HESI Questions Part 1 - Fundamental Skills
The nurse has provided instructions about back safety to a client. Which client statement indicates understanding of the instructions? 1. "I should carry objects about 18 inches from my body." 2. "I should sleep on my stomach with a firm mattress." 3. "I should carry objects close to my body." 4. "I should pull rather than push when moving heavy objects."
3. "I should carry objects close to my body."
A registered nurse is teaching a nursing student about caring for a client before leaving the healthcare facility. Which statement made by the nursing student indicates the need for further education? 1. "I should teach the client about potential food-drug interactions." 2. "I should involve the client and his or her family in the referral process." 3. "I should give limited information about the client to the healthcare provider who received the referral." 4. "I should teach the client and his or her family about safe and effective use of medications and medical equipment."
3. "I should give limited information about the client to the healthcare provider who received the referral."
A nurse hired to work in a metropolitan hospital provides services for a culturally diverse population. One of the nurses on the unit says it is the nurses' responsibility to discourage "these people" from bringing all that "home medicine stuff" to their family members. Which response by the recently hired nurse is most appropriate? 1. "Hospital policies should put a stop to this." 2. "Everyone should conform to the prevailing culture." 3. "Nontraditional approaches to health care can be beneficial." 4. "You are right because they may have a negative impact on people's health."
3. "Nontraditional approaches to health care can be beneficial."
A client asks the nurse, "Should I tell my partner that I just found out I'm human immunodeficiency virus (HIV) positive?" What is the nurse's most appropriate response? 1. "This is a decision you alone can make." 2. "Do not tell your partner unless asked." 3. "You are having difficulty deciding what to say." 4. "Tell your partner that you don't know how you became sick."
3. "You are having difficulty deciding what to say."
A client has a right-above-the-knee amputation after trauma sustained in a work-related accident. Upon awakening from surgery, the client states, "What happened to me? I don't remember a thing." What is the nurse's best response? 1. "Tell me what you think happened." 2. "You will remember more as you get better." 3. "You were in a work-related accident this morning." 4. "It was necessary to amputate your leg after the accident."
3. "You were in a work-related accident this morning."
A client who is receiving a screening test for tuberculosis (TB) asks the nurse what a positive reaction will mean. What should the nurse explain that a positive reaction indicates? 1. A depressed immune system 2. An active tuberculosis infection 3. A previous exposure to the organism 4. An imminent tuberculosis infection
3. A previous exposure to the organism
The family of an older adult who is aphasic reports to the nurse manager that the primary nurse failed to obtain a signed consent before inserting an indwelling catheter to measure hourly output. What should the nurse manager consider before responding? 1. Procedures for a client's benefit do not require a signed consent. 2. Clients who are aphasic are incapable of signing an informed consent. 3. A separate signed informed consent for routine treatments is unnecessary. 4. A specific intervention without a client's signed consent is an invasion of rights.
3. A separate signed informed consent for routine treatments is unnecessary.
A nurse realizes that a client has been administered a double dose of insulin by mistake and informs the primary healthcare provider. Which element of the decision-making reflects in the nurse's action? 1. Authority 2. Autonomy 3. Accountability 4. Responsibility
3. Accountability
A pregnant woman in her second trimester arrives at the local health department, requesting a flu shot. The client states that she gets the flu vaccine every year and has never had an adverse reaction. What action should the nurse perform? 1. Do not administer the vaccine until checking with the healthcare provider. 2. Do not administer the vaccine due to pregnancy contraindication. 3. Administer the usual dose of the vaccine. 4. Administer half the usual dose of the vaccine.
3. Administer the usual dose of the vaccine.
The nurse is preparing an intraoperative care plan for a client. Which intervention should be excluded from the care plan? 1. Ensuring the client's skin integrity 2. Reviewing the preoperative instructions 3. Administering general anesthetic to the client 4. Placing the client in the correct position on the operating table
3. Administering general anesthetic to the client
A client is receiving fresh frozen plasma (FFP). The nurse would expect to see improvement in which condition? 1. Thrombocytopenia 2. Oxygen deficiency 3. Clotting factor deficiency 4. Low hemoglobin
3. Clotting factor deficiency
What principle of teaching specific to an older adult should the nurse consider when providing instruction to such a client recently diagnosed with diabetes mellitus? 1. Knowledge reduces general anxiety. 2. Capacity to learn decreases with age. 3. Continued reinforcement is advantageous. 4. Readiness of the learner precedes instruction.
3. Continued reinforcement is advantageous.
A client reaches the point of acceptance during the stages of dying. What response should the nurse expect the client to exhibit? 1. Apathy 2. Euphoria 3. Detachment 4. Emotionalism
3. Detachment
A nurse reviews a medical record of a client with ascites. What does the nurse identify that may be causing the ascites? 1. Portal hypotension 2. Kidney malfunction 3. Diminished plasma protein level 4. Decreased production of potassium
3. Diminished plasma protein level
A nurse is transcribing a practitioner's orders for a group of clients. Which order should the nurse clarify with the practitioner? 1. Discharge in am 2. Blood glucose monitoring ac and bedtime 3. Erythromycin 250 mg TIW 4. Dalteparin 5000 international units Sub-Q BID
3. Erythromycin 250 mg TIW
The nurse is caring for a client who has an implanted port and is receiving intravenous fluids. To decrease the risk of infection, the nurse should change the noncoring needle how often? 1. Every 3 days 2. Every 5 days 3. Every 7 days 4. Every 9 days
3. Every 7 days
Which description relates to Gesell's theory of development? (Choose all that apply) 1. One growth pattern is common to all children. 2. Only genetic factors direct the sequence of development. 3. Growth in humans is both cephalocaudal and proximodistal. 4. Growth is maximized only if environmental conditions are adequate. 5. The pattern of maturation follows a fixed developmental sequence in humans.
3. Growth in humans is both cephalocaudal and proximodistal. 4. Growth is maximized only if environmental conditions are adequate. 5. The pattern of maturation follows a fixed developmental sequence in humans.
