HESI - Fundamentals

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

.A Rationale: The client has demonstrated a purposeful response to pain, which should be documented as such. Response to painful stimulus is assessed after response to verbal stimulus, not before. There is no indication for placing the client on seizure precautions. Reporting decorticate posturing to the health care provider is nonpurposeful movement.

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

B Rationale: The most accurate respiratory rate is the second count obtained by the nurse, which was not interrupted by coughing. Because it was counted for 30 seconds, the rate should be doubled. Options A, C, and D are inaccurate recordings.

The nurse is obtaining a lie-sit-stand blood pressure reading on a client. Which action is most important for the nurse to implement? A. Stay with the client while the client is standing. B. Record the findings on the graphic sheet in the chart. C. Keep the blood pressure cuff on the same arm. D. Record changes in the client's pulse rate.

A Rationale: Although all these measures are important, option A is most important because it helps ensure client safety. Option B is necessary but does not have the priority of option A. Options C and D are important measures to ensure accuracy of the recording but are of less importance than providing client safety.

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.

A Rationale: Active listening is conveyed using attentive verbal and nonverbal communication techniques. To facilitate therapeutic communication and attentiveness, the nurse should sit facing the client, 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 option B, and leaning toward the client, not option D. To communicate involvement and willingness to listen to the client, eye contact should be established and maintained.

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.

A Rationale: 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 bedpan is not necessary as long as safety is ensured. Whether the client needs to void or have a bowel movement, option 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.

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

A Rationale: Black sticky stool (melena) is a sign of gastrointestinal bleeding and should be reported to the health care provider promptly. Option C indicates constipation, which is a lesser priority. Options B and D are variations of normal.

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

A Rationale: In the Roman Catholic religion, any type of abortion is prohibited, 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. Jehovah's Witnesses, not Seventh-Day Adventists, prohibit blood transfusions. There is no conflict in the Muslim faith with regard to joint replacement.

A hospitalized client has had difficulty falling asleep for two nights and is becoming irritable and restless. Which action by the nurse is best? A. Determine the client's usual bedtime routine and include these rituals in the plan of care as safety allows. B. Instruct the UAP not to wake the client under any circumstances during the night. C. Place a "Do Not Disturb" sign on the door and change assessments from every 4 to every 8 hours. D. Encourage the client to avoid pain medication during the day, which might increase daytime napping.

A Rationale: Including habitual rituals that do not interfere with the client's care or safety may allow the client to go to sleep faster and increase the quality of care. Options B, C, and D decrease the client's standard of care and compromise safety.

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

A Rationale: Lightning is a jolt of electrical current and can produce a "natural" defibrillation, so assessment of the pulse rate and regularity is a priority. Because the client is talking, he has an open airway, so that assessment is not necessary. Assessing for options C and D should occur after assessing for adequate circulation.

The nurse 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

A Rationale: Long-term protein deficiency is required to cause significantly lowered serum albumin levels. Albumin is made by the liver only when adequate amounts of amino acids (from protein breakdown) are available. Albumin has a long half-life, so acute protein loss does not significantly alter serum levels. Option B is a serum protein with a half-life of only 8 to 10 days, so it will drop with an acute protein deficiency. Options C and D are not clinical measures of protein malnutrition.

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.

A Rationale: Nocturia is urination during the night. Option A is helpful to decrease the production of urine, thus decreasing the need to void at night. Option B helps prevent bladder infections. Option C may promote sleep, but the fluid will contribute to nocturia. Option D may result in urinary incontinence if the client is sedated and does not awaken to void.

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.

A Rationale: Obtaining a subjective estimate of the pain experience by asking the client to rate his pain helps the nurse determine which pain medication should be administered and also provides a baseline for evaluating the effectiveness of the medication. Medicating for pain should not be delayed so that it can be used as a sleep medication. Option C is judgmental. Option D should be used as an adjunct to pain medication, not instead of medication.

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."

A Rationale: Option A offers an open-ended question most relevant to the client's statement. Option B does not offer the client the opportunity to express concerns. Options C and D are even less relevant to the client's statement.

The nurse-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.

A Rationale: Performing range-of-motion exercises is beneficial in reducing contractures around joints. Options B, C, and D are all potentially harmful practices that place the immobile client at risk of complications.

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.

