HESI Fundamental practice
The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands the dietary restrictions? A. Tossed salad, low-sodium dressing, bacon and tomato sandwich. B. New England clam chowder, no-salt crackers, fresh fruit salad. C. Skim milk, turkey salad, roll, and vanilla ice cream. D. Macaroni and cheese, diet Coke, a slice of cherry pie.
Answer: (C)Skim milk, turkey salad, roll, and vanilla ice cream.
8. The nurse observes an unlicensed assistive personnel (UAP) who is providing a total bed bath for a confused and lethargic client. The UAP is soaking the client's foot in a basin of warm water placed on the bed. What action should the nurse take? a. Remove the basin of water from the client's bed immediately b. Remind the UAP to dry between the client's toes completely c. Advise the UAP that this procedure is damaging to the skin d. Add skin cream to the basin of water while the foot is soaking
(B) is especially important in making sure the patient does not experience skin breakdown due to excessive moisture. Keeping the client's feet clean is necessary, but keeping the client's feet dry is extremely important in skin maintenance.
1. A policy requiring the removal of acrylic nails by all nursing personnel was implemented 6 months ago. Which assessment measure best determines if the intended outcome of the policy is being achieved? a. Number of staff induced injury b. Client satisfaction survey c. Health care-associated infection rate. d. Rate of needle-stick injuries by nurse.
(C)--Acrylic nails are known to carry loads of bacteria and increase the risk of healthcare-associated infections. Therefore, by banning the wearing of acrylic nails, you would expect the prevalence of healthcare-associated infections to decrease. Acrylic nails have nothing to do with staff induced injuries, needle-stick injuries, or patient satisfaction scores.
18. To avoid nerve injury, what location should the nurse select to administer a 3 mL IM injection? a. Ventrogluteal b. Outer upper quadrant of the buttock c. Two inches below the acromion process d. Vastus lateralis
(a)--2-3mL IM injections should always be made in the ventrogluteal area to minimize discomfort. this muscle is the deepest muscle in body
40. While suctioning a client's nasopharynx the nurse observes that the client's oxygen saturation remains at 94% which is the same reading obtained prior to starting the procedure. What action should the nurse take in response to this finding? a. Complete the intermittent suction of the nasopharynx. b. Reposition the pulse oximeter clip to obtain a new reading. c. Stop suctioning until the pulse oximeter reading is above 95%. d. Apply an oxygen mask over the client's nose and mouth
(a)--94% is perfect for suctioning! Only if you see the patient's O2 Stat drop below 90% is when you stop the suctioning and hyper-oxygenate the patient for a couple minutes. (B) not helpful. (C) it is ok to keep suctioning until you see a dip below 90% for O2. (D) not necessary at 94%.
10. At 0100 on a male client's second postoperative night, the client states he is unable to sleep and plans to read until feeling sleepy. What action should the nurse implement? a. Leave the room and close the door to the client's room b. Assess the appearance of the client's surgical dressing c. Bring the client a prescribed PRN sedative-hypnotic d. Discuss symptoms of sleep deprivation with the client
(a)--Although the patient has stated he is unable to sleep, the patient has also stated he has a plan, "to read until feeling sleep", which implies the patient plans to sleep. Therefore, (D) is not necessary and (C ) is very unnecessary because it is a stronger sleep aid. Offering melatonin would be more appropriate, but since it is not an option, (A) is correct. (B) does not help the client sleep in any way.
21. To prepare a client for the potential side effects of a newly prescribed medication, what action should the nurse implement? a. Assess the client for health alterations that may be impacted by the effects of the medication b. Teach the client how to administer the medication to promote the best absorption c. Administer a half dose and observe the client for side effects before administering a full dosage d. Encourage the client to drink plenty of fluids to promote effective drug distribution
(a)--Before a new medication is given, an initial assessment should be completed to create a baseline for the patient; then the RN will be able to re-evaluate the patient and see if there have been any health alterations caused by the new medication. (B) this has nothing to do with potential side effects. (C) You should always administer a new medication as prescribed by the MD. (D) The amount of fluids the patient drinks will not affect the drug distribution in the body.
35. When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next? a. Determine if the expected outcomes were realistic b. Obtain current client data to compare with expected outcomes c. Modify the nursing interventions to achieve the client's goals d. Review related professional standards of care
(a)--Before you can determine if care is effective you need to be sure the original expected outcomes were realistic. (B) This step comes after (A). (C) Comes after evaluating if the goals are effective and obtaining data. (D) Not necessary in this case.
Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention? A. Apply a condom catheter. B. Apply a skin protectant. C. Encourage increased fluid intake. D. Assess for bladder distention.
Answer: (D)Assess for bladder distention.
22. A client is 2 days post-op from a thoracic surgery and is complaining of incisional pain. The client last received pain medication 2 hours ago. He is rating his pain a 5 on a 1-10 scale. After calling the provider, what is the nurse's next action? a. Instruct the client to use guided imagery and slow rhythmic breathing b. Provide at least 20 minutes of back massage and gentle effleurage c. Encourage the client to watch TV. d. Place a hot water circulation device, such as an Aqua K pad, to operative site
(a)--If there are no other PRN pain medications available after an initial dose was given, it is most appropriate to call the provider, then switch to alternative pain management methods; like guided imagery and encouraging slow rhythmic breathing. (B) while massage may be helpful, it is inappropriate for incisional pain as it may open the sutures. (C) While distraction can help reduce pain, watching TV does not rid the patient of the pain. (D) NEVER place a circulation device on an operative site as it may open the sutures!
