Hesi Fundamentals Practice Questions
And Answers
*Aw20-year-
oldwfemalewclientwwithwawnoticeablewbodywodorwhaswrefusedwtowshowerwforwthewlastw3wdays.w
Shewstates,w"Iwhavewbeenwtoldwthatwitwiswharmfulwtowbathewduringwmywperiod."wWhichwaction
wshouldwthewnursewtakewfirst?*
A.wAcceptwandwdocumentwthewclient'swwishwtowrefrainwfromwbathing.
B.wOfferwtowgivewthewclientwawbedwbath,wavoidingwthewperinealwarea.
C.wObtainwwrittenwbrochureswaboutwmenstruationwtowgivewtowthewclient.
D.wTeachwthewimportancewofwpersonalwhygienewduringwmenstruationwwithwthewclient.w-
wCORRECTwwANSWER-
D.wTeachwthewimportancewofwpersonalwhygienewduringwmenstruationwwithwthewclient.
Rationale:wBecausewawshowerwiswmostwbeneficialwforwthewclientwinwtermswofwhygiene,wthewcli
entwshouldwreceivewteachingwfirst,wrespectingwanywpersonalwbeliefswsuchwaswculturalworwspir
itualwvalues.wAfterwclientwteaching,wthewclientwmaywstillwchoosewoptionwAworwB.wBrochureswre
inforcewthewteaching.
*Aw65-year-
oldwclientwwhowattendswanwadultwdaycarewprogramwandwiswwheelchairwmobilewhaswrednessw
inwthewsacralwarea.wWhichwinstructionwiswmostwimportantwforwthewnursewtowprovide?*
A.w"Takewawvitaminwsupplementwtabletwoncewawday."
B.w"Changewpositionswinwthewchairwfrequently"
C.w"Increasewdailywintakewofwwaterworwotherworalwfluids."
D.w"Purchasewawnewerwmodelwwheelchair."w-wCORRECTwwANSWER-
B.w"Changewpositionswinwthewchairwfrequently"
Rationale:wThewmostwimportantwteachingwiswtowchangewpositionswfrequentlywbecausewpres
surewiswthewmostwsignificantwfactorwrelatedwtowthewdevelopmentwofwpressurewulcers.
*Aw75-year-
oldwclientwstateswtowthewnurse,w"Iwamwjustwnotwhungrywanymore."wThewclientwhaswlostw10wpo
unds/4.53wkgwinwthewpastw4wmonths.wWhichwsnackswwillwthewnursewrecommendwtowthewclien
t?w(Selectwallwthatwapply.)*
A.wNuts
B.wMilkshakes
C.wChocolatewcandywbar
D.wPeanutwbutterwandwcrackers
,E.Glasswofwwholewfatwmilkw-wCORRECTwwANSWER-A.wNuts
B.wMilkshakes
D.wPeanutwbutterwandwcrackers
E.Glasswofwwholewfatwmilk
Rationale:wThewnursewmustwrecommendwhighwcalorie/highwnutritionwfoodswforwthiswclientww
howiswunintentionallywlosingwweight.wThewcandywbarwiswhighwcalorie,wbutwemptywinwnutritiona
lwvalue.wThewremainingwselectionswarewhighwcalorie/highwnutrition.
*Aw76-year-
oldwclientwhaswreturnedwfromwsurgery.wThewnursewplanswonwdecreasingwthewchancewofwresp
iratorywcompromisewforwthiswclient.wWhatwwillwthewnursewincludewinwthiswclient'swplanwofwcare
?w(Selectwallwthatwapply.)*
A.wRaisewthewheadwofwthewbedwtownowlesswthanwaw45wdegreeswangle.
B.wHavewthewclientwusewanwincentivewspirometerw10wtimesweverywhourwwhilewawake.
C.wLimitwtotalwfluidwintakewtownowmorewthanw1000wmL/day.
D.wHavewthewclientwsitwonwthewsidewofwthewbedwinsteadwofwgettingwupwandwwalking.
E.wAskwthewclientwtowtakewdeepwbreathswandwcoughwfivewtimesweverywhourwwhilewawake.w-
wCORRECTwwANSWER-
A.wRaisewthewheadwofwthewbedwtownowlesswthanwaw45wdegreeswangle.
B.wHavewthewclientwusewanwincentivewspirometerw10wtimesweverywhourwwhilewawake.
E.wAskwthewclientwtowtakewdeepwbreathswandwcoughwfivewtimesweverywhourwwhilewawake.