A nurse keeps track of the immunization schedules for a childbearing family. Which type of nursing intervention is executed in this situation? 1. Acute care 2. Home care 3. Health promotion 4. Restorative and continuing care
3. Health promotion
Which nursing interventions indicate client care that supports physical functioning? .(Choose all that apply) 1. Interventions to facilitate client's learning 2. Interventions to alter client's undesirable behavior 3. Interventions to maintain client's nutritional status 4. Interventions to maintain client's regular bowel patterns 5. Interventions to prevent complications in the client related to electrolyte imbalance
3. Interventions to maintain client's nutritional status 4. Interventions to maintain client's regular bowel patterns
A nurse is helping a client who observes the traditional Jewish dietary laws to prepare a dietary menu. What considerations should the nurse make? 1. Eating beef and veal is prohibited. 2. Consumption of fish with scales is forbidden. 3. Meat and milk at the same meal are forbidden. 4. Consuming alcohol, coffee, and tea are prohibited.
3. Meat and milk at the same meal are forbidden.
The nurse is assisting with the end-of-life care of an older adult. Which activity is performed when the nurse views family as context? 1. Assess the resources available to the family 2. Meet the client's family's comfort and nutritional needs 3. Meet the client's comfort, hygiene and nutritional needs 4. Determine the family's need for rest and their stage of coping
3. Meet the client's comfort, hygiene and nutritional needs
A client has been admitted with a urinary tract infection. The nurse receives a urine culture and sensitivity report that reveals the client has vancomycin-resistant enterococci (VRE). After notifying the healthcare provider, which action should the nurse take to decrease the risk of transmission to others? 1. Insert a urinary catheter. 2. Initiate droplet precautions. 3. Move the client to a private room. 4. Use a high-efficiency particulate air (HEPA) respirator during care.
3. Move the client to a private room.
A client has been diagnosed as brain dead. The nurse understands that this means that the client has what? 1. No spontaneous reflexes 2. Shallow and slow breathing 3. No cortical functioning with some reflex breathing 4. Deep tendon reflexes only and no independent breathing
3. No cortical functioning with some reflex breathing
A client has a "prayer cloth" pinned to the hospital gown. The cloth is soiled from being touched frequently. What should the nurse do when changing the client's gown? 1. Make a new prayer cloth. 2. Discard the soiled prayer cloth. 3. Pin the prayer cloth to the clean gown. 4. Wash the prayer cloth with a mild detergent
3. Pin the prayer cloth to the clean gown.
A client spends several minutes making negative comments to the nurse about numerous aspects of the hospital stay. What is the nurse's best initial response? 1. Describe the purpose of different hospital therapies to decrease the client's anxiety. 2. Explain that becoming so upset does not allow the client to get much-needed rest. 3. Refocus the conversation on the client's fears, frustrations, and anger about the condition. 4. Permit the client to release feelings and then leave the room to allow the client to regain composure.
3. Refocus the conversation on the client's fears, frustrations, and anger about the condition.
A nurse is caring for a client with hemiplegia who becomes frustrated when performing skills. How can the nurse motivate the client toward independence? 1. Establish long-range goals for the client. 2. Identify errors that the client can correct. 3. Reinforce success in tasks accomplished. 4. Demonstrate ways to promote self-reliance.
3. Reinforce success in tasks accomplished.
A primary nurse completes a nursing assessment of all assigned clients and develops a care plan for each client. Which element of decision-making does the nurse execute in this situation? 1. Authority 2. Autonomy 3. Responsibility 4. Accountability
3. Responsibility
Which developmental changes should be evaluated in girls around 12 years of age? 1. Motor skills 2. Visual acuity 3. Skeletal growth 4. Hormonal changes
3. Skeletal growth
Which definition is involved in the caring process called knowing according to Swanson's theory of caring? 1. Being emotionally present for the other 2. Sustaining faith in the other's capacity to get through an event 3. Striving to understand an event as it has meaning in the life of the other 4. Facilitating the other's passage through life transitions and unfamiliar events
3. Striving to understand an event as it has meaning in the life of the other
How should the nurse prevent footdrop in a client with a leg cast? 1. Encourage complete bed rest to promote healing of the foot. 2. Place the foot in traction. 3. Support the foot with 90 degrees of flexion. 4. Place an elastic stocking on the foot to provide support.
3. Support the foot with 90 degrees of flexion.
A nurse in the emergency department is assessing a young child with a head injury. The child is accompanied by a parent. Which observation should prompt the nurse to assess the child for abuse? 1. The child has Mongolian spots on the back. 2. The child belongs to a single-parent family. 3. The child has received care for injuries twice earlier. 4. The child and parent narrate the same story about the injury.
3. The child has received care for injuries twice earlier.
The nurse is caring for a client who got discharged from the hospital. The nurse finds that the client is having difficulty in determining which medications to take. What would be the best nursing intervention in this situation? 1. The nurse fills and labels the medication bottles. 2. The nurse advises the caregiver to support the client in taking medication. 3. The nurse recommends the client's pharmacy to re-label the medication in large letters. 4. The nurse shows the client examples of pill organizers that will help the client to sort the medication.
3. The nurse recommends the client's pharmacy to re-label the medication in large letters.
A client with a leg fracture is hospitalized. The registered nurse instructs the nursing student to interrogate the client to ascertain the reason for the injury. Which question would help to determine an extrinsic factor? 1. Do you have clear vision? 2. Are you taking any sedatives or hypnotics? 3. Were you wearing inappropriate shoes? 4. Do you have a history of postural hypotension?
3. Were you wearing inappropriate shoes?
A nurse is providing preoperative teaching for a client regarding use of an incentive spirometer and should include what instructions? 1. "Inhale completely and exhale in short, rapid breaths." 2. "Inhale deeply through the spirometer, hold it as long as possible, and slowly exhale." 3."Exhale completely; take a slow, deep breath; hold it as long as possible, and slowly exhale." 4. "Exhale halfway, then inhale a rapid, small breath; repeat several times."
3."Exhale completely; take a slow, deep breath; hold it as long as possible, and slowly exhale."
The nurse is assessing a client with arthritis. Which statement made by the client indicates a precipitating factor that is an intellectual standard for critical thinking? 1. "The pain is usually present in my fingers and knees." 2. "I observed swelling and redness near the pain area." 3. "I feel the pain in each and every joint of my hands and legs." 4. "I run for 30 minutes every day; this exercise increases my pain."
4. "I run for 30 minutes every day; this exercise increases my pain."