44. The nurse observes a UAP positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. Which action should the nurse implement? a. Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows b. Ensure that the UAP has placed pillows effectively to protect the client c. Ask the UAP to use some pillows to prop the client in a side-lying position d. Assume responsibility for placing the pillows while the UAP complete another task
(a)--In an ideal world, you would have seizure guard pads, but in the HESI world, you do not have it. SO! Pillows guarding the rails is dangerous and could suffocate your patient if they seizure and it falls and covers their face. Blankets secured to the side rails can be tied down to ensure they do not fall on the patient's face.
9. The nurse in the emergency department observes a colleague viewing the electronic health record (EHR) of a client who holds an elected position in the community. The client is not a part of the colleague's assignment. Which action should the nurse implement? a. Communicate the colleague's actions to the unit charge nurse b. Send an email to facility administration reporting the action c. Write an anonymous complaint to a professional website d. Post a comment about the action on a staff discussion board
(a)--Looking up patients who are not under your direct care is a HIPPA violation and may result in termination of employment, despite the patient's status in society or your curiosity. The first action to implement is to report to your Charge Nurse so he or she may report the incident to the appropriate chain of command.
11. The nursing staff in the cardiovascular intensive care unit are creating a continuous quality improvement project on social media that addresses coronary artery disease (CAD). Which action should the nurse implement to protect client privacy? a. Remove identifying information of the clients who participated b. Recall that authored content may be legally discoverable c. Share material from credible, peer reviewed sources only d. Respect all copyright laws when adding website content
(a)--Since the improvement project is being creating on a social media platform, it is imperative to have all names and patient identifiers removed to protect the client's identity and privacy. Any names posted, regardless of whether or not it is a social media platform or a peer-reviewed source is a HIPPA violation.
29. When performing blood pressure measurement to assess for orthostatic hypotension, which action should the nurse implement first? a. Position the client supine for a few minutes b. Assist the client to stand at the bedside c. Apply the blood pressure cuff securely d. Record the client's pulse rate and rhythm
(a)--The first step to measure orthostatic hypotension is to lie the patient down in a supine position for 3-5 minutes, and measure their blood pressure before having the patient sit up. (B) comes after a measurement is made while sitting. (C) should be done anyways. (D) This step should be done after each position change.
50. The nurse receives a report that a client with an indwelling urinary catheter has an output of 150 mL, for the previous 6 hour shift. Which intervention should the nurse implement first? a. Check the drainage tubing for a kink b. Review the intake and output record. c. Notify the healthcare provider d. Give the client 8 oz of water to drink
(a)--The minimum amount of output a patient should have for one hour is 30mL. In 6 hours, it should at least be 180mL. Since it is under, the first thing to do is check the equipment, in this case the foley tubing! Kinks can prevent adequate output to be in the bag. (B) doesn't help the situation. (C) not necessary unless the tubing is not kinked, the patient has sufficient PO intake, and there are no issues with the foley. (D) giving water would be the last step if the patient is not fluid overloaded.
14. A postoperative client has three different PRN analgesics prescribed for different levels of pain. The nurse inadvertently administers a dose that is not within the prescribed parameters. What actions should the nurse take first? a. Access for side effects of the medication. b. Document the client's responses. c. Complete a medication error report. d. Determine if the pain was relieved.
(a)--This is a medication error. The first step in addressing a medication error is to access for any side effects of the medication on the patient. Certain analgesics may cause respiratory depression, so it is essential to monitor for vital sign changes or respiratory distress. Once noting the patient is stable, you may then contact the provider, document the response, and complete a medication error report.
38. The nurse is discharging an adult woman who was hospitalized for 6 days for treatment of pneumonia. While the nurse is reviewing the prescribed medications, the client appears anxious. What action is most important for the nurse to implement? a. Instruct the client to repeat the medication plan b. Encourage client to take a PRN antianxiety drug c. Provide written instructions that are easy to follow d. Include a family member in the teaching session
(a)--When a patient is anxious, they may not hear or retain what you are trying to teach them. So it is necessary to ask them repeat back your instructions so you can be sure they understood your teaching. This is called "teach back". (B) is not necessary and medication should not be a first line to rid a patient of anxiety. (C) while helpful, some patients may not be willing to read or if anxious, could not be focused enough to read. (D) while helpful, the patient may not always have a family member with them.
During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement? A. Provide additional coffee on the client's breakfast tray. B. Exchange the client's grape juice for cranberry juice. C. Bring the client additional fruit at mid-morning. D. Encourage additional oral intake of juices and water.
Answer: (D)Encourage additional oral intake of juices and water.
5. A 54-year-old male client and his wife were informed this morning that he has terminal cancer. Which nursing intervention is likely to most beneficial? A. Ask her how she would like to participate in the client's care. B. Provide the wife with information about hospice C. Encourage the wife to visit after painful treatments are completed D. Refer her to support group for family members of those dying of cancer
(a)--While the client's wife may be grieving and need support, the priority for the client and client's wife is to make sure the wife feels comfortable participating in the client's care, if at all. Most people have an easier time coming to terms with the death of a loved one when they are involved in their care. (D) is a nice gesture, but will be more appropriate at a later time.
31. The unlicensed assistive personnel (UAP) describes the appearance of the bowel movement of several clients. Which description warrants additional follow up by the nurse? (select all that applies). a. Solid with red streaks. Indicative of hemorrhoids or a lower GI Bleed. Not normal. b. Brown liquid Indicative of an upset stomach or C.Diff. Not normal. c. Multiple hard pellets. Indicative of dehydration or a lack of fiber. Not normal. d. Formed but soft. This is a normal poop! e. Tarry appearance. This is indicative of a lower GI bleed. Not normal.
(a,b,c,e)--Any reported abnormal results from a UAP warrants a follow-up from the Nurse. It's your job! Not theirs'!