Rationale:wAswlongwaswthewclientwiswnotwonwawfluidwrestriction,wofferwnowlesswthanw2000wmLwo
fwfluidwtowkeepwthewbodywwellwhydratedwandwkeepwrespiratorywsecretionswloose.wAmbulation
wiswkeywforwthiswclient.wSittingwatwthewside wofwthewbedwiswnotwa wreplacementwforwambulating.w
Havingwthewclientwsitwupwhelpswexpandwthewlungs.wTakingwdeepwbreaths,wthroughwcoughing
worwincentive wspirometry, whelpswexpandwthewlungswandwdecreasewatelectasis.
*Awclientwbecomeswangrywwhilewwaitingwforwawsupervisedwbreakwtowsmokewawcigarettewoutsi
dewandwstates,w"Iwwantwtowgowoutsidewnowwandwsmoke.wItwtakeswforeverwtowgetwanythingwdo
newhere!"wWhichwnursingwactionwiswbestwforwthiswclient?*
A.wEncouragewthewclientwtowusewawnicotinewpatch.
B.wReassurewthewclientwthatwitwiswalmostwtimewforwanotherwbreak.
C.wHavewthewclientwleavewthewunitwwithwanotherwstaffwmember.
D.wReviewwthewschedulewofwoutdoorwbreakswwithwthewclient.w-wCORRECTwwANSWER-
D.wReviewwthewschedulewofwoutdoorwbreakswwithwthewclient.
Rationale:wThewbestwnursingwactionwiswtowreviewwthewschedulewofwoutdoorwbreakswandwprov
idewconcretewinformationwaboutwthewschedule.wOptionwAwiswcontraindicatedwifwthewclientwwa
ntswtowcontinuewsmoking.wOptionwBwiswinsufficientwtowencouragewawtrustingwrelationshipwwit
hwthewclient.wOptionwCwiswpreferentialwforwthiswclientwonlywandwiswinconsistentwwithwunitwrules
.
,*Awclientwhaswawnasogastricwtubewconnectedwtowlowwintermittentwsuction.wWhenwadminister
ingwmedicationswthroughwthewnasogastricwtube,wwhichwactionwshouldwthewnursewdowfirst?*
A.wClampwthewnasogastricwtube.
B.wConfirmwplacementwofwthewtube.
C.wUsewawsyringewtowinstillwthewmedications.
D.wTurnwoffwthewintermittentwsuctionwdevicew-wCORRECTwwANSWER-
D.wTurnwoffwthewintermittentwsuctionwdevice
Rationale:wThewnursewshouldwfirstwturnwoffwthewsuctionwandwthenwconfirmwplacementwofwthew
tubewinwthewstomachwbeforewinstillingwthewmedications.wTowpreventwimmediatewremovalwofwt
hewinstilledwmedicationswandwallowwabsorption,wthewtubewshouldwbewclampedwforwawperiodw
ofwtimewbeforewreconnectingwthewsuction.
*Awclientwinwawlong-
termwcarewfacilitywreportswtowthewnurse,w"Iwhavewnotwhadwawbowelwmovementwinw2wdays."wW
hatwiswthewnurse'swfirstwaction?*
A.wInstructwthewcaregiverwtowofferwawglasswofwwarmwprunewjuicewatwmealtimes.
B.wNotifywthewhealthwcarewproviderwandwrequestwawprescriptionwforwawlarge-volumewenema.
C.wAssesswthewclient'swmedicalwrecordwtowdeterminewthewclient'swnormalwbowelwpattern.
D.wInstructwthewcaregiverwtowincreasewthewclient'swfluidswtowfivew8-ouncewglasseswperwday.w-
wCORRECTwwANSWER-
C.wAssesswthewclient'swmedicalwrecordwtowdeterminewthewclient'swnormalwbowelwpattern.
Rationale:wThiswclientwmaywnotwroutinelywhavewawdailywbowelwmovement,wsowthewnursewsho
uldwfirstwassesswthiswclient'swnormalwbowelwhabitswbeforewattemptingwanywintervention.wOpti
onswA,wB,worwDwmaywthenwbewimplemented,wifwwarranted.
*Awclientwiswlaughingwatwawtelevisionwprogramwwhenwtheweveningwnursewenterswthewroom.wT
hewclientwstates,w"Mywfootwiswhurting.wIwwouldwlikewawpainwpill."wHowwshouldwthewnursewrespo
nd?*
A.wAskwthewclientwtowratewthewpainwusingwaw1wtow10wscale.