The nurse is teaching a client about safe insulin administration. Which statement made by the client indicates the need for further education? 1. "I should see whether the insulin is expired." 2. "I should keep a daily logbook of times of insulin injection." 3. "I should keep my medication in its original labeled container." 4. "I should administer insulin only if there are any symptoms."
4. "I should administer insulin only if there are any symptoms."
The registered nurse teaches a nursing student about leadership skills for prioritizing the need of the client depending on the situation. Which statement is an example of an intermediate priority need? 1. "The teachings of home self-care." 2. "A psychological episode of an anxiety attack." 3. "A physiological episode of an obstructed airway." 4. "The measures required to decrease postoperative complications."
4. "The measures required to decrease postoperative complications."
A client is dying. Hesitatingly, his wife says to the nurse, "I'd like to tell him how much I love him, but I don't want to upset him." Which is the best response by the nurse? 1. "You must keep up a strong appearance for him." 2. "I think he'd have difficulty dealing with that now." 3. "Don't you think he knows that without you telling him?" 4. "Why don't you share your feelings with him while you can?"
4. "Why don't you share your feelings with him while you can?"
A dying client is coping with feelings regarding impending death. The nurse bases care on the theory of death and dying by Kübler-Ross. During which stage of grieving should the nurse primarily use nonverbal interventions? 1. Anger 2. Denial 3. Bargaining 4. Acceptance
4. Acceptance
Often when a family member is dying, the client and the family are at different stages of grieving. During which stage of a client's grieving is the family likely to require more emotional nursing care than the client? 1. Anger 2. Denial 3. Depression 4. Acceptance
4. Acceptance
A visitor comes to the nursing station and tells the nurse that a client and a relative had a fight and that the client is now lying unconscious on the floor. What is the most important action the nurse needs to take? 1. Ask the client if he or she is okay. 2. Call security from the room. 3. Find out if there is anyone else in the room. 4. Ask security to make sure the room is safe.
4. Ask security to make sure the room is safe.
A terminally ill client is furious with one of the staff nurses. The client refuses the nurse's care and insists on doing self-care. A different nurse is assigned to care for the client. What should be the newly assigned nurse's initial step in revising the client's plan of care? 1. Get a full report from the first nurse and adjust the plan accordingly. 2. Ask the primary healthcare provider for a report on the client's condition and plan appropriately. 3. Tell the client about the change in staff responsibilities and assess the client's reaction. 4. Assess the client's present status and include the client in a discussion of revisions to the plan of care.
4. Assess the client's present status and include the client in a discussion of revisions to the plan of care.
A nurse is applying a dressing to a client's surgical wound using sterile technique. While engaging in this activity, the nurse accidentally places a moist sterile gauze pad on the cloth sterile field. What physical principle is applicable for causing the sterile field to become contaminated? 1. Dialysis 2. Osmosis 3. Diffusion 4. Capillarity
4. Capillarity
The nurse is helping a client and his or her family to set and meet goals with minimal financial cost, time, and energy. Which professional role of the nurse is applicable in this situation? 1. Educator 2. Advocate 3. Manager 4. Caregiver
4. Caregiver
A nurse preparing to apply restraints to a client should understand which of the following principles? 1. The law prohibits restraining clients until a written prescription is obtained. 2. A felony charge may be leveled against nurses who use restraints improperly. 3. Nurses are not obligated to report institutions that use restraints unlawfully. 4. Charges of assault and battery may be leveled against nurses who use restraints improperly.
4. Charges of assault and battery may be leveled against nurses who use restraints improperly.
While caring for a client with a Hemovac portable wound drainage system, the nurse observes that the collection container is half full. The nurse empties the container. What is the next nursing intervention? 1. Encircle the drainage on the dressing. 2. Irrigate the suction tube with sterile saline. 3. Clean the drainage port with an alcohol wipe. 4. Compress the container before closing the port.
4. Compress the container before closing the port.
A nurse is providing immediate postoperative care to a client who had a lung resection for a malignancy. The client has a closed chest tube drainage system connected to suction. Which assessment finding requires additional evaluation by the nurse? 1. A column of water 20 cm high in the suction control chamber 2. 75 mL of bright red blood in the drainage collection chamber 3. An intact occlusive dressing at the insertion site 4. Constant bubbling in the water seal chamber
4. Constant bubbling in the water seal chamber
A nurse is caring for a client with albuminuria resulting in edema. What pressure change does the nurse determine to be the cause of the edema? 1. Decrease in tissue hydrostatic pressure 2. Increase in plasma hydrostatic pressure 3. Increase in tissue colloid osmotic pressure 4. Decrease in plasma colloid oncotic pressure
4. Decrease in plasma colloid oncotic pressure
While measuring the rectal temperature, the nurse inserts the thermometer probe 2.5 to 3.5 cm into the anus in the direction of the umbilicus. What would be the rationale behind this? 1. Provide comfort to the client 2. Minimize trauma to rectal mucosa 3. Reduce transmission of microorganisms 4. Ensure adequate exposure to the blood vessels
4. Ensure adequate exposure to the blood vessels
To ensure the safety of a client who is receiving a continuous intravenous normal saline infusion, the nurse should change the administration set how often? 1. Every 4 to 8 hours 2. Every 12 to 24 hours 3. Every 24 to 48 hours 4. Every 72 to 96 hours
4. Every 72 to 96 hours
Which theory proposes that older adults experience a shift from a materialistic to cosmic view of the world? 1. Activity theory 2. Continuity theory 3. Disengagement theory 4. Gerotranscendence theory
4. Gerotranscendence theory
The nurse is caring for a nonambulatory client with a reddened sacrum that is unrelieved by repositioning. What nursing diagnosis should be included in the client's plan of care? 1. Risk for pressure ulcer 2. Risk for impaired skin integrity 3. Impaired skin integrity, related to infrequent turning and repositioning 4. Impaired skin integrity, related to the effects of pressure and shearing force
4. Impaired skin integrity, related to the effects of pressure and shearing force
The nurse is performing nursing care therapies and including the client as an active participant in the care. Which basic step is involved in this situation? 1. Planning 2. Evaluation 3. Assessment 4. Implementation
4. Implementation
Which is the first sign that would help the nurse in diagnosing malignant hyperthermia in a client? 1. Abnormal rapid heart rate 2. Abnormal rapid breathing 3. Increased body temperature 4. Increased expired carbon dioxide
4. Increased expired carbon dioxide
Which skill in critical thinking requires to be orderly in data collection? 1. Analysis 2. Inference 3. Evaluation 4. Interpretation
4. Interpretation
Which is an example of a nurse-initiated intervention? 1. Preparing a client for endoscopy 2. Coordinating with an x-ray technician for imaging 3. Starting an intravenous line for a blood transfusion 4. Keeping edematous lower extremities elevated on pillows
4. Keeping edematous lower extremities elevated on pillows
A nurse is caring for an elderly client who has constipation. Which independent nursing intervention helps to reestablish a normal bowel pattern? 1. Administer a mineral oil enema. 2. Offer 1 cup of fluid every hour. 3. Manually remove fecal impactions. 4. Offer a cup of prune juice.