7. The nurse assesses a client who has a nasal cannula delivering oxygen at 2 L/min. To assess for skin damage related to the cannula, which areas should the nurse observe? (Select all that apply). A. Tops of the ear B. Bridge of the nose C. Around the nostrils D. Over the cheeks E. Across the forehead
(a,c,d)--This is proper placement of a nasal cannula. Constant pressure from the tubing may create skin damage to the areas of skin and bony prominences the nasal cannula will be resting on.
34. What assessment finding places a client at risk for problems associated with impaired skin integrity? a. Scattered macula of the face b. Capillary refill 5 seconds c. Smooth nail texture d. Absence of skin tenting
(b)--"At risk for problems associated with impaired skin integrity" . "At risk" is the key here; (B) normal capillary refill time is less than 3 seconds. Anything greater means that the patient is not having effective blood flow to the fingers and can cause skin to start necrosis (die). (A)(C)(D) are all normal findings.
36. The nurse attaches a pulse oximeter to a client's fingers and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading? a. BP 142/88 mmHg b. 2+ edema of fingers and hands c. Radial pulse volume is +3 d. Capillary refill time is 2 seconds
(b)--(A) blood pressure has nothing to do with the patient's O2 saturation. (C) This means the patient's pulse is strong and appropriate, but does nothing to the O2 stat. (D) The patient is having appropriate blood flow and this has nothing to do with O2 stats. (B) is correct because when a patient has too much fluid in their body, they will have 2+ edema of fingers and hands, which means this fluid could also be in their lungs or sitting on their chest. Thus, decreasing their O2 stats.
16. A female client's significant other has been at her bedside providing reassurances and support for the past 3 days, as desired by the client. The client's estranged husband arrives and demands that the significant other not be allowed to visit or be given condition updates. Which intervention should the nurse implement? a. Obtain a prescription from the healthcare provider regarding visitation privileges b. Request a consultation with the ethics committee for resolution of the situation c. Encourage the client to speak with her husband regarding his disruptive behavior d. Communicate the client's wishes to all members of the multidisciplinary team
(b)--(A) is not appropriate. (C) would cause excessive stress to the patient and the patient may not want to see her estranged husband at all. (D) while appropriate, it does not help calm the estranged husband or get him off the premises. (B) is most appropriate and professionals who are trained in ethical issues like this can take care of the situation.
45. A CVA (stoke) patient goes into respiratory distress and is placed on a ventilator. The client's daughter arrives with a durable power of attorney, and a living will that indicates there should be no extraordinary life saving measures. What action should the nurse take? a. Refer to the risk manager b. Notify the healthcare provider c. Discontinue the ventilator d. Review the medical record
(b)--A "DNR" or "FULL" code status change can only be completed by the Physician, and therefore requires you to first notify the Physician to put in an order for DNR to extubate the patient. If there is no specific order stating that the patient is a DNR, assume they are a full code! Only a living will or active Durable power of attorney can legally change the status of an unresponsive patient. (C ) can happen after (B) is completed and the MD changes the code status. (D) not this option because active legal documents will override possibly out of date medical records.
13. The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform? a. Tilt the pelvis forwards and backwards b. Bend the arm by flexing the ulnar to the humerus c. Turn the head to the right and left d. Extend the arm at the ide and rotate in circles
(b)--Active range of motion is when the patient is completing the physical activity with physical assistance or manipulation from the nurse. The elbow is a hinge joint, as stated in the question, and should be exercised by bending the forearm (ulnar) to the humerus (bicep area).
27. The nurse is providing wound care to a client with a stage 3 pressure ulcer that has a large amount of eschar. The wound care prescription states "clean the wound and then apply collagenase." Collagenase is a debriding agent. The prescription does not specify a cleaning method. Which technique should the nurse use to cleanse the pressure ulcer? a. Lightly coat the wound with povidone-iodine solution b. Irrigate the wound with sterile normal saline c. Flush the wound with sterile hydrogen peroxide d. Remove the eschar with a wet-to-dry dressing
(b)--Eschar is a natural part of a healing wound and can only be removed by the physician or wound care nurse. Unless directly stated in wound care notes, the ONLY solution to be used to clean a wound is sterile normal saline.
A 73 year old female client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting from a fall. In reviewing hip precautions with the client, which instruction should the nurse include in the client's teaching plan?
Answer: Place a pillow between your knees while lying in bed to prevent hip dislocation.
49. Which assessment data reflects the need for the nurses to include the problem, "Risk for falls" in a client's plan of care? a. Recent serum hemoglobin level of 16g/dL b. Opioid analgesic received one hour ago c. Stooped posture with a steady gait d. Expressed feelings of depression
(b)--Opioid analgesics can cause impaired balance, which puts the patient at a risk for falls. (A) is normal for males and slightly elevated for females but has nothing to do with increased fall risk. (C) "steady gait" negates the stooped posture and the patient is not prone to falls. (D) depression does not cause falls.
37. The nurse is caring for a hospitalized client who was placed in restraints due to confusion. The family removes the restraints while they are with the client. When the family leaves, what action should the nurse take first? a. Apply the restraints to maintain the client's safety. b. Reassess the client to determine the need for continuing restraints. c. Document the time the family left and continue to monitor the client. d. Call the healthcare provider for a new prescription.
(b)--Restraints, whenever possible should be discontinued when appropriate to decrease the risk of skin breakdown or injury to the patient. Since the patient successfully had them off while the family was around, before you place them back on the patient, you should first see if they are even necessary to begin with. Therefore (A) is not appropriate until after the assessment is done. (C) is not necessary, but you should continue to monitor the patient. (D) is only necessary when you put the restraints back on the patient.