A Rationale: The amount and appearance of the client's urine output is within normal limits, so the nurse should record the output, but no additional action is needed.

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.

A Rationale: The best action to decrease the risk of infection in vulnerable clients is handwashing. Option B is not necessary unless the client has an infection. Option C increases the risk of infection. Option D does not reduce the risk of infection.

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.

A Rationale: The client is exhibiting normal grieving behaviors, so referral to a grief counselor is the most important intervention for the nurse to implement. Option B is indicated but is not a high-priority intervention. Option 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, 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.

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

A Rationale: The contaminated gloves serve as the mode of transmission from the portal of exit of the reservoir to a portal of entry.

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.

A Rationale: To prevent burns or excessive chilling, the nurse must check the bath water temperature. Options B, C, and D promote comfort and privacy and are important interventions but are of less priority than promoting safety.

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.

A, B Rationale: The correct answers (A and B) are the appropriate administration of ear drops. The dropper should be held 1 cm (½ inch) above the ear canal (C). A cotton ball should be placed in the outermost canal (D). The auricle is pulled down and back for a child younger than 3 years of age, but not an adult (E).

The nurse 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 position. B. Help the client 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.

A, D Rationale: (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).

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

B Rationale: Anticoagulants increase the risk for bleeding during surgery, which can pose a threat for the development of surgical complications. The health care provider should be informed that the client is taking these drugs. Although clients who take birth control pills may be more susceptible to the development of thrombi, such problems usually occur postoperatively. A client with option C or D is at less of a surgical risk than with option B.

The nurse plans to administer diazepam, 4 mg IV push, to a client with severe anxiety. How many milliliters should the nurse administer? (Round to the nearest tenth.) A. 0.2 mL B. 0.8 mL C. 1.25 mL D. 2.0 mL

B Rationale: (1 mL × 4 mg)/5 mg = 0.8 mL

After a needle stick 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.

B Rationale: After a needle stick, the needle is considered used, so the nurse should discard it and select another needle. 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 or notify the occupational health nurse. Disinfecting a needle with an alcohol swab is not in accordance with standards for safe practice and infection control.

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.

B Rationale: 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. Drug tolerance, protein binding, and the drug's therapeutic index are not affected by the change in route from PO to IV. In addition, an increased therapeutic index reduces the risk of drug toxicity.

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.

B Rationale: Because the nurse can only stand on one side of the bed, bed rails should be up on the opposite side to ensure that the client does not fall out of bed. Option A can cause client injury to the skin or joint. Options C and D are useful techniques while turning a client but have less priority in terms of safety than use of the bed rails.

The nurse identifies a potential for infection in a client with partial-thickness (second-degree) 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 handwashing technique C. Application of a topical antibacterial cream D. Limiting visitors to the client with burns

B Rationale: Careful handwashing technique is the single most effective intervention for the prevention of contamination to all clients. Option A reverses the hypovolemia that initially accompanies burn trauma but is not related to decreasing the proliferation of infective organisms. Options C and D are recommended by various burn centers as possible ways to reduce the chance of infection. Option B is a proven technique to prevent infection.

A nurse is assigned to care for a close friend in the hospital setting. Which action should the nurse take first when given the assignment? A. Notify the friend that all medical information will be kept confidential. B. Explain the relationship to the charge nurse and ask for reassignment. C. Approach the client and ask if the assignment is uncomfortable. D. Accept the assignment but protect the client's confidentiality.

B Rationale: Caring for a close friend can violate boundaries for nurses and should be avoided when possible (B). If the assignment is unavoidable (there are no other nurses to care for the client) then C, A, and D should be addressed.

The nurse 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

B Rationale: Clients with cholecystitis (inflammation of the gallbladder) should follow a low-fat diet, such as option B. Option A is a high-protein diet, and options C and D contain high-fat foods, which are contraindicated for this client.

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.

B Rationale: 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. Ambulatory clients do not require the assistance of a wheelchair to be evacuated. Elevators should not be used during a fire, and fire doors should be kept closed to help contain the fire.

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? A. Standing on his wife's strong side, the caregiver is ready to hold the gait belt if any evidence of weakness is observed. B. Standing on his wife's weak side, the caregiver provides security by holding the gait belt from the back. C. Standing behind his wife, the caregiver provides balance by holding both sides of the gait belt. D. Standing slightly in front and to the right of his wife, the caregiver guides her forward by gently pulling on the gait belt.