4. Offer a cup of prune juice.
The nurse receives information about a client through another nurse. The nurse then finds that information has some missing facts. Which critical thinking attitude would the nurse use to clarify the information after talking to the client directly? 1. Fairness 2. Humility 3. Discipline 4. Perseverance
4. Perseverance
A client is undergoing radiation therapy. The nurse reassures the client and stays with the client throughout the therapy. Which caring behavior does this nursing action reflect? 1. Touch 2. Spiritual caring 3. Knowing the client 4. Providing presence
4. Providing presence
Which theories are most relevant to development in adults? .(Choose all that apply) 1. Piaget's theory 2. Erikson's theory 3. Kohlberg's theory 4. Stage-Crisis theory 5. Life Span approach
4. Stage-Crisis theory 5. Life Span approach
A client with a terminal illness reaches the stage of acceptance. How can the nurse best help the client during this stage? 1. Acknowledge the client's crying. 2. Encourage unrestricted family visits. 3. Explain details of the care being given. 4. Stay nearby without initiating conversation.
4. Stay nearby without initiating conversation.
What should the nurse include in dietary teaching for a client with a colostomy? 1. Liquids should be limited to 1 L per day. 2. Nondigestible fiber and fruits should be eliminated. 3. A formed stool is an indicator of constipation. 4. The diet should be adjusted to include foods that result in manageable stools.
4. The diet should be adjusted to include foods that result in manageable stools.
Which action of the nurse would be inappropriate in the context of critical thinking skills for making clinical decisions in nursing practice? 1. The nurse should observe changes in clients. 2. The nurse should identify new problems when they arise. 3. The nurse should follow direction in completing identified aspects of care. 4. The nurse should rely on his or her knowledge and experience when planning and implementing a client care plan.
4. The nurse should rely on his or her knowledge and experience when planning and implementing a client care plan.
Following a surgery on the neck, the client asks the nurse why the head of the bed is up so high. The nurse should tell the client that the high-Fowler position is preferred for what reason? 1. To avoid strain on the incision 2. To promote drainage of the wound 3. To provide stimulation for the client 4. To reduce edema at the operative site
4. To reduce edema at the operative site
The intake and output of a client over an 8-hour period (from 0800 to 1600) is as follows: 150 mL urine voided at 0800; 220 mL urine voided at 1200; 235 mL urine voided at 1600; 200 mL gastric tube formula + 50 mL water administered initially and then repeated x 2; IV had 900 mL in the bag at 0800, and 550 mL remains in the bag at 1600. What is the difference between the client's intake and output? Record your answer using a whole number.
495 mL Intake: Gastric tube: 250 x 3 = 750 mL; IV: 900 - 550 = 350 mL; Intake total: 1100 mL. Output: Urinary output: 150 + 220 + 235 = 605 mL. I & O difference: 1100 - 605 = 495 mL
At the beginning of the shift at 7:00 am, a client has 650 mL of normal saline solution left in the intravenous bag, which is infusing at 125 mL/hr. At 9:30 am the healthcare provider changes the IV solution to lactated Ringer solution, which is to infuse at 100 mL/hr. What total amount of intravenous solution should the client have received by the end of the 8-hour shift? Record your answer using a whole number.
863 mL
The nurse who is working during the 8:00 am to 4:00 pm shift must document a client's fluid intake and output. An intravenous drip is infusing at 50 mL per hour. The client drinks 4 oz of orange juice and 6 oz of tea at 8:30 am and vomits 200 mL at 9:00 am. At 10:00 am the client drinks 60 mL of water with medications; the client voids 550 mL of urine at 11:00 am. At 12:30 pm, 3 oz of soup and 4 oz of ice cream are ingested. The client voids 450 mL at 2:00 pm. Calculate the total intake for the 8:00 am to 4:00 pm shift. Record your answer using a whole number.
970 mL 1 ounce = 30 mL; therefore the client ingested 120 mL of orange juice at 8:30 am, 180 mL of tea at 8:30 am, 60 mL of water with medications at 10:00 am, 90 mL of soup at 12:30 am, and 120 mL of ice cream at 12:30 pm (counted as a liquid because it melts at room temperature). The client received 400 mL of IV fluid (50 mL × 8 hours = 400). Total intake is 970 mL. Vomit and urine output should not be included in the patient's intake.
The nurse is caring for a client who underwent a rhinoplasty surgical procedure 5 hours ago. After administering pain medication, the nurse notes the client is swallowing frequently. The nurse understands that the cause of frequent swallowing is most likely from what? 1. A normal response to the analgesic 2. Oral dryness caused by nasal packing 3. An adverse reaction to anesthesia 4. Bleeding posterior to the nasal packing
Bleeding posterior to the nasal packing
According to Kohlberg's development of moral reasoning, at which phase of life would a child develop premoral orientation? 1. Preschool 2. Adolescence 3. Middle childhood 4. Early childhood/toddler
Preschool
An older client asks, "How do I know that all the medications that I take are safe?" What information should the nurse include in response to this client's question? (Choose all that apply) 1. "Ask your healthcare provider how and when you should be taking your medications." 2. "Stop taking a prescribed medication if you are not feeling better in a few days." 3. "Discard medications into the toilet that have exceeded the expiration date on the bottle." 4. "Check the name, dose, and instructions about administration of drugs each time before leaving the pharmacy." 5. "Inform your healthcare provider of the over-the-counter drugs, recreational drugs, and amount of alcohol you ingest."