46. Earlier this morning, an elderly Hispanic female was discharged to a LTC facility. The family members are now gathered in the hallway outside her room. What is the best action? a. Ask the family to wait in the cafeteria when the next of kin makes the necessary arrangements b. Provide space and privacy for the family to share their concerns about the client's discharge c. Ask the social worker to encourage the family to clear the hallway d. Explain to the family the client's need for privacy so that she can make independent decisions
(b)--The problem here is that too many people in the hospital hallway can be a safety hazard, so the goal is to create a safe space for the family. Therefore (B) is the most appropriate answer. (A) is incorrect because it is moving the family into an open area which could violate the patient's privacy and the next of kin may not be the decision makers for the patient. (C) the social worker is busy, and it's not their job! (D) LTC infers the patient is elderly and may lack the ability to make independent decisions.
52. During the admission assessment of a terminally ill male client that he is an agnostic. What is the best nursing action in response to this statement? a. Provide information about the hours and location of the chapel b. Document the statement of the client's spiritual assessment c. Invite the client to a healing service for people of all religions d. Offer to contact a spiritual advisor of the client's choice
(b)--You should always respect a patient's religious or lack of, values and document it. (A) is inappropriate because the client is Agnostic. (C) is also inappropriate. (D) also inappropriate.
3. The father of an 11-year-old client reports to the nurse that the client has been "wetting the bed" since the passing of his mother and is concerned. Which action is most important for the nurse to enact? A. Reassure the father that it is normal for a pre-teen to wet the bed during puberty B. Inform the father that nocturnal emissions are abnormal and his son is developmentally delayed C. Inform the father that it is most important to let the son know that nocturnal emissions are normal after trauma D. Refer the father and the client to a psychologist
(c) --It is common for adolescents to regress in their biological progression after experiencing a severe trauma, like losing a parent, sibling, or friend. While uncomfortable for the adolescent and parent, it is nothing to be concerned for. Often times, as the patient grieves or comes to terms with the trauma, the nocturnal emissions will cease.
4. The nurse explains to an older adult male the procedure for collecting a 24-hour urine specimen for creatinine clearance. Which action is most important for the nurse to include in their care plan for the shift? A. Assess the client for confusion and reteach the procedure B. Check the urine for color and texture C. Empty the urinal contents into the 24-hour collection container D. Discard the contents of the urinal
(c)--An "older adult male" in the question may imply that the patient may have an altered mental status or be demented. While suggesting, it is not directly stated, therefore (A) is inappropriate. (B) is incorrect because the lab will be assessing the collection specimen after the test is complete. (C) is correct because the nurse should first discard the first specimen, then begin to collect and record the time the first urine specimen was collected. It is important to have strict documentation for output, and to collect every urine specimen within that 24 hour period, otherwise the test must be restarted. (D) defeats the purpose of the 24-hour urine collection test.
6. A client who has a body mass index (BMI) of 30 is requesting information on the initial approach to a weight loss plan. Which action should the nurse recommend first? A. Plan low carbohydrate and high protein meals B. Engage in strenuous activity for an hour daily C. Keep a record of food and drinks consumed daily D. Participated in a group exercise class 3 times a week
(c)--BMI of 30 indicates the patient is obese. (A) While a good step, it is not what should be completed first. (B) While a good step, it is not what should be completed first. (C) The best thing to recommend is to have the patient keep a food journal to be able to go back and track their calorie intake; it may be helpful when meal planning or creating a workout routine plan. (D) Would be appropriate later.
28. A client is admitted with a fever of unknown origin. To assess fever patterns, which intervention should the nurse implement? a. Document the client's circadian rhythms b. Assess for flushed, warm skin regularly c. Measure temperature at regular intervals d. Vary sites for temperature measurement
(c)--In order to best assess when the fevers are coming, it would be best for the RN to measure the patient's temperature once an hour, in regular intervals so comparisons can be made with regards to the patient's activities or medications. (A) Circadian rhythms may have little effect on body temperature. (B) A patient could be flushed and not have a fever, so this is not a precise way to measure temperature. (D) Only one consistent site should or method should be used to measure temperature.
The nurse is performing nasotracheal suctioning. After suctioning the clients trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next.
Answer: Re-oxygenate the client before attempting to suction again.
20. While changing a client's post-operative dressing, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Given there is a positive MRSA, which is the most important action for the nurse to take? A. Force oral fluids B. Request a nutrition consult C. Initiate contact precautions D. Limit visitors to immediate family only
(c)--MRSA is a type of antibiotic resistant bacteria and a patient with this should be placed on contact precautions. (A) oral fluids will not help rid the patient of the infection. (B) nor nutrition. (D) limiting visitors to immediate family is not necessary as anyone is at risk for contracting MRSA from an infected wound.
48. A male Native American presents to the clinic with complaints of frequent abdominal cramping and nausea. He states that he has chronic constipation and has not had a bowel movement in five days, despite trying several home remedies. Which intervention is most important for the nurse to implement? a. Evaluate the stool samples for presence of blood b. Assess for the presence of an impaction c. Determine what home remedies were used d. Obtain list of prescribed home medication
(c)--The key aspect here is that the patient is "Native American" and that he has had constipation despite trying "several home remedies" (assume herbal). The most important thing to do is to have an exact list of the home remedies so that you can be sure that any prescribed medications don't interact with the remedies that are already in the patient's system.
