select all that
apply. One, some, or all responses may be correct.
Relieving pain and suffering
Identifying errors and hazards in care
Participating in research activities when possible
Communicating with and educating clients effectively
Recognizing and respecting differences in clients' values, preferences, and
needs
Rationale
According to the IOM, providing patient-centered care includes relieving pain and
suffering, communicating with and educating clients effectively, and recognizing and
respecting differences in clients’ values, preferences, and needs. Identifying errors and
hazards in care is a part of applying quality improvement. Using evidence-based
practice includes participating in research activities when possible.
STUDY TIP: Focus your study time on the common health problems that nurses most
frequently encounter.
The health care provider prescribes 1000 mL of total parenteral nutrition
to be administered in 12 hours. Based on this prescription, which
dosage of solution would be administered per hour?
83 mL per hour
100 mL per hour
108 mL per hour
125 mL per hour
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Rationale
The correct calculation is 83 mL per hour; 1000 mL of solution divided by 12 hours
equals 83.3 mL per hour. Always round to the nearest whole number. One hundred
mL per hour is an incorrect calculation; it is too much solution per hour. Also, 108 mL
per hour is an incorrect calculation; it is too much solution per hour. Additionally, 125
mL per hour is an incorrect calculation; it is too much solution per hour.
Which instruction is most important for the nurse to include when
providing discharge instructions to a client related to urinary selfcatheterization?
"Wear sterile gloves when doing the procedure."
"Wash your hands before performing the procedure."
"Perform the self-catheterization every 12 hours."
"Dispose of the catheter after you have catheterized yourself."
Rationale
To avoid transferring organisms to the urinary system, the client is taught to wash his
or her hands thoroughly with soap and water before inserting a clean catheter. Sterile
gloves are not required for this procedure in the home care setting. Every 12 hours is
too long of a time frame between catheterizations. The client should be taught to
recognize when self-catheterization is needed and develop a 2- to 3-hour
catheterization schedule. Some home care settings may require the client to clean and
reuse catheters.
Which statement would be an appropriate response by the nurse when
coworkers inquire about test results of a friend being cared for by the
nurse?
Answer the questions softly so other people will not hear.
Decline to discuss the friend's medical condition.
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Give the coworker the name of the client's health care provider so the
coworker can contact the provider instead.
To provide reassurance, tell the coworker of the friend's test results that are
within normal limits.
Rationale
All client health information in this situation is confidential, regardless of the
relationship of the employee to the client. Therefore, declining to discuss this
information and suggesting visiting the client are the best responses. It is especially
important that answering any questions regarding the client's status or test results,
including names and room number, not be discussed in public places to maintain the
client's right to confidentiality. The client's health care provider should also follow the
same procedure regarding discussion of a client.
Test-Taking Tip: Calm yourself by closing your eyes, putting down your pencil (or
computer mouse), and relaxing. Deep-breathe for a few minutes (or as needed, if you
feel especially tense) to relax your body and to relieve tension.
Which ethical principle does the client's behavior illustrate when
deciding to have hospice care rather than an extensive surgical
procedure?
Justice
Veracity
Autonomy
Beneficence
Rationale
The client is exhibiting the freedom to make a personal decision, and this reflects the
concept of autonomy. Justice refers to fairness. Veracity refers to truthfulness.
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Beneficence refers to implementing actions that benefit others.
Which reason explains why quality improvement (QI) processes are
important to the nurse leader when executing QI processes in a team?
They involve chart audits.
They inspect nursing activities.
They discover and correct errors.
They review the nursing activities.
Rationale
QI processes improve quality by reviewing nursing activities. Quality assurance (QA)
processes involve chart audits. QI processes will review nursing activities but will not
inspect them. Inspection of nursing activities is done during the QA process. The QA
process discovers and corrects errors, whereas the QI process prevents errors.
STUDY TIP: Do not change your pattern of study. It obviously has contributed to your
being here, so it worked. If you have studied alone, continue to study alone. If you
have studied in a group, form a study group.
Which health belief system is being applied when the family member of
a client with depression believes the client would benefit from aromatic
therapy, more so than from medications?