B.wEncouragewthewclientwtowwaitwuntilwbedtimewforwthewpill.
C.wAttendwtowanwacutelywillwclient'swneedswfirstwbecausewthiswclientwiswlaughing.
D.wInstructwthewclientwinwthewusewofwdeepwbreathingwexerciseswforwpainwcontrol.w-
wCORRECTwwANSWER-A.wAskwthewclient wtowratewthewpainwusingwaw1 wtow10wscale.
Rationale:Obtainingwawsubjectivewestimatewofwthewpainwexperiencewbywaskingwthewclientwtow
ratewhiswpainwhelpswthewnursewdeterminewwhichwpainwmedicationwshouldwbewadministeredw
andwalsowprovideswawbaselinewforwevaluatingwtheweffectivenesswofwthewmedication.wMedicat
ingwforwpainwshouldwnotwbewdelayedwsowthatwitwcanwbewusedwaswawsleepwmedication.wOptionw
Cwiswjudgmental.wOptionwDwshouldwbewusedwaswanwadjunctwtowpainwmedication,wnotwinstead
wofwmedication.
, *Awclientwwithwfrequentwurinarywtractwinfectionsw(UTIs)waskswthewnursewtowexplainwawfriend's
wadvicewaboutwdrinkingwawglasswofwjuice wdailywto wpreventwfuturewUTIs.wWhichwresponsewiswb
estwforwthewnursewtowprovide?*
A.w"OrangewjuicewhaswvitaminwCwthatwdeterswbacterialwgrowth."
wB.w"Applewjuicewiswthewmostwusefulwin wacidifyingwthewurine."
wC.w"Cranberrywjuicewstopswpathogens'wadherencewtowthewbladder."
wD.w"Grapefruitwjuicewincreaseswabsorptionwofwmostwantibiotics."w-wCORRECTwwANSWER-
C.w"Cranberrywjuicewstopswpathogens'wadherencewtowthewbladder."
Rationale:wCranberrywjuicewmaintainswurinarywtractwhealthwbywreducingwthewadherencewofw
Escherichiawcoliwbacteriawtowcellswwithinwthewbladder.wOptionswA,wB,wandwDwhavewnotwbeenw
shownwtowbewasweffectivewaswcranberrywjuicewinwpreventingwUTIs.
*Awclient'swbloodwpressurewreadingwisw156/94wmmwHg.wWhichwactionwshouldwthewnursewtak
ewfirst?*
A.wTellwthewclientwthatwthewbloodwpressurewiswhighwandwthatwthewreadingwneedswtowbewverifie
dwbywanotherwnurse.
B.wContactwthewhealthwcarewproviderwtowreportwthewreadingwandwobtainwawprescriptionwforwa
nwantihypertensivewmedication.
C.wReplacewthewcuffwwithwawlargerwonewtowensurewanwamplewfitwforwthewclientwtowincreasewar
mwcomfort.
D.wComparewthewcurrentwreadingwwithwthewclient'swpreviouslywdocumentedwbloodwpressure
wreadings. w-wCORRECT wwANSWER-
D.wComparewthewcurrentwreadingwwithwthewclient'swpreviouslywdocumentedwbloodwpressure
wreadings.
Rationale:wComparingwthiswreadingwwithwpreviouswreadingswwillwprovidewinformationwabout
wwhatwiswnormalwforwthiswclient;wthiswactionwshouldwbewtakenwfirst.wOptionwA wmightwunnecess
arilywalarmwthewclient.wOptionwBwiswpremature.wFurtherwassessmentwiswneededwtowdetermin
ewifwthewreadingwiswabnormalwforwthiswclient.wOptionwCwcouldwfalselywdecreasewthewreadingw
andwiswnotwthewcorrectwprocedurewforwobtainingwawbloodwpressurewreading.
*Awcommunitywhospitalwiswopeningwawmentalwhealthwserviceswdepartment.wWhichwdocume
ntwshouldwthewnursewusewtowdevelopwthewunit'swnursingwguidelines?*
A.wAmericanswwithwDisabilitieswActwofw1990
B.wANAwCodewofwEthicswwithwInterpretativewStatements
C.wANA'swScopewandwStandardswofwNursingwPractice
D.wPatient'swBillwofwRightswofw1990w-wCORRECTwwANSWER-
C.wANA'swScopewandwStandardswofwNursingwPractice
Rationale:wThewANAwScopewofwStandardswofwPracticewforwPsychiatric-
MentalwHealthwNursingwserveswtowdirectwthewphilosophywandwstandardswofwpsychiatricwnurs
And Answers
*Aw20-year-
oldwfemalewclientwwithwawnoticeablewbodywodorwhaswrefusedwtowshowerwforwthewlastw3wdays.w
Shewstates,w"Iwhavewbeenwtoldwthatwitwiswharmfulwtowbathewduringwmywperiod."wWhichwaction
wshouldwthewnursewtakewfirst?*
A.wAcceptwandwdocumentwthewclient'swwishwtowrefrainwfromwbathing.