1. "Ask your healthcare provider how and when you should be taking your medications." 4. "Check the name, dose, and instructions about administration of drugs each time before leaving the pharmacy." 5. "Inform your healthcare provider of the over-the-counter drugs, recreational drugs, and amount of alcohol you ingest."
Which question asked by the nurse is an example of open-ended questions? 1. "How has your health been?" 2. "Are you feeling any pain now?" 3. "Do you think the medication is helping you?" 4. "How would you rate your pain on a scale from 0 to 10?"
1. "How has your health been?"
While assessing an elderly client, a nurse infers cognitive impairment. Which statements made by the client confirm the nurse's conclusion? (Choose all that apply) 1. "I have difficulty judging things." 2. "I forget to take medicines." 3. "I am unable to do financial calculations." 4. "I get confused about the proper date and time." 5. "I am unable to recall words during conversations with my family."
1. "I have difficulty judging things." 3. "I am unable to do financial calculations." 5. "I am unable to recall words during conversations with my family."
Which client's need should be considered high priority? 1. A client with dysphagia who is choking while eating 2. A client who needs discharge teaching about medications 3. A client who needs a dressing change of the surgical wound 4. A client who has a knowledge deficit regarding the use of an insulin pen
1. A client with dysphagia who is choking while eating
When caring for a client with varicella and disseminated herpes zoster, the nurse should implement which types of precautions? (Choose all that apply) 1. Airborne 2. Contact 3. Droplet 4. Hazardous wastes 5. Standard
1. Airborne 2. Contact 5. Standard
A client is transferred to an acute care nursing unit after surgery. Which action of the nurse is most important and should be performed first? 1. Assess the patency of airway. 2. Ask if the client is comfortable. 3. Determine the level of consciousness. 4. Review the order for intravenous fluids.
1. Assess the patency of airway.
The home healthcare nurse visits an elderly couple living independently. The wife cares for the husband who has dementia. Which interventions should the nurse implement for them? (Choose all that apply) 1. Assess the wife for caregiver burden. 2. Arrange hospice care for the husband. 3. Make healthcare decisions for the couple 4. Assess the husband for signs of physical abuse. 5. Identify social support within the community.
1. Assess the wife for caregiver burden. 4. Assess the husband for signs of physical abuse. 5. Identify social support within the community.
A nurse anticipates that a hospitalized client will be transferred to a nursing home. When should the nurse begin preparing the client for the transfer? 1. At the time of admission 2. After a relative gives permission 3. When the client talks about future plans 4. As soon as the client's transfer has been approved
1. At the time of admission
A nurse in the ambulatory preoperative unit identifies that a client is more anxious than most clients. What is the nurse's best intervention? 1. Attempt to identify the client's concerns. 2. Reassure the client that the surgery is routine. 3. Report the client's anxiety to the healthcare provider. 4. Provide privacy by pulling the curtain around the client.
1. Attempt to identify the client's concerns.
A mother of a seven-month-old infant reports that her baby still cannot sit without support. Upon asking further questions, the nurse realizes that the child's gross-motor skills are not properly developed. Which question did the nurse most likely ask the mother? 1. Can your child hold on to furniture? 2. Can your child show hand preference? 3. Does your child move on his or her hands and knees? 4. Can your child place objects in containers?
1. Can your child hold on to furniture?
The nurse is assessing a client working in a glass factory. Which occupational hazard should the nurse assess the client for? 1. Cataracts 2. Dermatitis 3. Lung disease 4. Nasopharyngeal cancer
1. Cataracts
Which nursing interventions would be beneficial for providing safe oxygen therapy? .(Choose all that apply) 1. Check tubing for kinks 2. Run wires under carpeting 3. Post "no smoking" signs in the clients' rooms 4. Place oxygen tanks flat in the carts when not in use 5. Make sure that the client is familiar with the phrase "Stop, drop, and roll"
1. Check tubing for kinks 3. Post "no smoking" signs in the clients' rooms
The nurse is providing postprocedure care for a client who had a central venous access device (CVAD) inserted. Before the CVAD is used, what procedure is performed to verify placement? 1. Chest x-ray 2. Flushing the line with heparin 3. Withdrawing blood to ensure patency 4. Chest fluoroscopy
1. Chest x-ray
A nurse is preparing to administer an ophthalmic medication to a client. What techniques should the nurse use for this procedure? (Choose all that apply) 1. Clean the eyelid and eyelashes. 2. Place the dropper against the eyelid. 3. Apply clean gloves before beginning the procedure. 4. Instill the solution directly onto the cornea. 5. Press on the nasolacrimal duct after instilling the solution.
1. Clean the eyelid and eyelashes. 3. Apply clean gloves before beginning the procedure. 5. Press on the nasolacrimal duct after instilling the solution.
A client complains of anxiety before a diagnostic procedure. The nurse explores and collects a thorough assessment to find the reason for client's anxiety. Which critical thinking attitude is involved in this situation? 1. Discipline 2. Confidence 3. Responsibility 4. Thinking independently
1. Discipline
A 2 g sodium diet is prescribed for a client with stage 2 hypertension, and the nurse teaches the client the rationale for this diet. The client reports distaste for the food. The primary nurse hears the client request that the family "bring in a ham and cheese sandwich and fries." What is the most effective nursing intervention? 1. Discuss the diet with the client and family. 2. Tell the client why salty foods should not be eaten. 3. Explain the dietary restriction to the client's visitors. 4. Ask the dietitian to teach the client and family about sodium restrictions.
1. Discuss the diet with the client and family.
A client is admitted to the hospital with a tentative diagnosis of infectious pulmonary tuberculosis. What infection control measures should the nurse take? 1. Don an N95 respirator mask before entering the room. 2. Put on a permeable gown each time before entering the room. 3. Implement contact precautions and post appropriate signage. 4. After finishing with patient care, remove the gown first and then remove the gloves.