B Rationale: His wife is most likely to lean toward the weak side and needs extra support on that side and from the back to prevent falling. Options A, C, and D provide less security for her.

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.

B Rationale: Option B describes the correct positioning of the nurse and affords the nurse a wide base of support while stabilizing the client's knees when assisting to a standing position. The chair should be placed at a 45-degree angle to the bed, with the back of the chair toward the head of the bed. Clients should never be lifted under the axillae; this could damage nerves and strain the nurse's back. The client should be instructed to use the arms of the chair and should never place his or her arms around the nurse's neck; this places undue stress on the nurse's neck and back and increases the risk for a fall.

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

B Rationale: 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. The basilic vein of the arm is used for IV access, not the brachial vein, which is too deep to be accessed for IV infusion. Although veins on the dorsal side of the right wrist are visible, they are fragile and using them would be painful, so they are not recommended for IV access. Option D is not specific enough for documenting the location of the IV access.

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."

B Rationale: The medication should be inhaled through the mouth simultaneously with compression of the inhaler. This will facilitate the desired destination of the aerosol medication deep in the lungs for an optimal bronchodilation effect. Options A, C, and D do not allow for deep lung penetration.

A 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.

B Rationale: The most important teaching is to change positions frequently because pressure is the most significant factor related to the development of pressure ulcers. Increased vitamin and fluid intake may also be beneficial and promote healing and reduce further risk. Option D is an intervention of last resort because this will be very expensive for the client.

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.

B Rationale: The nurse should first assess the client's feelings about her death and determine the extent to which this statement expresses her true feelings. The client may need additional pain management, but further assessment is needed before implementing option A. Options C and D are both premature interventions and should not be implemented until further assessment is obtained.

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.

B Rationale: The nurse should first check the tubing and height of the bag on the IV pole, 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, but the nurse should first adjust the IV pole height. The nurse may need to adjust the stabilizing tape on a positional needle or flush the venous access with normal saline, but less invasive actions should be implemented first.

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.

B Rationale: This statement may indicate that the client is confused. Informed consent must be provided by a mentally competent individual, so the nurse should further assess the client's neurologic status to be sure that the client understands and can legally provide consent for surgery. Option A does not provide sufficient follow-up. If the nurse determines that the client is confused, the surgeon must be notified and permission obtained from the next of kin.

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.

B Rationale: 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. Option A ensures an accurate assessment, and option C provides the best access to the artery. Systolic pressure in the popliteal artery is usually 10 to 40 mm Hg higher than in the brachial artery.

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.

B Rationale: Wound care instructions should be given directly to the client by the nurse with an interpreter 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. Family members should not be used to translate instructions 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 to ensure that the nurse's instructions are understood accurately by the client.

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"

C Rationale: A health promotion brochure about decreasing cholesterol is most important to provide this client, because the most significant risk factor contributing to development of arteriosclerosis is excess dietary fat, particularly saturated fat and cholesterol. Option A does not address the underlying causes of arteriosclerosis. Options B and D are also important factors for reversing arteriosclerosis but are not as important as lowering cholesterol.

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 to provide? A. Orange juice has vitamin C that deters bacterial growth. B. Apple juice is the most useful in acidifying the urine. C. Cranberry juice stops pathogens' adherence to the bladder. D. Grapefruit juice increases absorption of most antibiotics.

C Rationale: Cranberry juice maintains urinary tract health by reducing the adherence of Escherichia coli bacteria to cells within the bladder. Options A, B, and D have not been shown to be as effective as cranberry juice in preventing UTIs.

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.

C Rationale: Deflating the cuff for 30 to 60 seconds allows blood flow to return to the extremity so that an accurate reading can be obtained on that extremity a second time. Option A could result in a falsely high reading. Option B reduces circulation, causes pain, and could alter the reading. Option D is not an accurate method of assessing blood pressure.

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.

C Rationale: It is likely that the first catheter is in the vagina, rather than the bladder. Leaving the first catheter in place will help locate the meatus when attempting the second catheterization. The client should have at least 240 mL of urine after 8 hours. Option A does not resolve the problem. Option B will not change the location of the catheter unless it is completely removed, in which case a new catheter must be used. There is no evidence of a urinary tract obstruction if the catheter could be easily inserted.