B.wOfferwtowgivewthewclientwawbedwbath,wavoidingwthewperinealwarea.
C.wObtainwwrittenwbrochureswaboutwmenstruationwtowgivewtowthewclient.
D.wTeachwthewimportancewofwpersonalwhygienewduringwmenstruationwwithwthewclient.w-
wCORRECTwwANSWER-
D.wTeachwthewimportancewofwpersonalwhygienewduringwmenstruationwwithwthewclient.
Rationale:wBecausewawshowerwiswmostwbeneficialwforwthewclientwinwtermswofwhygiene,wthewcli
entwshouldwreceivewteachingwfirst,wrespectingwanywpersonalwbeliefswsuchwaswculturalworwspir
itualwvalues.wAfterwclientwteaching,wthewclientwmaywstillwchoosewoptionwAworwB.wBrochureswre
inforcewthewteaching.
*Aw65-year-
oldwclientwwhowattendswanwadultwdaycarewprogramwandwiswwheelchairwmobilewhaswrednessw
inwthewsacralwarea.wWhichwinstructionwiswmostwimportantwforwthewnursewtowprovide?*
A.w"Takewawvitaminwsupplementwtabletwoncewawday."
B.w"Changewpositionswinwthewchairwfrequently"
C.w"Increasewdailywintakewofwwaterworwotherworalwfluids."
D.w"Purchasewawnewerwmodelwwheelchair."w-wCORRECTwwANSWER-
B.w"Changewpositionswinwthewchairwfrequently"
Rationale:wThewmostwimportantwteachingwiswtowchangewpositionswfrequentlywbecausewpres
surewiswthewmostwsignificantwfactorwrelatedwtowthewdevelopmentwofwpressurewulcers.
*Aw75-year-
oldwclientwstateswtowthewnurse,w"Iwamwjustwnotwhungrywanymore."wThewclientwhaswlostw10wpo
unds/4.53wkgwinwthewpastw4wmonths.wWhichwsnackswwillwthewnursewrecommendwtowthewclien
t?w(Selectwallwthatwapply.)*
A.wNuts
B.wMilkshakes
C.wChocolatewcandywbar
D.wPeanutwbutterwandwcrackers
,E.Glasswofwwholewfatwmilkw-wCORRECTwwANSWER-A.wNuts
B.wMilkshakes
D.wPeanutwbutterwandwcrackers
E.Glasswofwwholewfatwmilk
Rationale:wThewnursewmustwrecommendwhighwcalorie/highwnutritionwfoodswforwthiswclientww
howiswunintentionallywlosingwweight.wThewcandywbarwiswhighwcalorie,wbutwemptywinwnutritiona
lwvalue.wThewremainingwselectionswarewhighwcalorie/highwnutrition.
*Aw76-year-
oldwclientwhaswreturnedwfromwsurgery.wThewnursewplanswonwdecreasingwthewchancewofwresp
iratorywcompromisewforwthiswclient.wWhatwwillwthewnursewincludewinwthiswclient'swplanwofwcare
?w(Selectwallwthatwapply.)*
A.wRaisewthewheadwofwthewbedwtownowlesswthanwaw45wdegreeswangle.
B.wHavewthewclientwusewanwincentivewspirometerw10wtimesweverywhourwwhilewawake.
C.wLimitwtotalwfluidwintakewtownowmorewthanw1000wmL/day.
D.wHavewthewclientwsitwonwthewsidewofwthewbedwinsteadwofwgettingwupwandwwalking.
E.wAskwthewclientwtowtakewdeepwbreathswandwcoughwfivewtimesweverywhourwwhilewawake.w-
wCORRECTwwANSWER-
A.wRaisewthewheadwofwthewbedwtownowlesswthanwaw45wdegreeswangle.
B.wHavewthewclientwusewanwincentivewspirometerw10wtimesweverywhourwwhilewawake.
E.wAskwthewclientwtowtakewdeepwbreathswandwcoughwfivewtimesweverywhourwwhilewawake.