1. Don an N95 respirator mask before entering the room.
The nurse is discussing discharge plans with a client who had a myocardial infarction. The client states, "I'm worried about going home." The nurse responds, "Tell me more about this." What interviewing technique did the nurse use? 1. Exploring 2. Reflecting 3. Refocusing 4. Acknowledging
1. Exploring
A client complains to the nurse manager about a coworker. The nurse manager listens to both the patient's and the coworker's side of the story. Which critical thinking quality is shown in this situation? 1. Fairness 2. Discipline 3. Risk-taking 4. Responsibility
1. Fairness
A client complains to the nurse that a staff member did not respond to the client's call. The nurse politely reassures the client, and makes the client comfortable. The nurse speaks to the staff member about the incident and solves the problem. Which critical thinking attitude has the nurse demonstrated in this situation? 1. Fairness 2. Discipline 3. Confidence 4. Responsibility
1. Fairness: listening to the client and the staff member regarding the client's complaint indicates
A client with a leg prosthesis and a history of syncopal episodes is being admitted to the hospital. When formulating the plan of care for this client, the nurse should include that the client is at risk for what? 1. Falls 2. Impaired cognition 3. Imbalanced nutrition 4. Impaired gas exchange
1. Falls
The nurse is caring for an infant at the healthcare facility. Which nursing intervention fosters the infant's development of trust? 1. Follow the parents' directions while providing care. 2. Ask parents to name objects in the infant's surroundings. 3. Encourage different caregivers to interact with the infant. 4. Encourage caregivers to talk to the infant while providing care.
1. Follow the parents' directions while providing care.
While instructing a community group regarding risk factors for coronary artery disease, the nurse provides a list of risk factors that cannot be modified. What should be included on the list? 1. Heredity 2. Hypertension 3. Cigarette smoking 4. Diabetes mellitus
1. Heredity
A nurse applies an ice pack to a client's leg for 20 minutes. The cold application will cause what physiologic effect? 1. Local anesthesia 2. Peripheral vasodilation 3. Depression of vital signs 4. Decreased viscosity of blood
1. Local anesthesia
An arterial blood gas report indicates the client's pH is 7.25, PCO 2 is 35 mm Hg, and HCO 3 is 20 mEq/L. Which disturbance should the nurse identify based on these results? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis
1. Metabolic acidosis
A client is admitted for surgery. Although not physically distressed, the client appears apprehensive and withdrawn. What is the nurse's best action? 1. Orient the client to the unit environment. 2. Have a copy of hospital regulations available. 3. Explain that there is no reason to be concerned. 4. Reassure the client that the staff is available if the client has questions.
1. Orient the client to the unit environment.
A client being treated for influenza A (H1N1) is scheduled for a computed tomography (CT) scan. To ensure client and visitor safety during transport, the nurse should take which precaution? 1. Place a surgical mask on the client. 2. Other than standard precautions, no additional precautions are needed. 3. Minimize close physical contact. 4. Cover the client's legs with a blanket.
1. Place a surgical mask on the client.
The nurse finds that a client prefers Reiki to antidepressants for treating depression. Which intervention of the nurse indicates open-mindedness? 1. Respecting the client's preference 2. Suggesting other options in addition to Reiki 3. Dissuading the client against continuing Reiki 4. Emphasizing that not taking antidepressants may be harmful
1. Respecting the client's preference
A nurse understands that the primary purpose for a client to undergo reconstructive surgery is to do what? 1. Restore function and/or appearance 2. Replace an organ or tissue 3. Relieve or reduce symptoms 4. Remove or excise an organ or tissue
1. Restore function and/or appearance
A nurse is assisting a client to transfer from the bed to a chair. What should the nurse do to widen the client's base of support during the transfer? 1. Spread the client's feet away from each other. 2. Move the client on the count of three. 3. Instruct the client to flex the muscles of the internal girdle. 4. Stand close to the client when assisting with the move.
1. Spread the client's feet away from each other.
Which warning signals should the nurse observe in a child suspected to be a victim of abuse? 1. The child doesn't want to be touched by anyone. 2. The child sleeps for an average of 15 hours a day. 3. The child frequently visits the emergency department. 4. The child suffers from fever and tenderness in the abdomen. 5. The child looks at the caregiver before answering any question.
1. The child doesn't want to be touched by anyone. 3. The child frequently visits the emergency department. 5. The child looks at the caregiver before answering any question.
The registered nurse tells a nursing student, "In the nursing model, the registered nurse is responsible for all aspects of care for one or more clients during a shift of care and the care can be delegated." Which disadvantage would be most likely related to this nursing model? 1. The continuity of care is a problem. 2. The registered nurse doesn't spend enough time with the client. 3. The team leader needs to take time to delegate work. 4. The associate nurse cannot change a care plan without consulting the primary nurse.
1. The continuity of care is a problem.
In which situation does the nurse consider the family as context? 1. The nurse is caring for an individual with tonsillitis. 2. The nurse is caring for a dying client and all the family members. 3. The nurse is teaching young parents about caring for their toddler. 4. The nurse is assessing the needs of the family caregivers of a client.
1. The nurse is caring for an individual with tonsillitis.
The nurse who works in a birthing unit understands that newborns may have impaired thermoregulation. Which nursing interventions may help prevent heat loss in the newborns? (Choose all that apply) 1. The nurse keeps the newborn covered in warm blankets. 2. The nurse keeps the newborn under the radiant warmer. 3. The nurse places the newborn on the mother's abdomen. 4. The nurse measures the newborn's temperature regularly. 5. The nurse encourages the mother to feed the newborn well to maintain the fluid balance.
1. The nurse keeps the newborn covered in warm blankets. 2. The nurse keeps the newborn under the radiant warmer. 3. The nurse places the newborn on the mother's abdomen.
During a newborn assessment the nurse identifies that the temperature, pulse, respirations, and other physical characteristics are within the expected range. The nurse records these findings on the clinical record. Legally, how should the nurse's action be interpreted? 1. The nurse performed her role correctly. 2. This is a medical diagnosis and the nurse overstepped the legal boundary. 3. Nursing assessments are not equivalent to a primary healthcare provider's assessments. 4. The initial assessment of the infant's physical status is the responsibility of the client's primary healthcare provider.
