HESI Live Review Test Bank for the NCLEX-RN Exam 2022.
A client reports to the nurse he has not had a BM in 2 days. Which intervention
should the nurse implement first?
A. instruct caregiver to offer a glass of prune juice
B. notify HCP and request script for stool softener
C. Assess clients med rec and see normal BM pattern
D. Instruct caregiver to increase clients fluids to five 8 ounce glasses per day.
✅- C!! Always assess first. You dont know enough to ask for stool softener
A client who has COPD is resting in semi fowlers w/ O2 BNC 2L. The client
develops dyspnea. What action does the nurse take first?
A. Call HCP
B. Obtain bedside pulse ox
C. Raise HOB
D. Assess clients vital signs
✅- C!! B and D are the same-- that is a flag
A client who has hyperparathyroidism is scheduled to receive a prescribed dose of
oral phosphate. The RN notes that the clients serum calcium level is 12.5mg/dL.
What action should to nurse take?
A. hold the phosphate and notify the HCP
B. review clients serum PTH
C. Give PRN IV Ca
D. Admin oral dose of PO4
✅- D! Ca and PO4 have an inverse relationship
In completing a clients pre-op routine, the RN finds that the consent has not been
signed. The clients begins to ask more questions about the surgical procedure.
What action should the nurse take next?
A. Witness the client's signature on the consent
B. Answer the clients questions about the surgery
C. Inform the HCP that the client has questions about the surgery.
,D. Reassure client that the surgeon will answer questions before anesthetic is
administered.
✅- C! The nurses role with surgical consent is to witness-- the HCP needs to
answer questions.
What foods do you avoid within 1 hour of taking iron?
✅- dairy and caffeine
Do you give injections to pt with edema?
✅- NO
living will ✅- a client documents his or her wishes regarding future care in the
event of terminal illness.
durable power of attorney
✅- a client appoints a representative (healthcare proxy) to make healthcare
decisions.
An awake and alert client with impending pulmonary edema is brought to the
emergency department. The client provides the nurse with a copy of a living will
that states that no invasive medical procedures should be used to keep her alive. the
healthcare team is questioning whether the client should be intubated. What
information should guide the teams decision?
A. the living will removes the obligation to involve the client in any medical
decision making.
B. The client is awake and alert, which makes the living will irrelevant and
nonbinding.
C. Lifesaving measures do not need to be explained to the client because of the
signed will.
D. The family should be contacted to determine who has durable POA for
healthcare for a client.
✅- B!! since the client is awake and alert, the living will is not indicated at the
time.
, A family member of a client who is in a posey vest restraint asks why the restraint
was applied. How should the nurse respond?
A. The restraint was prescribed.
B. There are not enough staff to keep client safe at all times.
C. The other clients are upset when the client wanders at night.
D. The client's actions place her at high risk for harming herself.
✅- D!!
What nursing action has the highest priority when admitting a client to a
psychiatric unit on an involuntary basis?
A. Reassure the client that the admission is only for a limited time.
B. Offer the client and family the opportunity to share their feelings about the
admission.
C. Determine the behaviors that resulted in the need for admission.
D. Advise the client about the legal rights of all hospitalized clients.
✅- C!! SAFETY FIRST!! You need to know why they are there. What if they are
there due to suicidal idealizations? you do not want to miss that.
The nurse enters the room of a preoperative client to obtain the client's signature on
the surgical consent form. Which question is most important for the nurse to ask
the client?
A. "When did the surgeon explain the procedure to you?"
B. "Is any member of your family going ot be here during surgery?"
C. "Have you been instructed in postoperative activities and restrictions?"
D. "Have you received any preoperative pain medications?"
✅- D!! It is MOST IMPORTANT because the client cannot sign if they have had
pain meds and she is there to obtain a signature.
The charge nurse confronts a staff nurse whose behavior has been resentful and
negative behavior has been resentful and negative since a change in unit policy was
announced. The staff nurse states, "Dont blame me; nobody likes this idea." What
is the charge nurse's priority action?