47. A client with rheumatoid arthritis is experiencing chronic pain in both hands and wrists. Which information about the client is most important for the nurse to obtain when planning care? a. Amount of support provided by family members b. Measurement of pain using a scale of 0 to 10 c. The ability to perform ADLs d. Nonverbal behaviors exhibited when pain occurs
(c)--The key words here are "Chronic pain" meaning the patient has dealt with this pain and lived with this pain for awhile. Therefore (B) is incorrect and more appropriate for acute pain or before you give pain meds. (A) is nice but has nothing to do with the patient's hands or wrists and the patient's plan of care. (D) while important, it is not the most important. With patients who have rheumatoid arthritis, ADLs are most important because if the patient has too much pain, they may not be able to complete their own basic care.
2. Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube? A) Aspirating gastric contents to assure a pH value of 4 or less. B) Hearing air pass in the stomach after injecting air into the tubing. C) Examining a chest x-ray obtained after the tubing was inserted. D) Checking the remaining length of tubing to ensure that the correct length was inserted. A) Aspirating gastric contents to assure a pH value of 4 or less.
(c)--This is a method used to determine proper placement of NG tubing, but not the most accurate. B) Hearing air pass in the stomach after injecting air into the tubing. This is a method used to determine proper placement of NG tubing, but not the most accurate. C) Examining a chest x-ray obtained after the tubing was inserted. After placing an NG-tube, the placement of the tube is confirmed via x-ray since it is the most accurate way to ensure the tube has not been placed in the lungs, which would pose an aspiration risk. D) Checking the remaining length of tubing to ensure that the correct length was inserted. This is not an indicator of proper placement. You could very well be in a lung.
32. A female UAP is assigned to take the vital signs of a client with pertussis for whom droplet precautions have been implemented. The UAP requests a change in assignment because she has not yet been fitted for a particulate filter mask. Which action should the nurse take? a. Advise the UAP to wear a standard face mask to take vital signs, and then get fitted for a filter mask before providing personal care b. Send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this client c. Instruct the UAP that a standard mask is sufficient for the provision of care for the assigned client d. Before changing assignments, determine which staff members have fitted particulate filter masks
(c)--This is one of Elsevier's famous trick questions! You need to pay attention to the wording of the question and know your precaution measures and differences! The question asks about DROPLET precautions, not AIRBORNE precautions, so only a standard mask is required to enter this room. AIRBORNE precautions are for patients' with TB, meningitis, etc. Droplet are for patients with the flu, rhinovirus, etc. Be careful!!
17. When measuring vital signs, the nurse observes that a client is using accessory neck muscles during respirations. What follow-up action should the nurse take first? a. Determine pulse pressure b. Auscultate heart sounds c. Measure oxygen saturation d. Check for neck vein distention
(c)--Using accessory neck muscles during respirations is a serious sign of respiratory distress. The patient is a having a hard time breathing and as such, the first thing to do would be to measure oxygen saturation. (A) Pulse pressure is the difference between systolic and diastolic blood pressure. It is measured in millimeters of mercury (mmHg). It represents the force that the heart generates each time it contracts. (B) This has nothing to do with the heart. (D) Neck vein distention that is present is a sign of increased CVP (force on the aorta) and is not appropriate here.
25. While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview? a. The client's comfort level is increased when the nurse breaks eye contact to type notes into the record b. The interview process is enhanced with electronic documentation and allows the client to speak at a normal pace c. The nurse has limited ability to observe nonverbal communication while entering the assessment electronically d. Completing the electronic record during an interview is a legal obligation of the examining nurse
(c)--While looking at the computer, the RN may have limited ability to visualize the nonverbal communication from the patient. (A) you should be trying to initiate some, not constant eye contact with your patient while completing electronic documentation. (B) The patient can speak at a normal pace with or without HER. (D) while the electronic record during an interview becomes a legal document, it is an obligation for your job, not for legal matters.
54. The nurse plans to assist a male client out of bed for the first time since his surgery yesterday. His wife objects and tells the nurse to get out of the room because her husband is too ill to get out of bed. A. Administer nasal oxygen at a rate of 5 L/min B. Help the client to lie back down in the bed C. Quickly pivot the client to the chair and elevate the legs D. Check the client's blood pressure and pulse deficit
(d)--(A) is incorrect because it does not say that the patient has a decrease in O2 stats. (B) is incorrect because you assume the patient is already laying down and you have a task at hand. (C) MOVE SLOW after surgery! Never quickly move a patient. You could injury yourself and the client. (D) is correct; make sure they are physiologically stable first before moving them.
12. A male client with unstable angina needs a cardiac catheterization, so the healthcare provider explains the risks and benefits of the procedure, and then leaves to set up for the procedure. When the nurse presents the consent form for signature, the client hesitates and asks how the wires will keep his heart going. Which action should the nurse take? a. Answer the client's specific questions with a short understandable explanation b. Postpone the procedure until the client understands the risks and benefits c. Call the client's next of kin and ask them to provide verbal consent d. Page the healthcare provider to return and provide additional explanation
(d)--A patient should not sign a consent if they do not completely understand the procedure, benefits and risks. Although you may have an understanding of the procedure, it is the Physician and physician ONLY who can review the process of the procedure and benefits/risks with the client. That task is out of your scope as an RN.
26. A female client with chronic back pain has been taking muscle relaxants and analgesics to manage the discomfort, but is now experiencing an acute episode of pain that is not relieved by this medication regime. The client tells the nurse that she does not want to have back surgery for a herniated intervertebral disk, and reports that she has found acupuncture effective in resolving past acute episodes. Which response is best for the nurse to provide? a. Surgery removes the disk and is the only treatment that can totally resolve the pain b. The medication regimen you previously used should be re-evaluated for dose adjustment c. Massage and hot pack treatments are less invasive and can provide temporary relief d. Acupuncture is a complementary therapy that is often effective for management of pain
(d)--Acknowledgment of pain-relieving methods that work for the patient is extremely important. Since the patient has stated that acupuncture, a complementary therapy and alternative therapy of pain relief, has worked for the patient, you can acknowledge the effectiveness. (A) while effective, surgery does not always relieve pain and is not necessary for acute pain. (B) medications can be re-evaluated but has not helped the patient's current pain and is not appropriate. (C) while massage and heat can help pain, the patient has already stated that acupuncture has been effective at managing her pain and is another safe method of pain relief.