1. The nurse performed her role correctly.
Which intervention reflects the nurse's approach of "family as a context"? 1. Trying to meet the client's comfort 2. Evaluating the client family's coping skills 3. Evaluating the client family's energy level 4. Trying to meet the client family's nutritional needs
1. Trying to meet the client's comfort
What type of functional health pattern would the nurse explain describes values and goals? 1. Value-belief pattern 2. Role-relationship pattern 3. Self-perception-self-concept pattern 4. Health perception-health management pattern
1. Value-belief pattern
The registered nurse is teaching a nursing student about the process of medication reconciliation for a client who was admitted in a healthcare setting. Which statement made by the nursing student indicates a need for further education? 1. "I should check the new medication order against the current list of medicines." 2. "I should avoid asking about the over-the counter medications." 3. "I should obtain a comprehensive and current list of the client's medications." 4. "I should avoid distractions and go slowly when reconciling the client's medications."
2. "I should avoid asking about the over-the counter medications."
The registered nurse is teaching a nursing student about how to educate clients based on their developmental capacity. Which statements made by the nursing student are applicable for older adults? (Choose all that apply) 1. "I should encourage independent learning." 2. "I should keep the teaching sessions short." 3. "I should involve the client in any discussion or activity." 4. "I should encourage learning through pictures and short stories." 5. "I should teach the client psychomotor skills to maintain his or her health."
2. "I should keep the teaching sessions short." 3. "I should involve the client in any discussion or activity."
A nurse is teaching an older client about proper medication use. Which statement made by the client indicates the need for further education? 1. "I will ask the pharmacist to give generic medications." 2. "I will use over-the-counter medicines along with prescribed drugs." 3. "I will continue my treatment by consulting a single healthcare provider." 4. "I will know the names and times of administration of the medications I am taking."
2. "I will use over-the-counter medicines along with prescribed drugs."
A newly hired nurse during orientation is approached by a surveyor from the department of health. The surveyor asks the nurse about the best way to prevent the spread of infection. What is the most appropriate nursing response? 1. "Let me get my preceptor." 2. "Wash your hands before and after any client care." 3. "Clean all instruments and work surfaces with an approved disinfectant." 4. "Ensure proper disposal of all items contaminated with blood or body fluids."
2. "Wash your hands before and after any client care."
While receiving a preoperative enema, a client starts to cry and says, "I'm sorry you have to do this messy thing for me." What is the nurse's best response? 1. "I don't mind it." 2. "You seem upset." 3. "This is part of my job." 4. "Nurses get used to this."
2. "You seem upset."
Which nursing interventions should the nurse provide to an older client with hypertension? (Choose all that apply) 1. Provide skin care 2. Advise the client to limit salt intake 3. Teach stress management 4. Instruct the client to quit smoking 5. Advise the client to eat finger foods
2. Advise the client to limit salt intake 3. Teach stress management 4. Instruct the client to quit smoking
When providing care for a client with a nasogastric (NG) tube, the nurse should take measures to prevent what serious complication? 1. Skin breakdown 2. Aspiration pneumonia 3. Retention ileus 4. Profuse diarrhea
2. Aspiration pneumonia
Which nursing intervention is most appropriate for a client in skeletal traction? 1. Add and remove weights as the client desires. 2. Assess the pin sites at least every shift and as needed. 3. Ensure that the knots in the rope are tied to the pulley. 4. Perform range of motion to joints proximal and distal to the fracture at least once a day.
2. Assess the pin sites at least every shift and as needed.
A 58-year-old client is planning to retire. Which action would be appropriate in this situation? 1. Assessing the activity level 2. Assessing issues related to income 3. Assessing the family to conduct an environmental check 4. Assessing the options of public transportation and number of community activities
2. Assessing issues related to income
The way individuals cope with an unexpected hospitalization depends on many factors. However, what is the one that is most significant? 1. Cognitive age 2. Basic personality 3. Financial resources 4. General physical health
2. Basic personality
A nurse addresses the needs of a client who is hyperventilating to prevent what complication? 1. Cardiac arrest 2. Carbonic acid deficit 3. Reduction in serum pH 4. Excess oxygen saturation
2. Carbonic acid deficit
What is a characteristic of the primary nursing model? 1. Care can be delegated. 2. Care is provided by the registered nurse to the client during a stay in a facility. 3. The registered nurse is responsible for all aspects of care for one or more clients during a shift of care. 4. The registered nurse leads a team of other registered nurses, practical nurses, and unlicensed assistive personnel.
2. Care is provided by the registered nurse to the client during a stay in a facility.
The nurse introduces him or herself and explains a procedure to be performed to clean and dress a surgical wound. Which critical thinking attitude is the nurse applying? 1. Risk taking 2. Confidence 3. Thinking independently 4. Responsibility and authority
2. Confidence
According to Swanson's caring process, the nurse must know the client. Which factors enable the nurse to know the client better? (Choose all that apply) 1. Economic constraints 2. Continuity of care by the nursing staff 3. Fewer nurses in the healthcare facility 4. Collection of data about the client's clinical condition 5. Engagement in a caring relationship without assumptions
2. Continuity of care by the nursing staff 4. Collection of data about the client's clinical condition 5. Engagement in a caring relationship without assumptions
The nurse understands that the action of an antidiuretic hormone (ADH) is to do what? 1. Reduce blood volume 2. Decrease water loss in urine 3. Increase urine output 4. Initiate the thirst mechanism
2. Decrease water loss in urine
Which caring process is defined as "facilitating the other's passage through life transitions and unfamiliar events" according to Swanson's theory of caring? 1. Knowing 2. Enabling 3. Doing for 4. Being with
2. Enabling
A client becomes anxious after being scheduled for a colostomy. What is the most effective way for the nurse to help the client? 1. Administer the prescribed as needed (PRN) sedative. 2. Encourage the client to express feelings. 3. Explain the post-procedure course of treatment. 4. Reassure the client that there are others with this problem.
2. Encourage the client to express feelings.
A client has an open reduction and internal fixation of the hip. The client is to be transferred to a chair for a half hour on the second postoperative day. Before transferring the client, what should the nurse do? 1. Assess the strength of the affected leg. 2. Explain the transfer procedure step by step. 3. Instruct the client to bear weight evenly on both legs. 4. Encourage the client to keep the affected leg elevated.