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."

C Rationale: Setting goals that bring pleasure is appropriate and should be encouraged by the nurse as long as the nurse does not perpetuate a client's denial. Option A is a negative response, implying that the client should not plan a party. Option 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.

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 Disabilities 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

C Rationale: The ANA Scope of Standards of Practice for Psychiatric-Mental Health Nursing serves to direct the philosophy and standards of psychiatric nursing practice. Options A and D define the client's rights. Option B provides ethical guidelines for nursing.

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.

C Rationale: The Good Samaritan Act protects health care professionals who practice in good faith and provide reasonable care from malpractice claims, regardless of the client outcome. Although the Patient's Bill of Rights protects clients, this nurse is protected by the Good Samaritan Act. The state Board of Nursing has no reason to revoke a registered nurse's license unless there was evidence that actions taken in the emergency were not done in good faith or that reasonable care was not provided. All four elements of malpractice were not shown.

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.

C Rationale: The foreskin (prepuce) of the penis should be gently retracted to cleanse all areas that could harbor bacteria. The child's cognitive development may not be at the level at which option A would be effective. Perineal care needs to be provided daily regardless of the client's age. Option D is not indicated and may be perceived as intrusive.

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."

C Rationale: The nurse needs to focus on the client's positive behaviors, so focusing on the client's demonstrated ability to self-administer the injection is likely to reinforce his level of competence without sounding punitive. Option A does not focus on the specific behaviors related to giving the injection and could be interpreted as punitive. Option 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. Option D reinforces the client's dependence on the nurse.

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.

C Rationale: The nurse should not give the medication and should document the reason because the client is a minor and needs a guardian's permission to receive medications. Permission to give medications is not granted by a signed hospital consent or a health care provider's permission, unless conditions are met to justify coerced treatment. Option D is not necessary unless the medication had previously been administered.

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.

C Rationale: The nurse should respond with a calm demeanor to help reduce the client's apprehension. After responding calmly to the client's apprehension, the nurse may implement to ensure safe completion of the procedure.

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.

C Rationale: The surgeon should be informed immediately that the permit is not signed. It is the surgeon's responsibility to explain the procedure to the client and obtain the client's signature on the permit. Although the nurse can witness an operative permit, the procedure must first be explained by the health care provider or surgeon, including answering the client's questions. The client's questions should be addressed before the permit is signed.

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.

C Rationale: This client may not routinely have a daily bowel movement, so the nurse should first assess this client's normal bowel habits before attempting any intervention. Option A, B, or D may then be implemented, if warranted.

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.

C Rationale: 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. Options A, B, and D are helpful to prevent other complications of immobility but are less effective in preventing venous thrombus formation than option C.

The nurse is preparing to administer 10 mL of liquid potassium chloride through a feeding tube, followed by 10 mL of liquid acetaminophen. 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.

C Rationale: Water should be instilled into the feeding tube between administering the two medications 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 when administered via a feeding tube and should be administered separately, with water instilled between each medication.

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.

D Rationale: Because a shower is most beneficial for the client in terms of hygiene, the client should receive teaching first, respecting any personal beliefs such as cultural or spiritual values. After client teaching, the client may still choose option A or B. Brochures reinforce the teaching.

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.

D Rationale: Comparing this reading with previous readings will provide information about what is normal for this client; this action should be taken first. Option A might unnecessarily alarm the client. Option B is premature. Further assessment is needed to determine if the reading is abnormal for this client. Option C could falsely decrease the reading and is not the correct procedure for obtaining a blood pressure reading.

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.

D Rationale: Health care providers may be found guilty of negligence, specifically assault and battery, if they carry out a treatment without the client's consent. The client's condition is stable, so option A is not a valid rationale. Advanced age does not automatically authorize the son to make all decisions for his mother, and there is no evidence that the client is mentally incompetent. Although option C may have been upheld in the past, when paternalistic medical practice was common, today's courts are unlikely to accept it.

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

D Rationale: Indwelling urinary catheters are a major source of infection. Options A and B are both problems that may require an indwelling catheter. Option C is not affected by an indwelling catheter.

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.