Folk health
Holistic health
Biomedical health
Alternative or complementary health
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Rationale
A client who opts for nonmedical treatment methods such as aromatic therapy
probably has an alternative or complementary health belief system. In a folk health
belief system, rituals or repentance may be used to treat the client. In a holistic health
belief system, the client’s family would look for ways to restore balance in the physical,
social, and metaphysical worlds surrounding the client. A family member who believes
in biomedical treatment would accept the medications for the client.
Test-Taking Tip: You have at least a 25% chance of selecting the correct response in
multiple choice items with four options. If you are uncertain about a question,
eliminate the choices you believe are wrong, and then call on your knowledge, skills,
and abilities to choose from the remaining responses.
Which statement about Lutheranism religious beliefs and health care
practices is true? Select all that apply. One, some, or all responses may
be correct.
Blood transfusions are not allowed because they violate God’s law.
Emergency baptisms are performed for newborns with a grave prognosis.
Adults may be baptized via the sprinkling, pouring, or immersion method.
A client with a poor prognosis may request an anointing and a blessing from
the minister.
Anyone 14 years of age or older must abstain from eating meat on Ash
Wednesday and on all Fridays during Lent.
Rationale
In the Lutheran faith, adults may be baptized. Appropriate modes of baptism include
sprinkling, pouring, and immersion. Lutheran clients sometimes request an anointing
and a blessing from the minister when the prognosis is poor. In the Roman Catholic
faith, emergency baptisms are required for newborns with a grave prognosis. Jehovah’s
Witnesses believe that blood transfusions violate God’s law. Roman Catholic beliefs
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specify that anyone 14 years of age or older must abstain from eating meat on Ash
Wednesday and on all Fridays during Lent.
Which term does the documentation of a pulse with a strength of 3+
describe?
It is diminished.
It is normal.
It is full.
It is bounding.
Rationale
The strength of a pulse is a measurement of the force at which blood is ejected against
the arterial wall. A 3+ rating indicates a full increased pulse. A zero rating indicates an
absent pulse. A rating of a 1+ indicates a diminished pulse that is barely palpable. A 2+
rating is an expected/normal pulse, and a 4+ rating is a bounding pulse.
The nurse is about to meet the family of a client in hospice care who is
near death. The nurse is aware that the client’s family belongs to the
Jewish faith. Which religious belief may the client’s family hold?
The client’s family is likely to prefer cremation to burial.
A witness must be present if the client chooses to pray for health.
The client or visitors should initiate any conversation about death.
The client or family will ask for a local pastor to come pray and provide
scripture readings.
Rationale
In observant Judaism, a witness must be present when a person prays for health so if
death occurs, God can protect the family and the spirit can be committed to God.
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Among members of the Unitarian Universalist Association, cremation or
embalming/burial is preferred. Observant Judaism does not encourage extraneous
conversations about death unless initiated by the client or visitors. A person belonging
to the Presbyterian Church might ask the nurse to notify a local pastor or elder to
come pray and provide scripture readings.
Which belief is true regarding birth control and abortion for Jewish
clients?
Vasectomy is preferred over contraception.
Abortion is allowed when the mother’s life is in danger.
Condoms are encouraged to control the birth rate.
Medical contraceptives are the preferred form of birth control.
Rationale
Judaism allows abortion if the life of the mother is in danger. Vasectomy is strictly
prohibited in Judaism. The use of artificial means of birth control methods such as
condoms and contraceptives are not encouraged in Judaism.
The registered nurse is discussing with a licensed practical nurse (LPN)
how to communicate with a client with hearing loss. Which statement
made by the LPN indicates a need for further discussion?
"I will face the client with my mouth visible to the client."
"I will provide a sign language interpreter to communicate."
"I will rephrase the sentence if the client misunderstands it."
"I will reduce any environmental noise while communicating."
Rationale
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When planning with the registered nurse, the LPN should find out how extensive the
client’s hearing loss is. A sign language interpreter may not be necessary. However, the
LPN’s other statements are appropriate for a client with hearing loss: The nurse should
face the client with his or her mouth visible to the client. The nurse should rephrase
the sentence rather than repeating it if the client misunderstood the first time. The
nurse should reduce any environmental noise while communicating.