42. A male client presents to the clinic stating that he has a high stress job and is having difficulty falling asleep at night. The client reports having a constant headache and is seeking medication to help him sleep. Which intervention should the nurse implement? a. Determine the client's sleep and activity pattern b. Obtain prescription for client to take when stressed c. Refer client for a sleep study and neurological follow-up d. Teach coping strategies to use when feeling stressed
(d)--Before medicating a patient, always consider other non-pharmaceutical therapeutic methods. In this case, the patient stated he has a high stress job that is CAUSING him to have difficulty sleeping. Therefore, teaching coping strategies to use when feeling stressed could help him sleep without the need for a sleeping pill. (A) is incorrect because the patient already said he is having difficulty sleeping, this would extra nice to know information. (B) save prescriptions for the last step if all other methods fail. (C) again, this is if the other methods fail first.
24. An older adult male client is admitted to the medical unit following a fall at home. When undressing him, the nurse notes that he is wearing an adult diaper and skin breakdown is obvious over his sacral area. What action should the nurse implement first? a. Establish a toileting schedule to decrease episodes of incontinence b. Complete a functional assessment of the client's self-care abilities c. Apply a barrier ointment to intact areas that may be exposed to moisture d. Determine the size and depth of skin breakdown over the sacral area
(d)--Before you can treat the skin breakdown, you must first measure and record the affected area so you can have something to compare after you begin your interventions/treatments. Then you can continue with (A)(B) and (C).
19. Which instruction should the nurse include in the discharge teaching plan for an adult client with hypernatremia? a. Monitor daily urine output volume b. Drink plenty of water whenever thirsty c. Use salt tablets for sodium content d. Review food labels for sodium content
(d)--Hypernatremia is when a patient has a Sodium level that is too high, therefore it is most appropriate to teach the patient to check sodium levels on food labels before discharging. (A) While a high sodium level can decrease urine output, it is most important for the patient to be able to identify high sodium foods to decrease the risk of developing hypernatremia again. (B) Drinking too much water when thirsty can cause hyponatremia. (C) is incorrect because the patient is already at risk for developing high sodium levels again.
53. The nurse is reviewing the signed operative consent with a client who is admitted for the removal of a lipoma on the left leg. The client states that the consent form should say the removal of a lipoma on the right leg. Which intervention should the nurse implement? A. Notify the OR staff of the client's confusion B. Have the client sign a new surgical consent C. Add the additional information to the consent D. Inform the surgeon about the client's concern
(d)--If there are any discrepancies or concerns from the patient prior to signing the surgery consent, then the RN needs to call the surgeon to come speak to the patient to clear any confusion. (A) this client is not confused, never assume they are. (B) You will do this after the proper leg is discussed with the surgeon. (C) never add information to a consent! That is not your job and is only done with the surgeon's knowledge.
An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgment? A. A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes. B. The nurse assigned to care for the client who was at lunch at the time of the fall. C. The nurse who transferred the client to the chair when the fall occurred. D. The charge nurse who completed rounds 30 minutes before the fall occurred.
Answer: (B)The nurse who transferred the client to the chair when the fall occurred.
33. In-home hospice care is arranged for a client with stage 4 lung cancer. While the palliative nurse is arranging for discharge, the client verbalizes concerns about pain. What action should the nurse implement? a. Explain the respiratory problems that can occur with morphine use. b. Teach family how to evaluate the effectiveness of analgesics. c. Recommend asking the healthcare professional for a patient-controlled analgesic (PCA) pump. d. Provide client with a schedule of around-the-clock prescribed analgesic use.
(d)--It is common for cancer patients to have recurrent pain and it is the patient's right to ask about aspects of their care, such as pain management. (A) Morphine is actually used for both pain and to help patient's breathe better, it is not an opioid and does not cause respiratory depression. (B) The family is not trained to do this and is not appropriate. Pain is subjective and only the patient can say if the analgesics are effective. (C) PCA pumps are given in extreme cases when pain cannot be controlled by a previously tried pain management schedule like (D).
39. What instruction should the nurse provide for an UAP caring for a client with MRSA who has an order for contact precautions? a. Do not allow visitors until precautions are discontinued b. Wear sterile gloves when handling the client's body fluid c. Have the client wear a mask whenever someone enters the room d. Don a gown and gloves when entering the return
(d)--MRSA requires contact precautions; an isolation gown, gloves. (A) visitors can still come if they wear the appropriate PPE. (B) not necessary as sterile gloves are not needed for body fluid. (C) a standard mask is only needed for droplet precautions...minus this time of COVID.
41. UAP has lowered the head of the bed to change the lines for a client who is bedbound with a foley catheter and enteral tube feeds. Which change from the client warrants the most immediate intervention by the nurse? a. A feeding is infusing at 40 mL/hr through an enteral feeding tube b. The urine meter attached to the urinary drainage bag is completely full c. There is a large dependent loop in the client's urinary drainage tubing d. Purulent drainage is present around the insertion site of the feeding tube
(d)--The wording here is key. If it were an NG tube feeding, then the patient must ALWAYS be at, at least a 30 degree angle. BUT because it says an enteral tube feeds (through the stomach), it is ok to lower the bed down all the way. That being said, purulent drainage (D) shows that the tube feeds are leaking and thus the nurse needs to pause the feeds and sit the patient up again. This is the most immediate need over the urine drainage bag being full or kinked.