A. Confront the other staff members involved in the chane of unit policy
B. Call a unit meting to review the reasons the change was made
A client reports to the nurse he has not had a BM in 2 days. Which intervention
should the nurse implement first?
A. instruct caregiver to offer a glass of prune juice
B. notify HCP and request script for stool softener
C. Assess clients med rec and see normal BM pattern
D. Instruct caregiver to increase clients fluids to five 8 ounce glasses per day.
✅- C!! Always assess first. You dont know enough to ask for stool softener
A client who has COPD is resting in semi fowlers w/ O2 BNC 2L. The client
develops dyspnea. What action does the nurse take first?
A. Call HCP
B. Obtain bedside pulse ox
C. Raise HOB
D. Assess clients vital signs
✅- C!! B and D are the same-- that is a flag
A client who has hyperparathyroidism is scheduled to receive a prescribed dose of
oral phosphate. The RN notes that the clients serum calcium level is 12.5mg/dL.
What action should to nurse take?
A. hold the phosphate and notify the HCP
B. review clients serum PTH
C. Give PRN IV Ca
D. Admin oral dose of PO4
✅- D! Ca and PO4 have an inverse relationship
In completing a clients pre-op routine, the RN finds that the consent has not been
signed. The clients begins to ask more questions about the surgical procedure.
What action should the nurse take next?
A. Witness the client's signature on the consent
B. Answer the clients questions about the surgery
C. Inform the HCP that the client has questions about the surgery.
,D. Reassure client that the surgeon will answer questions before anesthetic is
administered.
✅- C! The nurses role with surgical consent is to witness-- the HCP needs to
answer questions.
What foods do you avoid within 1 hour of taking iron?
✅- dairy and caffeine
Do you give injections to pt with edema?
✅- NO
living will ✅- a client documents his or her wishes regarding future care in the
event of terminal illness.
durable power of attorney
✅- a client appoints a representative (healthcare proxy) to make healthcare
decisions.
An awake and alert client with impending pulmonary edema is brought to the
emergency department. The client provides the nurse with a copy of a living will
that states that no invasive medical procedures should be used to keep her alive. the
healthcare team is questioning whether the client should be intubated. What
information should guide the teams decision?
A. the living will removes the obligation to involve the client in any medical
decision making.
B. The client is awake and alert, which makes the living will irrelevant and
nonbinding.
C. Lifesaving measures do not need to be explained to the client because of the
signed will.
D. The family should be contacted to determine who has durable POA for
healthcare for a client.
✅- B!! since the client is awake and alert, the living will is not indicated at the
time.
, A family member of a client who is in a posey vest restraint asks why the restraint
was applied. How should the nurse respond?
A. The restraint was prescribed.
B. There are not enough staff to keep client safe at all times.
C. The other clients are upset when the client wanders at night.
D. The client's actions place her at high risk for harming herself.
✅- D!!
What nursing action has the highest priority when admitting a client to a
psychiatric unit on an involuntary basis?
A. Reassure the client that the admission is only for a limited time.
B. Offer the client and family the opportunity to share their feelings about the
admission.
C. Determine the behaviors that resulted in the need for admission.
D. Advise the client about the legal rights of all hospitalized clients.
✅- C!! SAFETY FIRST!! You need to know why they are there. What if they are
there due to suicidal idealizations? you do not want to miss that.
The nurse enters the room of a preoperative client to obtain the client's signature on
the surgical consent form. Which question is most important for the nurse to ask
the client?
A. "When did the surgeon explain the procedure to you?"
B. "Is any member of your family going ot be here during surgery?"
C. "Have you been instructed in postoperative activities and restrictions?"
D. "Have you received any preoperative pain medications?"
✅- D!! It is MOST IMPORTANT because the client cannot sign if they have had
pain meds and she is there to obtain a signature.
The charge nurse confronts a staff nurse whose behavior has been resentful and
negative behavior has been resentful and negative since a change in unit policy was
announced. The staff nurse states, "Dont blame me; nobody likes this idea." What
is the charge nurse's priority action?
A. Confront the other staff members involved in the chane of unit policy
B. Call a unit meting to review the reasons the change was made