Which population is eligible for the Medicare insurance program?
Select all that apply. One, some, or all responses may be correct.
Disabled individuals
Low-income children
Clients receiving dialysis
People older than 65 years
Uninsured pregnant women
Rationale
Medicare covers disabled people, dialysis clients, and clients older than 65 years of
age. Medicaid insurance programs cover low-income children and uninsured pregnant
women.
Test-Taking Tip: Identify option components as correct or incorrect. This may help you
identify a wrong answer.
Which system would pay for a hip replacement for a low-income client
after a hip fracture?
Medicaid
Medicare
Prospective payment system (PPS)
Health maintenance organizations (HMO)
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Rationale
A daily wage worker may have a low socioeconomic status. Because the Medicaid
program pays for home-care services to low-income people of all ages, the client may
apply for this service. To receive Medicare services, the beneficiary would be disabled,
have end-stage renal disease, or be 65 years of age or older. Clients with a prospective
payment system (PPS) pay a set rate based on major diagnostic categories and
diagnosis-related groups (DRGs). A health maintenance organization (HMO) offers
prepaid health plans; they operate independently or through employer groups.
Which system has guidelines that include provision of physical
assistance only 2 hours per day?
Medicare
Third party
Private pay
Preferred provider organization
Rationale
For Medicare, aide services are provided in blocks of time ranging from 1 to 2 hours.
Third party, private party, and preferred provider organizations may allow a provision
of services for 8 to 24 hours.
Which of the four clients would qualify for home health services under
Medicaid?
A 40-year-old client with diabetes
A client with end-stage renal disease
A low-income client in the last stage of cancer
A 70-year-old client with cardiovascular disease
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Rationale
Medicaid provides benefits to poor people for all age groups. Therefore, a poor client
in the end stages of cancer would qualify for Medicaid.
Which organizational care suggested by the primary health care
provider is most appropriate for a client who has terminal breast cancer
and a life expectancy of 6 months?
Hospice
Palliative
Subacute
Long-term
Rationale
Hospice care would be appropriate for a client with a terminal illness and life
expectancy of 6 months. Palliative care is available to clients at any time and any stage
of illness. Subacute care is designed to transition a client out of acute care. Long-term
care is provided to clients with chronic illnesses or disabilities.
Test-Taking Tip: Multiple choice questions can be challenging, because students think
that they will recognize the right answer when they see it or that the right answer will
somehow stand out from the other choices. This is a misconception. The more
carefully the question is constructed, the more each of the choices will seem like the
correct response.
While assessing the body temperature of a client, the nurse finds the
client has a subnormal temperature. Which intervention is beneficial for
the client?
Administering acetaminophen
Covering the client with blankets
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Assessing for a headache, thirst, and chills
Assessing for a possible site of localized infection
Rationale
When a client’s temperature is subnormal, the nurse should cover the client with
more blankets. Acetaminophen is not appropriate for a subnormal temperature; it is
appropriate for an elevated temperature. If the client’s temperature is elevated, the
nurse should further assess for a headache, thirst, and chills. When the client’s
temperature is above normal, the nurse should assess for a possible site of infection.
Which statement is true regarding home health care organizations?
Select all that apply. One, some, or all responses may be correct.
The Visiting Nurse Association is an example of a home health agency.
Home health service organizations are typically nonprofits.
Individual payments may help fund home health services.
Physical therapy is a secondary skill of the home health service worker.
Occupational therapy is a primary skill of the home health service worker.
Rationale
The Visiting Nurse Association is an example of a home health agency. Home health
care services are funded by individual payments, private insurance, Medicare, and
Medicaid; therefore, they are for-profit organizations, not nonprofits. Physical therapy
is a primary (not secondary) skill, and occupational therapy is a secondary (not primary)
skill for home health workers.
1 topics covered
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Basics of Nursing Practice
Novice
PN Content Area / Fundamentals of Nursing
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