55. When entering the room of an adult male, the nurse finds that the client is very anxious. Before providing care, what action should the nurse take first? a. Divert the client's attention b. Call for additional help from staff c. Document the planned action d. Re-assess the client situation
(d)--When a patient is anxious, the first thing to do is re-assess them and find out why the are anxious. (A) can be helpful after finding out why they are anxious. (B) the patient is not a threat, no help is needed. (C) appropriate after you find out why they are anxious.
51. The nurse is conducting an initial admission assessment for a woman who is Mexican American and who is scheduled to deliver a baby by C-section in the next 24 hours. What should the nurse include in the assessment? a. Provider an interpreter to convey the meaning of words and messages in translation b. Commend the client for her patience after a long wait in the admission process c. Arrange for the hospital chaplain to visit the client during her hospital stay d. Rely on cultural norms as the basis for providing nursing care for this client
(d)--Whenever Elsevier points out the ethnicity or race of a patient, there are key cultural aspects you should look for in your answer (D). Don't assume (A) is correct because she could very well speak English!
15. When assessing a male client, the nurse finds that he is fatigued, and is experiencing muscle weakness, leg cramps, and cardiac dysrhythmias. Based on these findings, the nurse plans to check the client's laboratory values to validate the existence of which? a. Hyperphosphatemia b. Hypocalcemia c. Hypermagnesemia d. Hypokalemia
(d)--a. Hyperphosphatemia- muscle cramps, tetany, and perioral numbness or tingling b. Hypocalcemia - paresthesia, muscle spasms, cramps, tetany, numbness, and seizures c. Hypermagnesemia - (levels greater than 12 mmol/dL) can lead to cardiovascular complications (hypotension, and arrhythmias) and neurological disorder (confusion and lethargy) d. Hypokalemia- muscle weakness, leg cramps, and cardiac dysrhythmias. Normal range is 3.5- 5.0.
43. The nurse is teaching a client about the use of the syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions? a. Remove needle before discarding used syringes b. Wear gloves to dispose of the needle and syringe c. Don a face mask before administering the medication d. Washes hands before handling the needle and syringe
(d)--a. Remove needle before discarding used syringes (not safe, you could poke yourself) b. Wear gloves to dispose of the needle and syringe (yeah but not the best answer) c. Don a face mask before administering the medication (this is droplet precautions) d. Washes hands before handling the needle and syringe (this is standard precautions) Standard precautions; If you don't know these, review them because it is the foundation for nursing!
Triaging colors: Green, Yellow, Red, Black
-(not urgent, can get up and walk) -(not life threatening, can be treated within 30min-2hours) -(highest priority, respiratory issues, Loss of consciousness) -(dead)
Which patient would you assess first:
1st-Which patient can I look at and they will die if I don't do something 2nd-Most critical state 3rd-ABC 4th-SOB you should be very concerned
Which snack food is best for the nurse to provide a client with myasthenia gravis who is at risk for altered nutritional status? A. Chocolate pudding. B. Graham crackers. C. Sugar free gelatin. D. Apple slices.
Answer: (A)Chocolate pudding
When assisting an 82-year-old client to ambulate, it is important for the nurse to realize that the center of gravity for an elderly person is the A. Arms. B. Upper torso. C. Head. D. Feet.
Answer: (B) Upper Torso
23. A client with cirrhosis and ascites is receiving furosemide 40 mg BID. The pharmacy provides 20 mg tablets. How many tablets should the client receive each day? [Enter numeric value only]
4 tablets 40 mg BID (BID is 2 times a day). So 40mg x 2 = 80mg/day. 80 mg day/20mg tablets available = 4 tablets a day.
An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings though a gastrostomy tube. What is the best client position for administration of the bolus tube feedings? A. Prone. B. Fowler's. C. Sims'. D. Supine.
Answer: (B)Fowler's
Which action is most important for the nurse to implement when donning sterile gloves? A. Maintain thumb at a ninety degree angle. B. Hold hands with fingers down while gloving. C. Keep gloved hands above the elbows. D. Put the glove on the dominant hand first.
Answer: (C)Keep gloved hands above the elbows
A nurse assigns a UAP to obtain vital signs from a very anxious client. What instructions should the nurse give the UAP?
Answer: Report the results of the vital signs to the nurse
When evaluating a client's plan of care, the nurse determines that a desired outcome was not achieved. Which action will the nurse implement first? A. Establish a new nursing diagnosis. B. Note which actions were not implemented. C. Add additional nursing orders to the plan. D. Collaborate with the healthcare provider to make changes.
Answer: (B)Note which actions were not implemented.
A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge?
Answer: The client demonstrates the wound care procedure correctly.
A client who is 5'5" tall and weighs 200 pounds is scheduled for surgery the next day. What question is most important for the nurse to include during the preoperative assessment?
Answer: What vitamin and mineral supplements do you take?
A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last two hours. What action should the nurse take first? A. Irrigate the nasogastric tube with sterile normal saline. B. Reposition the client on her side. C. Advance the nasogastric tube an additional five centimeters. D. Administer an intravenous antiemetic prescribed for PRN use.
Answer: (B)Reposition the client on her side
The nurse prepares a 1,000 ml IV of 5% dextrose and water to be infused over 8 hours. The infusion set delivers 10 drops per milliliter. The nurse should regulate the IV to administer approximately how many drops per minute? A. 80 B. 8 C. 21 D. 25
Answer:(C)21
30. The nurse retrieves hydromorphone 4mg/mL from the Pyxis MedStation, an automated dispensing system, for a client who is receiving hydromorphone 3 mg IM 6 hours PRN for severe pain. How many mL should the nurse administer to the client? (Enter the numerical value only. If rounding is required, round to the nearest tenth)
Ans: 0.8 4mg/1 mL = 3mg/ X mL : 3mg/4mg = 0.75 (READ THE ROUNDING CAREFULLY, here is says to the nearest tenth. Therefore, the answer is 0.8 mL).
Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5½ hours. How much heparin has the client received? A. 11,000 units. B. 13,000 units. C. 15,000 units. D. 17,000 units.
Answer: (A)11000 units
An obese male client discusses with the nurse his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide? A. Be sure to have a complete physical examination before beginning your planned exercise program. B. Be careful that the exercise program doesn't simply add to your stress level, making you want to eat more. C. Increased exercise helps to reduce stress, so you may not need to spend money on a stress management class. D. Make sure to monitor your weight loss regularly to provide a sense of accomplishment and motivation.
Answer: (A)Be sure to have a complete physical examination before beginning your planned exercise program.
Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse? A. That means you have derived the maximum benefit, and the heat can be removed. B. Your blood vessels are becoming dilated and removing the heat from the site. C. We will increase the temperature 5 degrees when the pad no longer feels warm. D. The body's receptors adapt over time as they are exposed to heat.
Answer: (D)The body's receptors adapt over time as they are exposed to heat.
The healthcare provider prescribes the diuretic metolazone 7.5mg PO. Metolazone is available in 5mg tablets. How much should the nurse plan to administer?
Answer: 1 1/2 tablets
The healthcare provider prescribes furosemide (Lasix) 15mg IV stat. On hand is Lasix 20 mg/2ml. How many milliliters should the nurse administer.
Answer: 1.5ml
The nurse mixes 50mg of Nipride in 250ml of D5W and plans to administer the solution at a rate of 5mcg/kg/min to a client weighing 182lbs. Using a drip factor of 60gtt/ml, how many drops per min should the client receive?
Answer: 124gtt/min lbs to kg 182/2.2 = 82.73kg Dosage for the client 5mcg X 82.73 =413mcg/min mcg / ml 250/50000mcg =200 mcg/ml 2.07ml/min with a drip factor of 60gtt/ml 60 x 2.07 =124.28gtt/min
The IV infusion terbutaline sulfate 5mg in 500ml of D5W, infusing at a rate of 30 mcg/min, is prescribed for a client in premature labor. How many ml/hr should the nurse set the infusion pump?
Answer: 180mL/hr
A client is to receive 10mEq of KCL diluted in 250ml of normal saline over 4hrs. At what rate should the nurse set the clients IV infusion pump?
Answer: 63ml/hr
A healthcare provider prescribes an IV infusion of 1000ml of Ringer's Lactate with 30 units of Pitocin to run in over 4hrs for a client who has just delivered a 10lbs infant via cesarean section. The tubing has been changed to a 20gtt/ml administration set. The nurse plans to set the flow rate to how many gtt/min?
Answer: 83 gtt/min 20gtt/ml x 1000 ml/4hrs x 1hr/60mins = 83gtt/min
A male client is being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the nurse advise the client to follow?
Answer: 8am, 4pm, midnight
A hospitalized male client is receiving nasogastric tube feeding via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take?
Answer: After clearing the tube with 30ml of air, check the pH of fluid withdrawn from the tube.
The nurse is teaching a client with numerous allergies how to avoid allergens. Which instruction should be included in this teaching plan?
Answer: Avoid any types of spays, powders, and perfumes.
Which assessment data provides the most accurate determination of proper placement of a nasogastric tube?
Answer: Chest x-ray obtained after insertion
A client with chronic kidney disease (CKD) selects a scrambled egg for his breakfast. What action should the nurse take?
Answer: Commend the client for selecting a high biological value protein.
The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler delivered medication to demonstrate correct use of the inhaler.
Answer: During the inhalation
A client with acute hemorrhagic anemia is to receive four units of packed RBCs as rapidly as possible. Which intervention is most important for the nurse to implement?
Answer: Ensure the accuracy of the blood type match.
The nurse is instructing a client with high cholesterol about diet and lifestyle modification. what comment from the client indicated that the teaching has been effective
Answer: I will limit my intake of beef to 4 ounces per week
The nurse is caring for a client who is receiving 24hr total parenteral nutrition (TPN) via a central line at 54ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take?
Answer: Infuse 10% dextrose and water at 54ml/hr
Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse?
Answer: Instruct the client that the stoma will become smaller when the initial swelling Diminishes
A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse document that is most accurate?
Answer: Is disorientated to place and time
At the time of the first dressing change, the client refuses to look at her mastectomy incision. The nurse tells the client that the incision is healing well, but the client refuses to talk about it. What would be an appropriate response to the client's silence?
Answer: It is OK if you don't want to talk about your surgery. I will be available when you are ready
Examination of a client complaining of itching on his right arm reveals a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5cm in diameter. How should the nurse record this finding?
Answer: Localized red rash comprises flat areas, pinpoint to 0.5 cm in diameter.
When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first?
Answer: Loosen the right wrist restraint.
A client's infusion of normal saline infiltrated earlier today and approximately 500ml of saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding stronger pain medications. What initial action is most important for the nurse to take?
Answer: Measure the pulse volume and capillary refill distal to the infiltration.
The nurse observes that a male client has removed the covering form an ice pack applied to his knee. What action should the nurse take first?
Answer: Observe the appearance of the skin under the ice pack.
In developing a plan of care for a client with dementia, the nurse should remember that confusion in the elderly
Answer: Often follows relocation to new surroundings
Nursing assistant cannot do anything with:
assessing, change dressing or wounds, no teaching