Nurs 170 HESI Prep || Graded A+.
A client becomes angry while waiting for a supervised break to smoke a cigarette outside and
states, "I want to go outside now and smoke. It takes forever to get anything done here!" Which
intervention is best for the nurse to implement?
a. Encourage the client to use a nicotine patch.
b. Reassure the client that it is almost time for another break.
c. Have the client leave the unit with another staff.
d. Review the schedule of outdoor breaks with the client. correct answers Correct Answer: D
Rationale: The best nursing action is to review the schedule of outdoor breaks (D) and provide
concrete information about the schedule. (A) is contraindicated if the client wants to continue
smoking. (B) is insufficient to encourage a trusting relationship with the client. (C) is preferential
for this client only and is inconsistent with unit rules.
When the health care provider diagnoses metastatic cancer and recommends a gastrostomy for an
older female client in stable condition, the son tells the nurse that his mother must not be told the
reason for the surgery because she "can't handle" the cancer diagnosis. Which legal principle is
the court most likely to uphold regarding this client's right to informed consent?
a. The family can provide the consent required in this situation because the older adult is in no
condition to make such decisions.
b. Because the client is mentally incompetent, the son has the right to waive informed consent for
her.
c. The court will allow the health care provider to make the decision to withhold informed
consent under therapeutic privilege.
d. If informed consent is withheld from a client, health care providers could be found guilty of
negligence. correct answers Correct Answer: D
,Rationale: Health care providers may be found guilty of negligence (D), specifically assault and
battery, if they carry out a treatment without the client's consent. The client's condition is stable,
so (A) is not a valid rationale. Advanced age does not automatically authorize the son to make all
decisions for his mother, and there is no evidence that the client is mentally incompetent (B).
Although (C) may have been upheld in the past, when paternalistic medical practice was
common, today's courts are unlikely to accept it.
Urinary catheterization is prescribed for a postoperative female client who has been unable to
void for 8 hours. The nurse inserts the catheter, but no urine is seen in the tubing. Which action
will the nurse take next?
a. Clamp the catheter and recheck it in 60 minutes.
b. Pull the catheter back 3 inches and redirect upward.
c. Leave the catheter in place and reattempt with another catheter.
d. Notify the health care provider of a possible obstruction. correct answers Correct Answer: C
Rationale: It is likely that the first catheter is in the vagina, rather than the bladder. Leaving the
first catheter in place will help locate the meatus when attempting the second catheterization (C).
The client should have at least 240 mL of urine after 8 hours. (A) does not resolve the problem.
(B) will not change the location of the catheter unless it is completely removed, in which case a
new catheter must be used. There is no evidence of a urinary tract obstruction if the catheter
could be easily inserted (D).
The nurse is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose
client winces and pulls away from a painful stimulus. Which action should the nurse take next?
a. Document that the client responds to painful stimulus.
b. Observe the client's response to verbal stimulation.
c. Place the client on seizure precautions for 24 hours.
d. Report decorticate posturing to the health care provider. correct answers Correct Answer: A
,Rationale: The client has demonstrated a purposeful response to pain, which should be
documented as such (A). Response to painful stimulus is assessed after response to verbal
stimulus, not before (B). There is no indication for placing the client on seizure precautions (C).
Reporting (D) is nonpurposeful movement.
A female nurse is assigned to care for a close friend, who says, "I am worried that friends will
find out about my diagnosis." The nurse tells her friend that legally she must protect a client's
confidentiality. Which resource describes the nurse's legal responsibilities?
a. Code of Ethics for Nurses
b. State Nurse Practice Acts
c. Patient's Bill of Rights
d. ANA Standards of Practice correct answers Correct Answer: B
Rationale: The State Nurse Practice Act (B) contains legal requirements for the protection of
client confidentiality and the consequences for breaches in confidentiality. (A) outlines ethical
standards for nursing care but does not include legal guidelines. (C and D) describe expectations
for nursing practice but do not address legal implications.
The nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV
rate by gravity has slowed, even though the venous access site is healthy. What should the nurse
do next?
a. Apply a warm compress proximal to the site.
b. Check for kinks in the tubing and raise the IV pole.
c. Adjust the tape that stabilizes the needle.
d. Flush with normal saline and recount the drop rate. correct answers Correct Answer: B
Rationale: The nurse should first check the tubing and height of the bag on the IV pole (B),
which are common factors that may slow the rate. Gravity infusion rates are influenced by the
height of the bag, tubing clamp closure or kinks, needle size or position, fluid viscosity, client
, blood pressure (crying in the pediatric client), and infiltration. Venospasm can slow the rate and
often responds to warmth over the vessel (A), but the nurse should first adjust the IV pole height.
The nurse may need to adjust the stabilizing tape on a positional needle (C) or flush the venous
access with normal saline (D), but less invasive actions should be implemented first.
The nurse is instructing a client in the proper use of a metered-dose inhaler. Which instruction
should the nurse provide the client to ensure the optimal benefits from the drug?
a. "Fill your lungs with air through your mouth and then compress the inhaler."
b. "Compress the inhaler while slowly breathing in through your mouth."
c. "Compress the inhaler while inhaling quickly through your nose."
d. "Exhale completely after compressing the inhaler and then inhale." correct answers Correct
Answer: B
Rationale: The medication should be inhaled through the mouth simultaneously with
compression of the inhaler (B). This will facilitate the desired destination of the aerosol
medication deep in the lungs for an optimal bronchodilation effect. (A, C, and D) do not allow
for deep lung penetration.
Which nonverbal action should the nurse implement to demonstrate active listening?
a. Sit facing the client.
b. Cross arms and legs.
c. Avoid eye contact.
d. Lean back in the chair. correct answers Correct Answer: A
Rationale: Active listening is conveyed using attentive verbal and nonverbal communication
techniques. To facilitate therapeutic communication and attentiveness, the nurse should sit facing
the client (A), which lets the client know that the nurse is there to listen. Active listening skills
include postures that are open to the client, such as keeping the arms open and relaxed, not (B),
A client becomes angry while waiting for a supervised break to smoke a cigarette outside and
states, "I want to go outside now and smoke. It takes forever to get anything done here!" Which
intervention is best for the nurse to implement?
a. Encourage the client to use a nicotine patch.
b. Reassure the client that it is almost time for another break.
c. Have the client leave the unit with another staff.
d. Review the schedule of outdoor breaks with the client. correct answers Correct Answer: D
Rationale: The best nursing action is to review the schedule of outdoor breaks (D) and provide
concrete information about the schedule. (A) is contraindicated if the client wants to continue
smoking. (B) is insufficient to encourage a trusting relationship with the client. (C) is preferential
for this client only and is inconsistent with unit rules.
When the health care provider diagnoses metastatic cancer and recommends a gastrostomy for an
older female client in stable condition, the son tells the nurse that his mother must not be told the
reason for the surgery because she "can't handle" the cancer diagnosis. Which legal principle is
the court most likely to uphold regarding this client's right to informed consent?
a. The family can provide the consent required in this situation because the older adult is in no
condition to make such decisions.
b. Because the client is mentally incompetent, the son has the right to waive informed consent for
her.
c. The court will allow the health care provider to make the decision to withhold informed
consent under therapeutic privilege.
d. If informed consent is withheld from a client, health care providers could be found guilty of
negligence. correct answers Correct Answer: D
,Rationale: Health care providers may be found guilty of negligence (D), specifically assault and
battery, if they carry out a treatment without the client's consent. The client's condition is stable,
so (A) is not a valid rationale. Advanced age does not automatically authorize the son to make all
decisions for his mother, and there is no evidence that the client is mentally incompetent (B).
Although (C) may have been upheld in the past, when paternalistic medical practice was
common, today's courts are unlikely to accept it.