2. Explain the transfer procedure step by step.
The nurse observes that an older client seldom eats the meat on the meal trays. The nurse discusses this observation with the client, and the client states, "I only eat meat once a week because old people don't need protein every day." What does the nurse determine that the client needs to be taught about? 1. Need for home-delivered meals 2. Foods that meet basic nutritional needs 3. Effect of aging on the need for some foods 4. Need for meat at least once per day throughout life
2. Foods that meet basic nutritional needs
Which carative factor of Watson's transpersonal caring theory is reflected when the nurse practices loving kindness in practice? 1. Instilling faith-hope 2. Forming a human-altruistic value system 3. Cultivating sensitivity to one's self and others 4. Promoting and expressing positive and negative feelings
2. Forming a human-altruistic value system
The nurse is caring for a dying client. Which interventions should the nurse implement for the client and family? .(Choose all that apply) 1. Arrange for restorative care. 2. Help the family set up home care if required. 3. Refrain from telling the family that the client is dying. 4. Know the client and family's strengths and weaknesses. 5. Arrange for church or community support for the family.
2. Help the family set up home care if required. 4. Know the client and family's strengths and weaknesses. 5. Arrange for church or community support for the family.
A client experiences a muscle sprain of the ankle. When assessing the injury, the nurse discovers that a hematoma is developing, edema is present, and the client reports tenderness when the ankle is palpated. The nurse anticipates that the plan of care will include the application of what? 1. Binder 2. Ice bag 3. Elastic bandage 4. Warm compress
2. Ice bag Application of ice directly to a soft tissue injury causes vasoconstriction, which results in decreasing hemorrhage, edema, and pain.
A client with chronic obstructive pulmonary disease (COPD) states, "I have had steady weight loss, and I am often too tired to eat." Which nursing diagnosis would be most appropriate for this client? 1. Fatigue related to weight loss secondary to COPD 2. Imbalanced nutrition: less than body requirements, related to fatigue 3. Imbalanced nutrition: less than body requirements, related to COPD 4. Ineffective breathing pattern, related to alveolar hypoventilation
2. Imbalanced nutrition: less than body requirements, related to fatigue
A client with cancer has undergone treatment. The client's primary healthcare provider receives a record of the client's care from the oncologist. Which descriptions are given under the care summary received by the primary healthcare provider? (Choose all that apply) 1. Description of recommended cancer screening 2. Information about treatment institutions and key providers 3. Identification of a key point of contact and coordinate of care 4. Information about possible late and long-term effects of treatment 5. Information about possible signs of recurrence and secondary tumors
2. Information about treatment institutions and key providers 3. Identification of a key point of contact and coordinate of care
A day after an explanation of the effects of surgery to create an ileostomy, a 68-year-old client remarks to the nurse, "It will be difficult for my wife to care for a helpless old man." This comment by the client regarding himself is an example of Erikson's conflict of what? 1. Initiative versus guilt 2. Integrity versus despair 3. Industry versus inferiority 4. Generativity versus stagnation
2. Integrity versus despair
A client is receiving an intravenous infusion of 5% dextrose in water. The client loses weight and develops a negative nitrogen balance. The nurse concludes that what likely contributed to this client's weight loss? 1. Excessive carbohydrate intake 2. Lack of protein supplementation 3. Insufficient intake of water-soluble vitamins 4. Increased concentration of electrolytes in cells
2. Lack of protein supplementation
The nurse is assessing a new mother at a healthcare facility. Which symptom does the nurse identify as a risk factor for postpartum blues? 1. Frantic energy 2. Mild irritability 3. Hallucinations 4. Unwillingness to sleep
2. Mild irritability
An older adult in an acute care setting is having urinary incontinence. Which interventions would help the client? (Choose all that apply) 1. Provide nutritional support 2. Provide voiding opportunities 3. Avoid indwelling catheterization 4. Provide beverages and snacks frequently 5. Promote measures to prevent skin breakdown
2. Provide voiding opportunities 3. Avoid indwelling catheterization 5. Promote measures to prevent skin breakdown
A client who sustained a large open wound as a result of an accident is receiving daily sterile dressing changes. To maintain sterility when changing the dressing, what should the nurse do? 1. Put the unopened sterile glove package carefully on the sterile field. 2. Remove the sterile drape from its package by lifting it by the corners. 3. Don sterile gloves before opening the package containing the field drape. 4. Pour irrigation liquid from a height of at least 3 inches (2.5 cm) above the sterile container.
2. Remove the sterile drape from its package by lifting it by the corners.
Which therapeutic communication technique involves using a coping strategy to help the nurse and client adjust to stress? 1. Sharing hope 2. Sharing humor 3. Sharing empathy 4. Sharing observations
2. Sharing humor
The registered nurse is teaching the student nurse about Lawrence Kohlberg's theory of moral development. While teaching, the registered nurse states, "Children follow the parents' rule of being at home on time." Which stage of Lawrence Kohlberg's theory of moral development is the registered nurse explaining? 1. Stage 1 2. Stage 2 3. Stage 3 4. Stage 4
2. Stage 2
The nurse is preparing discharge instructions for a client who acquired a nosocomial Clostridium difficile infection. What should the nurse include in the instructions? 1. Anticipate that nausea and vomiting will continue until the infection is no longer present. 2. The infection causes diarrhea accompanied by flatus and abdominal discomfort. 3. Consume a diet that is high in fiber and low in fat. 4. Other than routine hand washing, it is not necessary to perform special disinfection procedures.
2. The infection causes diarrhea accompanied by flatus and abdominal discomfort.
The nurse is assessing the newborn in the first hour after birth. Which findings does the nurse identify as normal for the newborn? (Choose all that apply) 1. The newborn has a flat abdomen. 2. The newborn weighs 6 lbs (2,700 g). 3. The newborn's hands and feet appear cyanosed. 4. The newborn does not blink in the presence of light. 5. The circumference of the head is 33 cm (13 in).
2. The newborn weighs 6 lbs (2,700 g). 3. The newborn's hands and feet appear cyanosed. 5. The circumference of the head is 33 cm (13 in).
A client has a stage III pressure ulcer. Which nursing intervention can prevent further injury by eliminating shearing force? 1. Maintain the head of the bed at 35 degrees or less. 2. With the help of another staff member, use a drawsheet when lifting the client in bed. 3. Reposition the client at least every 2 hours and support the client with pillows. 4. At least once every 8 hours, perform passive range-of-motion exercises of all extremities.
2. With the help of another staff member, use a drawsheet when lifting the client in bed.