Rationale:wAswlongwaswthewclientwiswnotwonwawfluidwrestriction,wofferwnowlesswthanw2000wmLwo
fwfluidwtowkeepwthewbodywwellwhydratedwandwkeepwrespiratorywsecretionswloose.wAmbulation
wiswkeywforwthiswclient.wSittingwatwthewside wofwthewbedwiswnotwa wreplacementwforwambulating.w
Havingwthewclientwsitwupwhelpswexpandwthewlungs.wTakingwdeepwbreaths,wthroughwcoughing
worwincentive wspirometry, whelpswexpandwthewlungswandwdecreasewatelectasis.
*Awclientwbecomeswangrywwhilewwaitingwforwawsupervisedwbreakwtowsmokewawcigarettewoutsi
dewandwstates,w"Iwwantwtowgowoutsidewnowwandwsmoke.wItwtakeswforeverwtowgetwanythingwdo
newhere!"wWhichwnursingwactionwiswbestwforwthiswclient?*
A.wEncouragewthewclientwtowusewawnicotinewpatch.
B.wReassurewthewclientwthatwitwiswalmostwtimewforwanotherwbreak.
C.wHavewthewclientwleavewthewunitwwithwanotherwstaffwmember.
D.wReviewwthewschedulewofwoutdoorwbreakswwithwthewclient.w-wCORRECTwwANSWER-
D.wReviewwthewschedulewofwoutdoorwbreakswwithwthewclient.
Rationale:wThewbestwnursingwactionwiswtowreviewwthewschedulewofwoutdoorwbreakswandwprov
idewconcretewinformationwaboutwthewschedule.wOptionwAwiswcontraindicatedwifwthewclientwwa
ntswtowcontinuewsmoking.wOptionwBwiswinsufficientwtowencouragewawtrustingwrelationshipwwit
hwthewclient.wOptionwCwiswpreferentialwforwthiswclientwonlywandwiswinconsistentwwithwunitwrules
.
,*Awclientwhaswawnasogastricwtubewconnectedwtowlowwintermittentwsuction.wWhenwadminister
ingwmedicationswthroughwthewnasogastricwtube,wwhichwactionwshouldwthewnursewdowfirst?*
A.wClampwthewnasogastricwtube.
B.wConfirmwplacementwofwthewtube.
C.wUsewawsyringewtowinstillwthewmedications.
D.wTurnwoffwthewintermittentwsuctionwdevicew-wCORRECTwwANSWER-
D.wTurnwoffwthewintermittentwsuctionwdevice
Rationale:wThewnursewshouldwfirstwturnwoffwthewsuctionwandwthenwconfirmwplacementwofwthew
tubewinwthewstomachwbeforewinstillingwthewmedications.wTowpreventwimmediatewremovalwofwt
hewinstilledwmedicationswandwallowwabsorption,wthewtubewshouldwbewclampedwforwawperiodw
ofwtimewbeforewreconnectingwthewsuction.
*Awclientwinwawlong-
termwcarewfacilitywreportswtowthewnurse,w"Iwhavewnotwhadwawbowelwmovementwinw2wdays."wW
hatwiswthewnurse'swfirstwaction?*
A.wInstructwthewcaregiverwtowofferwawglasswofwwarmwprunewjuicewatwmealtimes.
B.wNotifywthewhealthwcarewproviderwandwrequestwawprescriptionwforwawlarge-volumewenema.
C.wAssesswthewclient'swmedicalwrecordwtowdeterminewthewclient'swnormalwbowelwpattern.
D.wInstructwthewcaregiverwtowincreasewthewclient'swfluidswtowfivew8-ouncewglasseswperwday.w-
wCORRECTwwANSWER-
C.wAssesswthewclient'swmedicalwrecordwtowdeterminewthewclient'swnormalwbowelwpattern.
Rationale:wThiswclientwmaywnotwroutinelywhavewawdailywbowelwmovement,wsowthewnursewsho
uldwfirstwassesswthiswclient'swnormalwbowelwhabitswbeforewattemptingwanywintervention.wOpti
onswA,wB,worwDwmaywthenwbewimplemented,wifwwarranted.
*Awclientwiswlaughingwatwawtelevisionwprogramwwhenwtheweveningwnursewenterswthewroom.wT
hewclientwstates,w"Mywfootwiswhurting.wIwwouldwlikewawpainwpill."wHowwshouldwthewnursewrespo
nd?*
A.wAskwthewclientwtowratewthewpainwusingwaw1wtow10wscale.
B.wEncouragewthewclientwtowwaitwuntilwbedtimewforwthewpill.