Urinary catheterization is prescribed for a postoperative female client who has been unable to
void for 8 hours. The nurse inserts the catheter, but no urine is seen in the tubing. Which action
will the nurse take next?
a. Clamp the catheter and recheck it in 60 minutes.
b. Pull the catheter back 3 inches and redirect upward.
c. Leave the catheter in place and reattempt with another catheter.
d. Notify the health care provider of a possible obstruction. correct answers Correct Answer: C
Rationale: It is likely that the first catheter is in the vagina, rather than the bladder. Leaving the
first catheter in place will help locate the meatus when attempting the second catheterization (C).
The client should have at least 240 mL of urine after 8 hours. (A) does not resolve the problem.
(B) will not change the location of the catheter unless it is completely removed, in which case a
new catheter must be used. There is no evidence of a urinary tract obstruction if the catheter
could be easily inserted (D).
The nurse is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose
client winces and pulls away from a painful stimulus. Which action should the nurse take next?
a. Document that the client responds to painful stimulus.
b. Observe the client's response to verbal stimulation.
c. Place the client on seizure precautions for 24 hours.
d. Report decorticate posturing to the health care provider. correct answers Correct Answer: A
,Rationale: The client has demonstrated a purposeful response to pain, which should be
documented as such (A). Response to painful stimulus is assessed after response to verbal
stimulus, not before (B). There is no indication for placing the client on seizure precautions (C).
Reporting (D) is nonpurposeful movement.
A female nurse is assigned to care for a close friend, who says, "I am worried that friends will
find out about my diagnosis." The nurse tells her friend that legally she must protect a client's
confidentiality. Which resource describes the nurse's legal responsibilities?
a. Code of Ethics for Nurses
b. State Nurse Practice Acts
c. Patient's Bill of Rights
d. ANA Standards of Practice correct answers Correct Answer: B
Rationale: The State Nurse Practice Act (B) contains legal requirements for the protection of
client confidentiality and the consequences for breaches in confidentiality. (A) outlines ethical
standards for nursing care but does not include legal guidelines. (C and D) describe expectations
for nursing practice but do not address legal implications.
The nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV
rate by gravity has slowed, even though the venous access site is healthy. What should the nurse
do next?
a. Apply a warm compress proximal to the site.
b. Check for kinks in the tubing and raise the IV pole.
c. Adjust the tape that stabilizes the needle.
d. Flush with normal saline and recount the drop rate. correct answers Correct Answer: B
Rationale: The nurse should first check the tubing and height of the bag on the IV pole (B),
which are common factors that may slow the rate. Gravity infusion rates are influenced by the
height of the bag, tubing clamp closure or kinks, needle size or position, fluid viscosity, client
, blood pressure (crying in the pediatric client), and infiltration. Venospasm can slow the rate and
often responds to warmth over the vessel (A), but the nurse should first adjust the IV pole height.
The nurse may need to adjust the stabilizing tape on a positional needle (C) or flush the venous
access with normal saline (D), but less invasive actions should be implemented first.
The nurse is instructing a client in the proper use of a metered-dose inhaler. Which instruction
should the nurse provide the client to ensure the optimal benefits from the drug?
a. "Fill your lungs with air through your mouth and then compress the inhaler."
b. "Compress the inhaler while slowly breathing in through your mouth."
c. "Compress the inhaler while inhaling quickly through your nose."
d. "Exhale completely after compressing the inhaler and then inhale." correct answers Correct
Answer: B
Rationale: The medication should be inhaled through the mouth simultaneously with
compression of the inhaler (B). This will facilitate the desired destination of the aerosol
medication deep in the lungs for an optimal bronchodilation effect. (A, C, and D) do not allow
for deep lung penetration.
Which nonverbal action should the nurse implement to demonstrate active listening?
a. Sit facing the client.
b. Cross arms and legs.
c. Avoid eye contact.
d. Lean back in the chair. correct answers Correct Answer: A
Rationale: Active listening is conveyed using attentive verbal and nonverbal communication
techniques. To facilitate therapeutic communication and attentiveness, the nurse should sit facing
the client (A), which lets the client know that the nurse is there to listen. Active listening skills
include postures that are open to the client, such as keeping the arms open and relaxed, not (B),