D Rationale: 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. The pharmacist does not prescribe medications or renew prescriptions. The nurse must have a current prescription before administering any medications.

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

D Rationale: Monitoring serum sodium levels for hyponatremia is indicated during prolonged NG suctioning because of loss of fluids. Changes in levels of option A, B, or C are not typically associated with prolonged NG suctioning.

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.

D Rationale: Observing the client directly will allow the nurse to determine if mastery of the skill has been obtained and provide an opportunity to affirm the skill. Option A may be therapeutic but will not provide an opportunity to evaluate the client's ability to perform the procedure. Option B may be threatening to an older client and will not determine his ability. Option C is not as effective as direct observation by the nurse.

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.

D Rationale: Option D is the most prudent intervention and is the priority nursing action to prevent injury to the client and the nurse. Lowering the client to the floor should be done when the client cannot support his own weight. The client should be placed in a bed or chair only when sufficient help is available to prevent injury. Option A is important but should be done after the client is in a safe position. Because the client is not supporting himself, option B is impractical. Option C is likely to cause chaos on the unit and might alarm the other clients.

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.

D Rationale: Option D provides an opportunity for the client to verbalize her concerns and provides the nurse with more assessment data. Options A and B may not be related to her current concern, assume that obesity is the problem, and are communication blocks. Option C may be appropriate after discussing the concerns she is having.

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.

D Rationale: Pain, anxiety, and increasing fluid accumulation in the lungs can cause tachypnea (increased respiratory rate). Encouraging the client to increase ambulation when the respiratory rate is rising above normal limits puts the client at risk for further oxygen desaturation. Option B can increase the client's carbon metabolism, so an alternative source of energy, such as Pulmocare liquid supplement, should be offered instead. Option C could increase respiratory congestion in a client with a poorly functioning cardiopulmonary system, placing the client at risk of fluid overload.

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

D Rationale: School-age children often resist bedtime. The nurse should begin by assessing the environment of the home to determine factors that may not be conducive to the establishment of bedtime rituals that promote sleep. Option A often causes daytime fatigue rather than resistance to going to sleep. Option B is unlikely to provide useful data. The nurse cannot determine option C.

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.

D Rationale: Solutions labeled as opened within 24 hours may be used for clean procedures, but only newly opened solutions are considered sterile. This solution is not newly opened and is out of date, so it should be discarded. Options A, B, and C describe incorrect procedures.

The 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.

D Rationale: The best nursing action is to discuss the client another time. Confidentiality must be observed at all times, so the nurse should not discuss the client when the conversation can be overheard by others. Details can identify the client when referring to the client by gender or age, even when not using the client's name.

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 member. D. Review the schedule of outdoor breaks with the client.

D Rationale: The best nursing action is to review the schedule of outdoor breaks and provide concrete information about the schedule. Option A is contraindicated if the client wants to continue smoking. Option B is insufficient to encourage a trusting relationship with the client. Option C is preferential for this client only and is inconsistent with unit rules.

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."

D Rationale: The client's recognition of a "new" pill requires further assessment 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. Although comments about cost should be considered when developing a discharge plan, option 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.

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 he is currently following.

D Rationale: The nurse should first evaluate whether the client has been adhering to the original instructions. A verbal report of the client's routine will provide more specific information than the client's written diary. The nurse can then determine which changes need to be made. The routine practiced by the client is clearly unsuccessful, so encouragement alone is insufficient.

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.

D Rationale: The nurse should first turn off the suction and then confirm placement of the tube in the stomach before instilling the medications. To prevent immediate removal of the instilled medications and allow absorption, the tube should be clamped for a period of time before reconnecting the suction.

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.

D Rationale: The nurse's first concern should be for the client's safety, so an immediate assessment of the client's situation is needed. Option A is incorrect; the nurse should implement the intervention. The nurse may offer to stay nearby after first assessing the situation more fully. Although option C may be correct, the nurse should determine if the client's safety is compromised and offer assistance, even if it is refused.

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.

D Rationale: 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 in the hallway. Option A helps promote alveolar expansion, reducing the risk for atelectasis. Option B reduces the risk for aspiration. Option C reduces the risk for postoperative infection.

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.

D Rationale: To ensure safe medication use, the nurse should encourage the client to call the nurse or health care provider if any questions arise. Options 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.