C.wAttendwtowanwacutelywillwclient'swneedswfirstwbecausewthiswclientwiswlaughing.
D.wInstructwthewclientwinwthewusewofwdeepwbreathingwexerciseswforwpainwcontrol.w-
wCORRECTwwANSWER-A.wAskwthewclient wtowratewthewpainwusingwaw1 wtow10wscale.
Rationale:Obtainingwawsubjectivewestimatewofwthewpainwexperiencewbywaskingwthewclientwtow
ratewhiswpainwhelpswthewnursewdeterminewwhichwpainwmedicationwshouldwbewadministeredw
andwalsowprovideswawbaselinewforwevaluatingwtheweffectivenesswofwthewmedication.wMedicat
ingwforwpainwshouldwnotwbewdelayedwsowthatwitwcanwbewusedwaswawsleepwmedication.wOptionw
Cwiswjudgmental.wOptionwDwshouldwbewusedwaswanwadjunctwtowpainwmedication,wnotwinstead
wofwmedication.
, *Awclientwwithwfrequentwurinarywtractwinfectionsw(UTIs)waskswthewnursewtowexplainwawfriend's
wadvicewaboutwdrinkingwawglasswofwjuice wdailywto wpreventwfuturewUTIs.wWhichwresponsewiswb
estwforwthewnursewtowprovide?*
A.w"OrangewjuicewhaswvitaminwCwthatwdeterswbacterialwgrowth."
wB.w"Applewjuicewiswthewmostwusefulwin wacidifyingwthewurine."
wC.w"Cranberrywjuicewstopswpathogens'wadherencewtowthewbladder."
wD.w"Grapefruitwjuicewincreaseswabsorptionwofwmostwantibiotics."w-wCORRECTwwANSWER-
C.w"Cranberrywjuicewstopswpathogens'wadherencewtowthewbladder."
Rationale:wCranberrywjuicewmaintainswurinarywtractwhealthwbywreducingwthewadherencewofw
Escherichiawcoliwbacteriawtowcellswwithinwthewbladder.wOptionswA,wB,wandwDwhavewnotwbeenw
shownwtowbewasweffectivewaswcranberrywjuicewinwpreventingwUTIs.
*Awclient'swbloodwpressurewreadingwisw156/94wmmwHg.wWhichwactionwshouldwthewnursewtak
ewfirst?*
A.wTellwthewclientwthatwthewbloodwpressurewiswhighwandwthatwthewreadingwneedswtowbewverifie
dwbywanotherwnurse.
B.wContactwthewhealthwcarewproviderwtowreportwthewreadingwandwobtainwawprescriptionwforwa
nwantihypertensivewmedication.
C.wReplacewthewcuffwwithwawlargerwonewtowensurewanwamplewfitwforwthewclientwtowincreasewar
mwcomfort.
D.wComparewthewcurrentwreadingwwithwthewclient'swpreviouslywdocumentedwbloodwpressure
wreadings. w-wCORRECT wwANSWER-
D.wComparewthewcurrentwreadingwwithwthewclient'swpreviouslywdocumentedwbloodwpressure
wreadings.
Rationale:wComparingwthiswreadingwwithwpreviouswreadingswwillwprovidewinformationwabout
wwhatwiswnormalwforwthiswclient;wthiswactionwshouldwbewtakenwfirst.wOptionwA wmightwunnecess
arilywalarmwthewclient.wOptionwBwiswpremature.wFurtherwassessmentwiswneededwtowdetermin
ewifwthewreadingwiswabnormalwforwthiswclient.wOptionwCwcouldwfalselywdecreasewthewreadingw
andwiswnotwthewcorrectwprocedurewforwobtainingwawbloodwpressurewreading.
*Awcommunitywhospitalwiswopeningwawmentalwhealthwserviceswdepartment.wWhichwdocume
ntwshouldwthewnursewusewtowdevelopwthewunit'swnursingwguidelines?*
A.wAmericanswwithwDisabilitieswActwofw1990
B.wANAwCodewofwEthicswwithwInterpretativewStatements
C.wANA'swScopewandwStandardswofwNursingwPractice
D.wPatient'swBillwofwRightswofw1990w-wCORRECTwwANSWER-
C.wANA'swScopewandwStandardswofwNursingwPractice
Rationale:wThewANAwScopewofwStandardswofwPracticewforwPsychiatric-
MentalwHealthwNursingwserveswtowdirectwthewphilosophywandwstandardswofwpsychiatricwnurs
